Management Escalation Plan

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					                     WSHT Top Topics

                                                                               Item                                                                                                                             WSH
Objective                               Action                                         Lead      Supported by   Measure                                WSH Evidence             Initial Date     Revised Date              WSH Evidence             Interdependencies        Impact area
                                                                                 #                                                                                                                              Evidence
1. IMPROVING A&E PERFORMANCE
3. Introduce internal professional      Clarify the role of the POD and                                                                                E-mail sent                                                                                  None                     EAU Flow
standards, aligned with internal        circulate to those on the POD rota     10       CL                                                                                        Jun-10                            G
escalation
                                        Initial assessment of care needs                                        Captured on A&E Card                   Audit, performance                                                  Improvement in both Linked to re-providing        A&E
                                        within 15 minutes of arrival           11       AS            SL                                               monitoring                 May-10           Sep-10           A      15 and 30 minutes   minors area                   Performance
                                                                                                                                                                                                                           assement
                                        Initial assessment & ordering of                                        Captured on PAS & CRIS                 PAS reports                                                                             None                          A&E
                                        diagnostics by doctor within 1         12       AS            SL                                                                          May-10           Sep-10           A                                                        Performance
                                        hour
                                        Review by senior decision maker                                         Captured on PAS                        PAS reports                                                                                  A&E escalation           A&E
                                        within 2 hours - completion of         13       AS            SL                                                                          May-10           Sep-10           A                               important                Performance
                                        management plan & pathway
                                        Speciality response no greater                                          Captured on A&E Card                   Audit                                                                                        Other emergencies        A&E
                                        than 30 minutes from referral time     14       AS           CD's                                                                         May-10          On-going          G                               could impinge on         Performance
                                                                                                                                                                                                                                                    response time
                                        Turnaround time for diagnostics                                         Captured on CRIS                       CRIS report                                                                                  Other activities could   A&E
                                        <30 minutes                            15       AS           SM's                                                                         May-10           Sep-10           A                               impinge on response      Performance
                                                                                                                                                                                                                                                    time
                                        Revision of internal escalation                                         Revised process published              Version control                                                                              None                     A&E
                                        processes as a result of trend         16       AS            SL                                                                          May-10           Sep-10           A                                                        Performance
                                        identification - current version 1.2
                                        External audit of compliance with                                       Compliance                             Report                                                              Awaiting                 None                     Systemic
                                        escalation processes                          Internal                                                                                                                             implementation of
                                                                               17                                                                                                 Jun-10           Dec-10           A
                                                                                       Audit                                                                                                                               revised escalation
                                                                                                                                                                                                                           policy.
6. Improve Mental Health services to    Improve response times from            20       JC            SL        Improved response time to <2 hours for Achievement of plan       Monthly                            G                               Other activities could   A&E
WSH                                     SMHPT. Agree baseline for                                               assessment                                                                                                                          impinge on response      Performance
                                        response times & incremental                                                                                                                                                                                time
                                        improvement. Analysis breach
                                        causes
                                        Care plans for frequent attenders,     21       SL          AS/CH       Care plans available                   Held on file               May-10                            G                               Also access to EPEX, A&E
                                        known to SMHPT, available in                                                                                                                                                                                Mental Health System, Performance
                                        A&E                                                                                                                                                                                                         to review care plans

                                        Escalate to COO SMHPT any              22       JC           COO        Email evidence of escalation           Email & response on         Daily                            G
                                        delays                                                                                                         file
7. Ensure appropriate use of space in   Option appraisal of re-providing                                        Option appraisal paper                 Presented to                                                        First pilot option                                A&E
A&E                                     waiting area for minors stream         23       SL            AS                                               Directorate                May-10           Sep-10           A      rejected, on 2nd pilot                            Performance
                                                                                                                                                       Performance meeting
                                        Scope need for A&E Observation                                          Scoping paper                          Presented to                                                                                                          Systemic
                                        area                                   24       SL            AS                                               Directorate                Jul-10          ON-HOLD
                                                                                                                                                       Performance meeting
                                        Option appraisal for A&E                                                Option appraisal paper                 Presented to                                                                                                          Systemic
                                        Observation area if scoping            25       SL            AS                                               Directorate                Jul-10          ON-HOLD
                                        exercise identifies need                                                                                       Performance meeting
2. MANAGING THE FLOW IN EAU
2. Review functions of EAU &            Change of EAU model                                                     Model agreed and implementation plan   TEG presentation                                                                                                      EAU Flow
                                                                               30       CL            JC                                                                          Apr-10                            G
Physicians                                                                                                      in place
                                                                                                                Model agreed and implementation plan   Business Case - TEG                                                 Business Case                                     Systemic/EAU
                                                                               31       CL            JC                                                                          Jul-10           Aug-10           G
                                                                                                                in place                                                                                                   agreed Aug.                                       flow
                                                                                                                Model agreed and implementation plan   Implementation (if                                                                                                    EAU Flow
                                                                               32       CL            JC                                                                          Oct-10            Apr-11          R
                                                                                                                in place                               approved)
                                                                                                                Increase in ward/board rounds          Revised job plans                                                   completion of job                                 EAU Flow
                                                                               33       CL            JC                                                                          Jul-10           Sep-10           A
                                                                                                                identified in each plan                                                                                    planning
                                        Conduct a review of the overnight
                                                                                                                                                                                3-mth from
                                        'On-Call Take' to determine if a
                                                                                                                                                                             completion of EAU
                                        Unified Medical take would be          34       CL                                                                                                          Apr-11          R
                                                                                                                                                                                Consultant
                                        appropriate - links to EAU
                                                                                                                                                                               development
                                        Consultant development
3. CREATING FLOW
10. Improve weekend discharges   Medical teams to identify, on                                  Increased number of weekend            PAS report                                                          Systemic
                                 handover lists, patients who                                   discharges
                                                                                Consultants/W
                                 require senior review over          89   CL                                                                                Apr-10            G
                                                                                ard Managers
                                 weekend with a view to discharge

                                 Lists to be held on ward & in EAU                              Folders in place                       Folder
                                                                     90   CL         SL                                                                     Apr-10            G
                                 SHO and Registrar to review                                    Increased number of weekend            PAS report &                               Requires embedding       Systemic
                                 patients as per list during am/pm                              discharges                             documentation                              and improved
                                                                     91   SL         JC                                                                     Jun-10   Aug-10   A
                                 handovers                                                                                                                                        compliance from
                                                                                                                                                                                  Medical Teams.
1. Performance Management &      Reduction in LoS by 0.5 days for                               Reduction in LoS from Jan 2010         Monthly reports                                                     Systemic
                                                                     95   DOR        CL                                                                     Jun-10            G
Improvement                      all physicians                                                 baseline
                                 Provide data at individual                                     * Reduction in LoS by 0.5 days         Monthly reports                            Problem with server      Flow/13:00 disch
                                 consultant level to consultants                                * 40% TTOs in pharmacy by 11am                                                    retrieval of TTO data.
                                 and managers, to include                                       * Increased percentage of patients                                                Changed to Green
                                 * Length of stay - monthly 13                                  discharged by 1pm                                                                 11 Aug.
                                 week rolling average, plotted
                                 against Trust & National average
                                 and National top quartile           96   DOR        KR                                                                     Apr-10   Aug-10   G
                                 * TTO's in pharmacy by 11am -
                                 monthly rolling 13 week average,
                                 plotted against Trust average
                                 * Discharges by 1pm monthly
                                 rolling 13 week average, plotted
                                 against Trust average
                                 Review data & agree actions at                                 Improvement against target/trajectories Specialty meeting                         Requires improved        Flow/13:00 disch
                                 Speciality Meetings                                                                                    notes                                     consistency and
                                                                     97   JC        SM's                                                                    Apr-10   Aug-10   G   embedding.
                                                                                                                                                                                  Changed to Green
                                 Review data and agree                                          Improvement against target/trajectories Notes of meeting                          11 Aug. improved
                                                                                                                                                                                  Requires                 Flow/13:00 disch
                                 actions/targets for discharge                   SM's/Ward                                                                                        consistency and
                                 performance column during ward      98   JC                                                                                Apr-10   Oct-10   A   embedding.
                                                                                 Managers
                                 meetings
                                 Review data and agree targets at                               Improvement against target/trajectories Notes of meeting
                                 Directorate Performance Meetings    99   COO       GM'S                                                                    Jan-10            G

KEY                              No action commenced
                                 Action commenced but not
                                 completed
                                 Action completed
                 WSHT URGENT CARE ACTION PLAN 12 Aug 2010

Objective                                 Action                                          Item #    Lead      Supported by Measure                                       WSH Evidence              Initial Date   Revised     RAG Comments                              Interdependencies   Impact area         Updates       Review process
                                                                                                                                                                                                                   Date      rating                                                                             July
1. IMPROVING A&E PERFORMANCE
1. Ensure A&E performance monitoring Daily 'debrief' at 08:00 to identify issues                                             Issues and action identified                Daily record sheet                                                                                                                     Request       Are issues summarised and
addresses current issues             from previous day and overnight                        1        SL            AS                                                                                Jan-10                   G                                                                                               reviewed? Any specific
                                                                                                                                                                                                                                                                                                                              changes as a result
                                          Daily validation of breaches                                                       Standard Operating Procedure dictates       Info team records &
                                                                                            2        SL          AS/JC       that validation must have occurred before   A&E Daily Summary            Daily                   G
                                                                                                                             production of evidence
                                          Thrice daily board rounds in A&E                                                   Actions identified during rounds and        Shift Co-ordinators Log
                                                                                            3        SL            AS                                                                                 Daily                   G
                                                                                                                             implemented dynamically
                                          Increase A&E Board rounds to 4 hourly -                                            Actions identified during rounds and        Shift Co-ordinators Log
                                                                                            4        SL            AS                                                                               May-10                    G
                                          from end of April 10                                                               implemented dynamically
                                          Weekly monitoring of performance and                                               Follow up of previous actions. Changes in   Notes of meeting
                                          identification of breach trends. PCT attend       5        SL          AS/JC       position noted. Further action identified                               Weekly                   G
                                          alternate weeks
                                          Feedback of specialty breaches - those                                             Daily record sheet sent to specialties      Daily record sheet to &
                                          referred to specialists within 2 hours of         6        SL         AS/CL/JC     appropriately                               response from                Daily                   G
                                          arrival in A&E                                                                                                                 speciality
2. Address specific breach causes         Review specialist referral pathways to                                             50% reduction in delays of patients in      Notes of weekly
                                                                                            7        AS            SL                                                                                Weekly                   G
                                          reduce delays                                                                      specialist pathways i.e.. T&O, Gynae        performance meeting
                                          Ensure escalation to specialist                                                    50% reduction in non-A&E attributable       Notes of weekly                                                                                                                        Request
                                                                                            8        AS            SL                                                                                Jan-10                   G
                                          consultants as per protocol                                                        breaches                                    performance meeting
                                          Review effectiveness of Triage system                                              Reduction to zero minor breaches            Evaluation report of                                     SL to provide evidence of reports.                        A&E Performance     Request       Where is the review?
                                                                                            9        SL            JC                                                                                Apr-10                   G
                                                                                                                                                                         pilot
3. Introduce internal professional        Clarify the role of the POD and circulate to
                                                                                           10        CL                                                                                              Jun-10                   G
standards, aligned with internal          those on the POD rota
escalation                                Initial assessment of care needs within 15                                         Captured on A&E Card                        Audit, performance                                       Performance report available. Being                       A&E Performance     Request       Review as part of 21/06
                                          minutes of arrival                               11        AS            SL                                                    monitoring                 May-10         Sep-10     A   reviewed as part of triage.                                                                 focus exercise

                                          Initial assessment & ordering of                                                   Captured on PAS & CRIS                      PAS reports                                              Performamce report available. Being                       A&E Performance     Request       Review as part of 21/06
                                          diagnostics by doctor within 1 hour              12        AS            SL                                                                               May-10         Sep-10     A   reviewed as part of triage.                                                                 focus exercise


                                          Review by senior decision maker within 2                                           Captured on PAS                             PAS reports                                              Will be reviewed at A&E                                   A&E Performance     Request       Review as part of 21/06
                                          hours - completion of management plan &          13        AS            SL                                                                               May-10         Sep-10     A   performance meetings.                                                                       focus exercise
                                          pathway
                                          Speciality response no greater than 30                                             Captured on A&E Card                        Audit                                                                                                              A&E Performance     Request       Review as part of 21/06
                                                                                           14        AS           CD's                                                                              May-10        On-going    G
                                          minutes from referral time                                                                                                                                                                                                                                                          focus exercise
                                          Turnaround time for diagnostics <30                                                Captured on CRIS                            CRIS report                                              Initial meeting with A&E and                              A&E Performance     Request       Review as part of 21/06
                                          minutes                                          15        AS           SM's                                                                              May-10         Sep-10     A   radiology taken place, further                                                              focus exercise
                                                                                                                                                                                                                                  meeting in Sept.
                                          Revision of internal escalation processes                                          Revised process published                   Version control                                                                                                    A&E Performance     Request       Review as part of 21/06
                                          as a result of trend identification - current    16        AS            SL                                                                               May-10         Sep-10     A                                                                                               focus exercise
                                          version 1.2
                                          External audit of compliance with                        Internal                  Compliance                                  Report                                                   Awaiting implementation of revised                        Systemic            Request/NH    Report
                                                                                           17                                                                                                        Jun-10        Dec-10     A
                                          escalation processes                                      Audit                                                                                                                         escalation policy.                                                            SS Internal
4. Recruit 2 Consultants                  Job description, advert, interview, appoint                                        Full substantive establishment - locums in Start date or current                                     1 Consultant appointed awaiting the                       A&E Performance     Request       Please update
                                                                                                               AS/HR/Med     place if not successful                    position identifiable
                                                                                           18        CL                                                                                             May-10         Dec-10     A   re-advertisement of 2nd post.
                                                                                                                Staffing

5. Implement Rapid Assessment &           Scope additional resource requirements                                             Scoping paper                               Presented to                                             Martin Hunt leading LEAN event in                         Systemic            Request/NH    Report
Treatment (RAT) Model of care                                                                                                                                            Directorate                                              Sept.                                                                         SS Internal
                                                                                           19        AS            SL                                                                                Jun-10        Oct-10     R
                                                                                                                                                                         Performance
                                                                                                                                                                         Management Meeting
6. Improve Mental Health services to      Improve response times from SMHPT.                                                 Improved response time to <2 hours for      Achievement of plan                                      Tracked on weekly performance
WSH                                       Agree baseline for response times &                                                assessment                                                                                           charts.
                                                                                           20        JC            SL                                                                               Monthly                   G
                                          incremental improvement. Analysis
                                          breach causes
                                          Care plans for frequent attenders, known                                           Care plans available                        Held on file                             Requires        Requires update as to what is                             A&E Performance     NHSS
                                                                                           21        SL          AS/CH                                                                              May-10                    A
                                          to SMHPT, available in A&E                                                                                                                                              new date        happening.                                                                    internal
                                          Escalate to COO SMHPT any delays                                                   Email evidence of escalation                Email & response on
                                                                                           22        JC           COO                                                                                 Daily                   G
                                                                                                                                                                         file
7. Ensure appropriate use of space in     Option appraisal of re-providing waiting                                           Option appraisal paper                      Presented to                                             Pilot started 19-Apr.                                                         Request       Any metric for impact
                                                                                                                                                                                                                  Requires
A&E                                       area for minors stream                           23        SL            AS                                                    Directorate                May-10                    A
                                                                                                                                                                                                                  new date
                                                                                                                                                                         Performance meeting
                                          Scope need for A&E Observation area                                                Scoping paper                               Presented to                                             Decided not to proceed at this                            Systemic
                                                                                           24        SL            AS                                                    Directorate                 Jul-10       ON-HOLD     R   moment.
                                                                                                                                                                         Performance meeting
                                          Option appraisal for A&E Observation                                               Option appraisal paper                      Presented to                                             Decided not to proceed at this                            Systemic
                                          area if scoping exercise identifies need         25        SL            AS                                                    Directorate                 Jul-10       ON-HOLD     R   moment.
                                                                                                                                                                         Performance meeting
2. MANAGING THE FLOW IN EAU                                                                26
1. Improve flow of arrivals to EAU        Pilot 'appointment time' with EEAST and                                            Improved turnaround times to 70% within Submit button reports                                        Reported at Performance meeting -                         EAU Flow            NHSS
                                                                                                              Simon Chase/
                                          Primary Care for GP expected patients                                              15 mins. 95% within 30 mins                                                                          performance improving.                                                        internal
                                                                                                              Marcus Bailey/                                                                                      Requires
                                          transported via ambulance                        27        JC                                                                                             May-10                    A
                                                                                                              Primary Care                                                                                        new date
                                                                                                                  lead
                                          Conduct a review as to how GP EAU                                                  Potential increase in short stay            Report on review of                                      Will be addressed by Urgent Care
                                          referrals are accepted/redirected to             28        JC            CL        admmissions or referrals to EIT etc         EAU and Short stay          Jul-10        Oct-10     A   Transformation Project - ? Resource
                                          alternative routes for accessing care                                                                                          admissions                                               Hub.
                                          Timely declaration of EAU beds to A&E                                              Identified on traffic lights                Report from T/L
                                                                                           29        SL            CB                                                                                 Daily                   G
2. Review functions of EAU &                                                                                                 Model agreed and implementation plan in TEG presentation                                                                                                       EAU Flow            Internal
                                          Change of EAU model                              30        CL            JC                                                                                Apr-10                   G
Physicians                                                                                                                   place                                                                                                                                                                              NHSS
                                                                                                                             Model agreed and implementation plan in Business Case - TEG                                          Business Case agreed Aug.                                 Systemic/EAU flow
                                                                                           31        CL            JC        place                                                                   Jul-10       Aug-10      G




                                                                                                                                                                                                   3 of 29
2. Review functions of EAU &
Physicians

Objective                                   Action                                           Item #   Lead   Supported by Measure                                    WSH Evidence              Initial Date     Revised      RAG Comments                                  Interdependencies   Impact area   Updates         Review process
                                                                                                                                                                                                                 Date       rating                                                                           July
                                                                                                                            Model agreed and implementation plan in Implementation (if                                                                                                         EAU Flow
                                                                                              32      CL          JC                                                                             Oct-10          Apr-11      R
                                                                                                                            place                                    approved)
                                                                                                                            Increase in ward/board rounds identified Revised job plans                                           Job plans will be reviewed at senior                          EAU Flow
                                                                                              33      CL          JC                                                                             Jul-10          Sep-10      A
                                                                                                                            in each plan                                                                                         level in Sept.
                                            Conduct a review of the overnight 'On-Call                                                                               Review report             3-mth from
                                            Take' to determine if a Unified Medical                                                                                  available              completion of EAU
                                                                                              34      CL                                                                                                         Apr-11      R
                                            take would be appropriate - links to EAU                                                                                                           Consultant
                                            Consultant development                                                                                                                            development
                                            Implement specialty clinic slots to facilitate                                                                           Clinics in place
                                            early discharge - links to job planning           35      JC          CL                                                                                             Apr-11      R

                                            Implement daily 'Care of the Elderly'                                           Patients seen in CoE Rapid Access        Reduction in Care of
                                            admission avoidance Out-patient slots -                                         Clinic                                   the Elderly
                                                                                              36      JC          CL                                                                             Aug-10                      A
                                            linked to CoE Strategy and job planning                                                                                  admissions

3. Develop ambulatory care pathways         Work with PBC and LMC to develop &                                              Appropriate pathways identified and      Presented to Urgent                                         Emma Derbyshire identified as lead                            EAU Flow      NHSS            ? Transformation Grp and
                                            implement care pathways for common                37      CL          JC        programme developed                      Care Group                  May-10          Aug-11      A   for WSCF.                                                                   internal        Audit
                                            conditions
                                            Pulmonary Embolus                                                               Uptake Royal College pathways            Internal use of                                             Emma Derbyshire identified as lead
                                                                                              38      PM                                                                                                         Aug-11      A
                                                                                                                                                                     pathway                                                     for WSCF.
                                            Low risk GI bleed with no reduction in HB                                       Uptake Royal College pathways            Internal use of                                             Emma Derbyshire identified as lead
                                                                                              39      PM                                                                                                         Aug-11      A
                                                                                                                                                                     pathway                                                     for WSCF.
                                            Headache                                                                        Uptake Royal College pathways            Internal use of                                             Emma Derbyshire identified as lead
                                                                                              40      PM                                                                                                         Aug-11      A
                                                                                                                                                                     pathway                                                     for WSCF.
                                            Acute Coronary Syndrome                                                         Uptake Royal College pathways            Internal use of                                             Emma Derbyshire identified as lead
                                                                                              41      PM                                                                                                         Aug-11      A
                                                                                                                                                                     pathway                                                     for WSCF.
                                            Epilepsy & Seizure                                                              Uptake Royal College pathways            Internal use of                                             Emma Derbyshire identified as lead
                                                                                              42      PM                                                                                                         Aug-11      A
                                                                                                                                                                     pathway                                                     for WSCF.
                                            Cellulitis                                                                      Uptake Royal College pathways            Internal use of                                             Emma Derbyshire identified as lead
                                                                                              43      PM                                                                                                         Aug-11      A
                                                                                                                                                                     pathway                                                     for WSCF.
                                            Hypoglycaemia                                                                   Uptake Royal College pathways            Internal use of                                             Emma Derbyshire identified as lead
                                                                                              44      PM                                                                                                         Aug-11      A
                                                                                                                                                                     pathway                                                     for WSCF.
4. Provision of alternatives to             Develop rapid access clinic slots                                               Business case for change in model        Business case                                               In-place to comment mid-August.                               Systemic
                                                                                              45      CL          JC                                                                             Oct-10          Sep-10      G
admission                                                                                                                                                            approved TEG
                                            Implement Consultant telephone advice                              JC/SM's/     GP contact with Consultants              Report on telephone
                                                                                              46      CL                                                                                        Available       Completed    G
                                                                                                              Consultants                                            clinics
                                            Discussions with NHS Suffolk/Harmoni                                            Reduction in number of patients          PAS Report                                                  Performance meeting.
                                            around what needs to be seen within A&E                                         being referred
                                                                                              47      DOR        GN                                                                                                          G
                                            or redirected to OoH Service

5. Implement short stay beds                Identify demand & capacity requirements                            JC/SM's/     Report to Urgent Care meeting            Notes of meeting                                            COMPLETE, 2 Bays on G5.                                       EAU Flow      NHSS            ? Transformation Grp and


                                                                                    COMP
                                                                                              48      CL                                                                                         May-10                      G
                                                                                                              Consultants                                                                                                                                                                                    internal        Audit
                                            Identify appropriate clinical area                                              Ward identified                          Notes of meeting                                            Proposal being put to the                                     Systemic      Request/NH      Weekly meeting
                                                                                                               JC/SM's/
                                                                                              49      CL                                                                                         Jun-10          Sep-10      G   Emergency Medicine meeting -                                                SS Internal
                                                                                                              Consultants
                                                                                                                                                                                                                                 August.
                                            Implement short stay beds                                                       Ward configuration changed               Ops Group notes                                             Reallocation of nurses required,                              Systemic
                                                                                                               JC/SM's/
                                                                                              50      CL                                                                                         Oct-10                      A   consultation in progress.
                                                                                                              Consultants

6. Ensure all patients have EDD within      Provisional diagnosis to be updated onto                                        100% patients have EDD within 12 hours PAS report                                                    Technical issue with EPRO being           IT System changes   Flow
12 hours                                    PAS to generate EDD                                                             of admission                                                                                         resolved. LB to attend Emergency
                                                                                              51       JY       CB/CH                                                                            May-10          Sep-10      A
                                                                                                                                                                                                                                 Med and Surgery meetings.

7. Reduce the number of frequent            Review individual patient attendances,                                          PAS analysis                             PAS report
attenders in EAU                            identify which patients require care plan         52      CL        JY/SL                                                                          Completed        Completed    G

                                            Work with clinicians (including Primary                                         Individual patient care plan             Copy                                                        Individual patient pathways changed -                         EAU Flow      NHSS
                                            Care) to develop and implement care plan          53      CL        JY/SL                                                                            Jul-10          Oct-11      A   MTU rather than EAU.                                                        Internal/TGrp

3. CREATING FLOW                                                                              54
1. Ensure daily review of all adult non-    Identify Consultant or SpR rounds with                                          Published schedule by ward. Board ward EPRO report links into                                        Reported monthly on scorecard.                                Flow          Request         Completed? Process? Lead?
elective inpatients                         agreed schedule by ward                           55      DOR        CD's       round report                           schedule. Board ward          Apr-10                      G
                                                                                                                                                                   round report
                                            Daily review undertaken by each member                                          100% compliance with daily update      Board Round Report
                                                                                              56      CL        ND/GN                                                                            Apr-10                      G
                                            of the MDT
                                            Junior doctors update 'medically fit' status                                    100% compliance with daily update        LOSPT                                                       Changed to Green 11 Aug.                                      Flow          Request         Completed? Process? Lead?
                                                                                                                Lead
                                            (on ward/board rounds) and EDD on                 57      CL                                                                                         Apr-10                      G
                                                                                                              Consultants
                                            EPRO patient list daily
                                            Roll-out Nurse (Criteria) led discharge                                         Increase in discharges before 1pm led by LOSPT                                                       Commenced on G3 & F10. Changed
                                                                                              58      ND          JC                                                                             Sep-10                      G
                                                                                                                            nurses.                                                                                              to Green 11 Aug.
                                            Record of daily review retained                                                 100% compliance with daily update        Report to Discharge                                         Still embedding, record of daily review                       Flow          Request         Completed? Process? Lead?
                                                                                              59      LB       Matrons                                               Implementation Group        Apr-10          Sep-10      A   not being collected.
                                                                                                                                                                     meeting
2. All patients have a clear plan of care   Monthly record audits to be carried out to                                      20% of total inpatients on each ward,    Report to Discharge                                         Record of audits are on the scorecard,                        Flow          Request         Completed? Process? Lead?
that is up to date, reflects current        check that care plans are present and                                           100% of records checked have clear       Implementation Group                                        process is imbedded and reported
                                                                                              60      JH       Matrons                                                                           Apr-10                      G
position and correlates with the EDD        clear, and are accurately reflected on                                          action plan                              meeting                                                     monthly.
                                            LOSPT
                                            Results of audits to be given to medical                                        100% of records checked have clear       Report to Discharge                                         Feedback to staff given; still requires                       Flow          Request         Completed? Process? Lead?
                                            teams and areas for improvement                   61      CL         CD's       action plan                              Implementation Group        Apr-10          Sep-10      A   improved compliance.
                                            identified                                                                                                               meeting
                                            Development of process for making                                                                                        Documented in Notes                                         Process being reviewed through the                            Flow
                                            patients/relatives/carers aware of EDD            62      D'OR       GN                                                                              Jul-10          Sep-10      A   DOG, will agree measures at later
                                                                                                                                                                                                                                 date.
                                            Identify teams where improvement is not                                         100% of records checked have clear       Report to Discharge                                                                                                       Flow          Request         Why is this red?
                                            taking place and agree action needed with         63      DOR        CD's       action plan                              Implementation Group        Apr-10          Sep-10      A
                                            individual Consultants                                                                                                   meeting
                                            Review of EDD being completed on LOS                                            Patients have EDD within 24hrs of        Performance Report                                          RT to make changes to LOSPT.                                  Systemic      Request/NH      Weekly meeting
                                                                                                                CD's/
                                            Tracker and that all patients have EDD            64      DOR                   admission                                                            Jun-10          Sep-10      A                                                                               SS Internal
                                                                                                              Consultants
                                            within 24hrs of admission




                                                                                                                                                                                               4 of 29
Objective                                 Action                                        Item #   Lead   Supported by Measure                                             WSH Evidence           Initial Date   Revised     RAG Comments                                     Interdependencies   Impact area        Updates         Review process
                                                                                                                                                                                                                Date      rating                                                                                   July
3. Improve referral to and response for Review role and function of Complex Care                                         Revision of role & function                     Published                                               ND taking lead as Executive on                                                                    Status
Psychogeriatric assessment              Team                                             65      ND         CL/LS                                                                                May-10         Sep-10      A    Project team. Meeting with David
                                                                                                                                                                                                                                 Jarrold arranged.
                                          Implement revised process for Consultant                                       Revision of process                             Published                                                                                                                                                 Status
                                          Psychogeriatric referral & assessment          66      JC         CL/LS                                                                                May-10         Sep-10      A

4. Ensure LOSPT accurately reflects       Ward Manager accountable for ensuring                                            100% patients have EDD within 24 hours Report to Discharge                                                                                                           Flow               Request         Completed? Process? Lead?
patient status and PDD                    information from ward/board round is           67      COO    Ward Manager of admission                                 Implementation Group            Apr-10                    G
                                          updated in LOSPT                                                                                                        meeting
                                          Nurses, Care Co-ordinators and AHPs to                                           100% patients have EDD within 24 hours Report to Discharge                                                                                                           Flow               Request         What is current position?
                                          update information on LOSPT as they            68      COO    All clinical staff of admission                           Implementation Group            Mar-10                    G
                                          become aware of changes                                                                                                 meeting
                                          Service Manager, in conjunction with                                             100% patients have EDD within 24 hours Report to Discharge
                                          Ward Managers to identify named                                SM's/Ward of admission                                   Implementation Group
                                                                                         69      COO                                                                                              Mar-10                    G
                                          individual responsible for data input to                         Managers                                               meeting
                                          LOSPT (including cover for absence)
                                          Matrons and Ward Managers to identify                                          List of staff with training status identified   List
                                                                                                        Matrons/ Ward
                                          individuals who need training to enter data    70      COO                                                                                              Mar-10                    G
                                                                                                         Managers
                                          onto LOSPT and EPRO
                                          IT to provide system training to identified                                    List of staff with training status identified   List                                                    Trainer and trainees identified awaiting                       Flow               Request         What is current position?
                                                                                         71      NM       IT trainers                                                                             Mar-10        Sep-10      A
                                          staff                                                                                                                                                                                  dates. JH to check on this.
                                          Weekly snapshot audit of all wards to                                          100% compliance                                 LOSPT
                                                                                         72      LB     SM's/ Matrons                                                                             Apr-10                    G
                                          ensure LOSPT reflects patient PDD
                                          Escalation of non-compliance to Directors                        Service       Escalation records                              Report to Discharge                                     Requires improved consistency.                                                    Request         Action in hand?
                                          (DOR/ND/NK)                                    73      JC       Managers/                                                      Implementation Group     Apr-10        Sep-10      G    Changed to Green 11 Aug.
                                                                                                           Matrons                                                       meeting
5. Utilise LOSPT information for      Review number of medically fit patients                                            Bed status report                               Report to Discharge                                     Requires embedding and improved                                                   Request         Action in hand?
                                                                                                        SMOC/Bed
proactive decision making and improve and definite discharges at 09:30 bed                                                                                               Implementation Group                                    compliance.
                                                                                         74      JC     Management                                                                                Apr-10        Sep-10      A
awareness of 'medically fit' patients meeting                                                                                                                            meeting
                                                                                                          Team
                                          Audit of patients due to be discharged                                         80% compliance with PDD                         Report to Discharge                                     Performance improving but not at 80%                           Flow               Request         What is current position?
                                          within 48 hours and actual date of                             Governance/                                                     Implementation Group                                    compliance yet. DOG Advises to
                                          discharge                                      75      JH      Information                                                     meeting                  Mar-10                    A    remove from Action Plan. GN to
                                                                                                            Team                                                                                                                 discuss with JH.

                                         3 times/week review of all patients                                             Decrease in number of patients in               LOSPT
                                                                                         76      LS          AT                                                                                                Aug-10       A
                                         with LOS >14 days                                                               hospital with LOS >14 days.
6. TTOs to be available when the patient TTOs to be submitted on EPRO within 2                                           100% compliance                                 Monthly report from                                     CL to conduct audit.                                           13:00 discharge                    Current Performance
                                                                                         77      CL      Consultants                                                                              Jul-10        Oct-10      R
is ready for discharge                   hours of decision to discharge                                                                                                  EPRO
                                         Turnaround time Prescription submitted                                          100% compliance, baseline & trajectory          Monthly report from                                                                                                                       Request
                                         on EPRO to dispensing <2 hours                                   Pharmacy                                                       Pharmacy, compliance
                                                                                         78      SW                                                                                               Jan-10                    G
                                                                                                            Staff                                                        with trajectory

                                          Increase proportion of patients for                                            40% or more TTOs in pharmacy by 11am Monthly report from                                                Performance improving but not at 40%                           Flow/13:00 disch   Request         Actions to manage
                                          discharge to 40% having TTO request in                        CD's/Cons/Car                                         Pharmacy included in                                               compliance yet.                                                                                   performance?
                                                                                         79      CL                                                                                               Apr-10        Oct-10      R
                                          pharmacy by 11am                                              e Coordinators                                        the Trust Monthly
                                                                                                                                                              Performance Report.
                                          Highlight need for medical teams to                                            100% compliance                      Notes of relevant
                                          prioritise the writing of TTOs in a timely     80      CL         CD's                                              physicians meetings                On-going      On-going     G
                                          fashion
7. Ensure escalation of delays in the     Produce escalation pathway for all delays                                      Pathway published                               Pathway
discharge process                         and identify key roles & responsibilities      81      LS          LB                                                                                   Mar-10                    G

8. Reduce delayed transfers of care       Provide twice weekly reports on number of                     Disch Liaison Report produced                                    Report                                                                                                                 Flow               Internal - in
                                                                                         82       SJ                                                                                              Mar-10                    G
(DTOCs)                                   DTOCs, in WSH, by type                                            Team                                                                                                                                                                                                   UC TG?
                                          Escalation pathway invoked where                                            Noted on 2x weekly report                          Dated updates
                                                                                         83      LS          SJ                                                                                                             G
                                          indicated
                                          Action taken as a result of escalation                                         Reduction in length of delay/number of          Noted on 2x weekly
                                                                                         84      JC     SM's/ Matrons                                                                                                       G
                                                                                                                         DTOCs                                           report
                                          Ensure Exec Lead for discharge is fully                                        Circulation list                                Email chain
                                                                                         85      JC          ND                                                                                   Mar-10                    G
                                          informed of DTOCs
                                          Update Direction of Choice Policy                                              Revised version published (version              Reduction in delays
                                                                                         86      LS           All                                                                                 Mar-10                    G
                                                                                                                         number x)
9. Identify need for and implement if     Scope the need for discharge lounge -                                          Pathway published                               Pathway                                                 Placed on-hold 26/07/10.                                       EAU Flow           Request/NH      Update on pathway
necessary - Discharge Lounge              including demand & capacity in the             87      JC          LS                                                                                  May-10        ON-HOLD      R                                                                                      SS internal
                                          context of escalation requirements
                                          Identify suitable area & staffing                                              Area & staffing identified                      Published                                               Placed on-hold 26/07/10.                                       EAU Flow           Request/NH      Update on pathway
                                                                                         88      JC          LS                                                                                  May-10        ON-HOLD      R
                                                                                                                                                                                                                                                                                                                   SS internal
10. Improve weekend discharges            Medical teams to identify, on handover                                         Increased number of weekend discharges PAS report
                                          lists, patients who require senior review                     Consultants/W
                                                                                         89      CL                                                                                               Apr-10                    G
                                          over weekend with a view to discharge                         ard Managers

                                          Lists to be held on ward & in EAU              90      CL          SL          Folders in place                       Folder                            Apr-10                    G
                                          SHO and Registrar to review patients                                           Increased number of weekend discharges PAS report &                                                     Requires embedding and improved                                Systemic           Request/NH      Report
                                          as per list during am/pm handovers             91      SL          JC                                                 documentation                     Jun-10       Aug-10       A    compliance from Medical Teams.                                                    SS Internal

11. Optimise the role of use of EIT in    JC to liaise with BVR                                                          Policy available                                Statistics                                              Changed to Green 11 Aug.
                                                                                         92      JC         BVR                                                                                                             G
supporting early discharge
12. Update internal escalation plan to                                                                                                                                   Policy updated
include protocols for patient transfers                                                  93      AC          SL                                                                                                Aug-10       A

4. PERFORMANCE MANAGEMENT - DISCHARGE                                                    94
1. Performance Management &    Reduction in LoS by 0.5 days for all                                                      Reduction in LoS from Jan 2010 baseline Monthly reports                                                                                                                Systemic           NHSS            Update performance
                                                                                         95      DOR         CL                                                                                   Jun-10                    G
Improvement                    physicians




                                                                                                                                                                                                5 of 29
Objective
1. Performance Management &                 Action                                        Item #   Lead   Supported by Measure                                     WSH Evidence              Initial Date   Revised    RAG Comments                                     Interdependencies   Impact area        Updates     Review process
Improvement                                                                                                                                                                                                  Date     rating                                                                                   July
                                            Provide data at individual consultant level                                  * Reduction in LoS by 0.5 days            Monthly reports                                           Problem with server retrieval of TTO                           Flow/13:00 disch   Request/Che IT actions?
                                            to consultants and managers, to include                                      * 40% TTOs in pharmacy by 11am                                                                      data. Changed to Green 11 Aug.                                                    ck NHSS
                                            * Length of stay - monthly 13 week rolling                                   * Increased percentage of patients                                                                                                                                                    internal
                                            average, plotted against Trust & National                                    discharged by 1pm
                                            average and National top quartile
                                            * TTO's in pharmacy by 11am - monthly
                                            rolling 13 week average, plotted against       96      DOR         KR                                                                              Apr-10        Aug-10     G
                                            Trust average                           *
                                            Discharges by 1pm monthly rolling 13
                                            week average, plotted against Trust
                                            average


                                            Review data & agree actions at Speciality                                    Improvement against target/trajectories   Specialty meeting notes                                   Requires improved consistency and                              Flow/13:00 disch   Request     Current assessment?
                                            Meetings                                       97      JC         SM's                                                                             Apr-10        Aug-10     G    embedding. Changed to Green 11
                                                                                                                                                                                                                             Aug.
                                            Review data and agree actions/targets for                                    Improvement against target/trajectories   Notes of meeting                                          Requires improved consistency and                              Flow/13:00 disch   Request     Current assessment?
                                                                                                           SM's/Ward
                                            discharge performance column during            98      JC                                                                                          Apr-10        Oct-10     A    embedding.
                                                                                                           Managers
                                            ward meetings
                                            Review data and agree targets at                                             Improvement against target/trajectories   Notes of meeting
                                                                                           99      COO       GM'S                                                                              Jan-10                   G
                                            Directorate Performance Meetings
5. PERFORMANCE MONITORING                                                                  100
1. Provide assurance on progress            Medical Directorate monthly performance                                      Agenda Item                               Notes of meeting
                                            meetings & Trust-wide Urgent Care              101     COO       GM'S                                                                             Monthly                   G
                                            meetings
2. External Benchmarking                    Participate in FTN Benchmarking for                            SL, CL, AS,   Project report                            Findings published                                        KR is currently developing this. Initial
                                                                                           102     COO                                                                                         Sep-10                   A
                                            Accident & Emergency Services                                    JC, KR                                                                                                          report sent to FTN this week.
3. Agree internal professional              PTWR Documentation - Medicine                                                Standards agreed and published            Findings published
standards and performance monitor:                                                         103     CL                                                                                          Jul-10        Sep-10     A

                                            A&E                                                                          Standards agreed and published            Findings published
                                                                                           104     DO'R      CL/JC                                                                             Jul-10        Sep-10     A
                                            Radiology                                                                    Standards agreed and published            Findings published
                                                                                           105     DO'R       LW                                                                               Jul-10        Sep-10     A
                                            Therapies                                                                    Standards agreed and published            Findings published
                                                                                           106     DO'R     LW/BVR                                                                             Jul-10        Sep-10     A
6. ADDITIONAL ACTIONS FOLLOWING
ECIST CLINICAL CHALLENGE EVENT                                                             107

1. Increase the number of Cardiology                                                                                                                               Number of patients                                        Commenced.                                                                                    Review of job plans and
patients on G3 under the care of                                                           108     CL         MM                                                   increased                   Jun-10                   G                                                                                                  bed numbers
Consultant Cardiologist
2. Care of the Elderly Strategy to be       Implementation of the key priorities as                                      Presented at TEG                          Minuted
presented at TEG                            outlined within the strategy.                  109     CL          SS                                                                              Jul-10        Sep-10     A

3. Engage with NHS Suffolk and                                                                                           Requires Measure                                                                                    This is on-hold until after new
conduct a review of tariff for                                                                     Exec                                                                                                                      contract negotiations have been
ambulatory care pathways                                                                   110                                                                                                              ON-HOLD     R    completed in late summer.
                                                                                                   Team

4. Ensure Consultant availability to                                                                                     Available as POD, free from               On-call Consultants
provide advice and guidance in                                                                                           commitments                               available
                                                                                           111     DO'R        CL                                                                              Jun-10                   G
management of patients to GPs

                                       KEY No action commenced
                                           Action commenced but not completed
                                           Action completed
                                           Trust Top Six




                                                                                                                                                                                             6 of 29
                January 10 Completions
Objective                             Action                                 Item   Lead   Supported by Measure                                   WSH Evidence           Initial Date   Revised Date     WSH      WSH Evidence   Interdependencies   Impact area
                                                                               #                                                                                                                       Evidence

1. Ensure A&E performance             Daily 'debrief' at 08:00 to identify                                Issues and action identified            Daily record sheet
monitoring addresses current issues   issues from previous day and            1     SL          AS                                                                         Jan-10                         G
                                      overnight
                                      Ensure escalation to specialist                                     50% reduction in non-A&E attributable   Notes of weekly
                                      consultants as per protocol             8     AS          SL        breaches                                performance meeting      Jan-10                         G

6. TTOs to be available when the      Turnaround time Prescription                                        100% compliance, baseline & trajectory Monthly report from
patient is ready for discharge        submitted on EPRO to dispensing        78     SW     Pharmacy Staff                                         Pharmacy, compliance     Jan-10                         G
                                      <2 hours                                                                                                    with trajectory
                                      Review data and agree targets at                                    Improvement against target/trajectories Notes of meeting
                                      Directorate Performance Meetings       99     COO        GM'S                                                                        Jan-10                         G




                                                                                                                                             7 of 29
Updates   Review process
July

Request   Are issues summarised and
          reviewed? Any specific
          changes as a result
Request


Request




                                      8 of 29
                  March 10 Completions

Objective                               Action                                Item   Lead   Supported by Measure                                      WSH Evidence            Initial Date                  WSH        WSH Evidence           Interdependencies   Impact area   Updates         Review process
                                                                                #                                                                                                            Revised Date   Evidence                                                            July
                                        Nurses, Care Co-ordinators and                                           100% patients have EDD within 24     Report to Discharge                                                                                         Flow          Request         What is current position?
                                        AHPs to update information on                                            hours of admission                   Implementation Group
                                                                              68     COO    All clinical staff                                                                  Mar-10                          G
                                        LOSPT as they become aware of                                                                                 meeting
                                        changes
                                        Service Manager, in conjunction                                          100% patients have EDD within 24     Report to Discharge
                                        with Ward Managers to identify                                           hours of admission                   Implementation Group
                                                                                              SM's/Ward
                                        named individual responsible for      69     COO                                                              meeting                   Mar-10                          G
                                                                                              Managers
                                        data input to LOSPT (including
                                        cover for absence)
                                        Matrons and Ward Managers to                                      List of staff with training status          List
                                        identify individuals who need                       Matrons/ Ward identified
                                                                              70     COO                                                                                        Mar-10                          G
                                        training to enter data onto LOSPT                     Managers
                                        and EPRO
                                        IT to provide system training to                                         List of staff with training status   List                                                             Trainer and trainees                       Flow          Request         What is current position?
                                        identified staff                                                         identified                                                                                            identified awaiting
                                                                              71     NM       IT trainers                                                                       Mar-10         Sep-10           A
                                                                                                                                                                                                                       dates. JH to check
                                                                                                                                                                                                                       on this.
                                        Audit of patients due to be                                              80% compliance with PDD              Report to Discharge                                              Performance                                Flow          Request         What is current position?
                                        discharged within 48 hours and                                                                                Implementation Group                                             improving but not at
                                        actual date of discharge                             Governance/                                              meeting                                                          80% compliance yet.
                                                                              75     JH      Information                                                                        Mar-10                          A      DOG Advises to
                                                                                                Team                                                                                                                   remove from Action
                                                                                                                                                                                                                       Plan. GN to discuss
                                                                                                                                                                                                                       with JH.
7. Ensure escalation of delays in the   Produce escalation pathway for                                           Pathway published                    Pathway
discharge process                       all delays and identify key roles &   81     LS            LB                                                                           Mar-10                          G
                                        responsibilities
8. Reduce delayed transfers of care     Provide twice weekly reports on                                          Report produced                      Report                                                                                                      Flow          Internal - in
                                                                                            Disch Liaison
(DTOCs)                                 number of DTOCs, in WSH, by           82     SJ                                                                                         Mar-10                          G                                                               UC TG?
                                                                                                Team
                                        type
                                        Ensure Exec Lead for discharge is                                        Circulation list                     Email chain
                                                                              85     JC            ND                                                                           Mar-10                          G
                                        fully informed of DTOCs
                                        Update Direction of Choice Policy                                        Revised version published (version   Reduction in delays
                                                                              86     LS            All                                                                          Mar-10                          G
                                                                                                                 number x)




                                                                                                                                                                    9 of 29
                    April 10 Completions

Objective                                  Action                                Item   Lead   Supported by Measure                                      WSH Evidence             Initial Date   Revised Date     WSH      WSH Evidence             Interdependencies   Impact area
                                                                                   #                                                                                                                            Evidence
                                           Review effectiveness of Triage                                      Reduction to zero minor breaches          Evaluation report of                                              SL to provide                                A&E Performance
                                                                                  9     SL          JC                                                                              Apr-10                         G
                                           system                                                                                                        pilot                                                             evidence of reports.
2. Review functions of EAU &               Change of EAU model                                                 Model agreed and implementation plan      TEG presentation                                                                                               EAU Flow
                                                                                 30     CL          JC                                                                              Apr-10                         G
Physicians                                                                                                     in place
1. Ensure daily review of all adult non-   Identify Consultant or SpR rounds                                   Published schedule by ward. Board         EPRO report links into                                            Reported monthly on                          Flow
elective inpatients                        with agreed schedule by ward          55     DOR        CD's        ward round report                         schedule. Board ward       Apr-10                         G       scorecard.
                                                                                                                                                         round report
                                           Daily review undertaken by each                                     100% compliance with daily update         Board Round Report
                                                                                 56     CL        ND/GN                                                                             Apr-10                         G
                                           member of the MDT
                                           Junior doctors update 'medically                                    100% compliance with daily update         LOSPT                                                                                                          Flow
                                           fit' status (on ward/board rounds)                      Lead
                                                                                 57     CL                                                                                          Apr-10                         G
                                           and EDD on EPRO patient list                         Consultants
                                           daily
                                           Record of daily review retained                                     100% compliance with daily update         Report to Discharge                                               Still embedding,                             Flow
                                                                                                                                                         Implementation Group                                              record of daily review
                                                                                 59     LB        Matrons                                                                           Apr-10         Sep-10          A
                                                                                                                                                         meeting                                                           not being collected.

2. All patients have a clear plan of care Monthly record audits to be carried                                  20% of total inpatients on each ward,     Report to Discharge                                               Record of audits are                         Flow
that is up to date, reflects current      out to check that care plans are       60     JH        Matrons      100% of records checked have clear        Implementation Group       Apr-10                         G       on the scorecard,
position and correlates with the EDD      present and clear, and are                                           action plan                               meeting                                                           process is imbedded
                                          Results of audits to be given to                                     100% of records checked have clear        Report to Discharge                                               Feedback to staff                            Flow
                                          medical teams and areas for                                          action plan                               Implementation Group                                              given; still requires
                                                                                 61     CL         CD's                                                                             Apr-10         Sep-10          A
                                          improvement identified                                                                                         meeting                                                           improved
                                                                                                                                                                                                                           compliance.
                                           Identify teams where improvement                                    100% of records checked have clear        Report to Discharge                                                                                            Flow
                                           is not taking place and agree                                       action plan                               Implementation Group
                                                                                 63     DOR        CD's                                                                             Apr-10         Sep-10          A
                                           action needed with individual                                                                                 meeting
                                           Consultants
4. Ensure LOSPT accurately reflects        Ward Manager accountable for                                        100% patients have EDD within 24          Report to Discharge                                                                                            Flow
patient status and PDD                     ensuring information from                                           hours of admission                        Implementation Group
                                                                                 67     COO    Ward Manager                                                                         Apr-10                         G
                                           ward/board round is updated in                                                                                meeting
                                           LOSPT
                                           Weekly snapshot audit of all wards                                  100% compliance                           LOSPT
                                           to ensure LOSPT reflects patient      72     LB     SM's/ Matrons                                                                        Apr-10                         G
                                           PDD
                                           Escalation of non-compliance to                                     Escalation records                        Report to Discharge                                               Requires improved
                                                                                                 Service
                                           Directors (DOR/ND/NK)                                                                                         Implementation Group                                              consistency.
                                                                                 73     JC      Managers/                                                                           Apr-10         Sep-10          G
                                                                                                                                                         meeting                                                           Changed to Green 11
                                                                                                 Matrons
                                                                                                                                                                                                                           Aug.
5. Utilise LOSPT information for      Review number of medically fit                                           Bed status report                         Report to Discharge                                               Requires embedding
                                                                                               SMOC/Bed
proactive decision making and improve patients and definite discharges at                                                                                Implementation Group                                              and improved
                                                                                 74     JC     Management                                                                           Apr-10         Sep-10          A
awareness of 'medically fit' patients 09:30 bed meeting                                                                                                  meeting                                                           compliance.
                                                                                                  Team
                                           Increase proportion of patients for                                40% or more TTOs in pharmacy by            Monthly report from                                               Performance                                  Flow/13:00 disch
                                           discharge to 40% having TTO                         CD's/Cons/Car 11am                                        Pharmacy included in                                              improving but not at
                                                                                 79     CL                                                                                          Apr-10          Oct-10         R
                                           request in pharmacy by 11am                         e Coordinators                                            the Trust Monthly                                                 40% compliance yet.
                                                                                                                                                         Performance Report.
10. Improve weekend discharges             Medical teams to identify, on                                       Increased number of weekend               PAS report
                                           handover lists, patients who                                        discharges
                                                                                               Consultants/W
                                           require senior review over            89     CL                                                                                          Apr-10                         G
                                                                                               ard Managers
                                           weekend with a view to discharge

                                           Lists to be held on ward & in EAU                                   Folders in place                          Folder
                                                                                 90     CL          SL                                                                              Apr-10                         G
                                           Provide data at individual                                          * Reduction in LoS by 0.5 days            Monthly reports                                                   Problem with server                          Flow/13:00 disch
                                           consultant level to consultants and                                 * 40% TTOs in pharmacy by 11am                                                                              retrieval of TTO data.
                                           managers, to include                                                * Increased percentage of patients                                                                          Changed to Green 11
                                           * Length of stay - monthly 13 week                                  discharged by 1pm                                                                                           Aug.
                                           rolling average, plotted against
                                           Trust & National average and
                                           National top quartile                 96     DOR         KR                                                                              Apr-10         Aug-10          G
                                           * TTO's in pharmacy by 11am -
                                           monthly rolling 13 week average,
                                           plotted against Trust average
                                           * Discharges by 1pm monthly
                                           rolling 13 week average, plotted
                                           against Trust average
                                           Review data & agree actions at                                      Improvement against target/trajectories   Specialty meeting                                                 Requires improved                            Flow/13:00 disch
                                           Speciality Meetings                                                                                           notes                                                             consistency and
                                                                                 97     JC         SM's                                                                             Apr-10         Aug-10          G
                                                                                                                                                                                                                           embedding. Changed
                                                                                                                                                                                                                           to Green 11 Aug.



                                                                                                                                              10 of 28
                     May 10 Completions

Objective                                 Action                                 Item   Lead   Supported by Measure                                      WSH Evidence              Initial Date     Revised Date        WSH      WSH Evidence             Interdependencies   Impact area
                                                                                   #                                                                                                                                  Evidence
                                          Increase A&E Board rounds to 4                                      Actions identified during rounds and       Shift Co-ordinators Log
                                                                                  4     SL          AS                                                                               May-10                              G
                                          hourly - from end of April 10                                       implemented dynamically
                                          Initial assessment of care needs                                    Captured on A&E Card                       Audit, performance                                                                                                   A&E Performance
                                                                                 11     AS          SL                                                                               May-10            Sep-10            A
                                          within 15 minutes of arrival                                                                                   monitoring
                                          Initial assessment & ordering of                                    Captured on PAS & CRIS                     PAS reports                                                                                                          A&E Performance
                                          diagnostics by doctor within 1 hour    12     AS          SL                                                                               May-10            Sep-10            A

                                          Review by senior decision maker                                     Captured on PAS                            PAS reports                                                                                                          A&E Performance
                                          within 2 hours - completion of         13     AS          SL                                                                               May-10            Sep-10            A
                                          management plan & pathway
                                          Speciality response no greater                                      Captured on A&E Card                       Audit                                                                                                                A&E Performance
                                          than 30 minutes from referral time     14     AS         CD's                                                                              May-10           On-going           G

                                          Turnaround time for diagnostics                                     Captured on CRIS                           CRIS report                                                                                                          A&E Performance
                                                                                 15     AS         SM's                                                                              May-10            Sep-10            A
                                          <30 minutes
                                          Revision of internal escalation                                     Revised process published                  Version control                                                                                                      A&E Performance
                                          processes as a result of trend         16     AS          SL                                                                               May-10            Sep-10            A
                                          identification - current version 1.2
4. Recruit 2 Consultants                  Job description, advert, interview,                                 Full substantive establishment - locums Start date or current                                                      1 Consultant                                 A&E Performance
                                          appoint                                               AS/HR/Med     in place if not successful              position identifiable                                                      appointed awaiting
                                                                                 18     CL                                                                                           May-10            Aug-10            A
                                                                                                 Staffing                                                                                                                        the re-advertisement
                                                                                                                                                                                                                                 of 2nd post.
                                          Care plans for frequent attenders,                                  Care plans available                       Held on file                                                                                                         A&E Performance
                                          known to SMHPT, available in           21     SL        AS/CH                                                                              May-10       Requires new date      A
                                          A&E
7. Ensure appropriate use of space in     Option appraisal of re-providing                                    Option appraisal paper                     Presented to                                                            Pilot started 19-Apr.
A&E                                       waiting area for minors stream         23     SL          AS                                                   Directorate                 May-10       Requires new date      A
                                                                                                                                                         Performance meeting
1. Improve flow of arrivals to EAU        Pilot 'appointment time' with                                       Improved turnaround times to 70%           Submit button reports                                                   Reported at                                  EAU Flow
                                                                                               Simon Chase/
                                          EEAST and Primary Care for GP                                       within 15 mins. 95% within 30 mins                                                                                 Performance meeting
                                                                                               Marcus Bailey/
                                          expected patients transported via      27     JC                                                                                           May-10       Requires new date      A       - performance
                                                                                               Primary Care
                                          ambulance                                                                                                                                                                              improving.
                                                                                                   lead
3. Develop ambulatory care pathways       Work with PBC and LMC to                                            Appropriate pathways identified and        Presented to Urgent                                                     Emma Derbyshire                              EAU Flow
                                          develop & implement care               37     CL          JC        programme developed                        Care Group                  May-10            Aug-11            A       identified as lead for
                                          pathways for common conditions                                                                                                                                                         WSCF.
5. Implement short stay beds              Identify demand & capacity                             JC/SM's/     Report to Urgent Care meeting              Notes of meeting                                                        COMPLETE, 2 Bays                             EAU Flow
                                                                                 48     CL                                                                                           May-10                              G
                                          requirements                                          Consultants                                                                                                                      on G5.
6. Ensure all patients have EDD within    Provisional diagnosis to be                                         100% patients have EDD within 12           PAS report                                                              Technical issue with                         Flow
12 hours                                  updated onto PAS to generate                                        hours of admission                                                                                                 EPRO being
                                          EDD                                                                                                                                                                                    resolved. LB to
                                                                                 51     JY        CB/CH                                                                              May-10            Sep-10            A
                                                                                                                                                                                                                                 attend Emergency
                                                                                                                                                                                                                                 Med and Surgery
                                                                                                                                                                                                                                 meetings.
3. Improve referral to and response for   Review role and function of                                         Revision of role & function                Published
                                                                                 65     ND         CL/LS                                                                             May-10            Sep-10            A
Psychogeriatric assessment                Complex Care Team
                                          Implement revised process for                                       Revision of process                        Published
                                          Consultant Psychogeriatric referral    66     JC         CL/LS                                                                             May-10            Sep-10            A
                                          & assessment
9. Identify need for and implement if     Scope the need for discharge                                        Pathway published                          Pathway                                                                 Placed on-hold                               EAU Flow
necessary - Discharge Lounge              lounge - including demand &                                                                                                                                                            26/07/10.
                                                                                 87     JC          LS                                                                               May-10           ON-HOLD            R
                                          capacity in the context of
                                          escalation requirements
                                          Identify suitable area & staffing                                   Area & staffing identified                 Published                                                               Placed on-hold                               EAU Flow
                                                                                 88     JC          LS                                                                               May-10           ON-HOLD            R
                                                                                                                                                                                                                                 26/07/10.




                                                                                                                                              11 of 29
                    June 10 Completions

Objective                            Action                               Item    Lead      Supported by Measure                                   WSH Evidence         Initial Date   Revised Date     WSH      WSH Evidence          Interdependencies   Impact area
                                                                            #                                                                                                                         Evidence
3. Introduce internal professional   Clarify the role of the POD and
standards, aligned with internal     circulate to those on the POD rota   10       CL                                                                                     Jun-10                         G
escalation
                                     External audit of compliance with                                    Compliance                               Report                                                        Awaiting                                  Systemic
                                     escalation processes                        Internal                                                                                                                        implementation of
                                                                          17                                                                                              Jun-10         Dec-10          A
                                                                                  Audit                                                                                                                          revised escalation
                                                                                                                                                                                                                 policy.
5. Implement Rapid Assessment &      Scope additional resource                                            Scoping paper                            Presented to                                                  Martin Hunt leading                       Systemic
Treatment (RAT) Model of care        requirements                                                                                                  Directorate                                                   LEAN event in Sept.
                                                                          19       AS           SL                                                                        Jun-10          Oct-10         R
                                                                                                                                                   Performance
                                                                                                                                                   Management Meeting
                                     Identify appropriate clinical area                      JC/SM's/     Ward identified                          Notes of meeting                                                                                        Systemic
                                                                          49       CL                                                                                     Jun-10         Sep-10          G
                                                                                            Consultants
                                     Review of EDD being completed                                        Patients have EDD within 24hrs of        Performance Report                                            RT to make changes                        Systemic
                                     on LOS Tracker and that all                              CD's/       admission                                                                                              to LOSPT.
                                                                          64      DOR                                                                                     Jun-10         Sep-10          A
                                     patients have EDD within 24hrs of                      Consultants
                                     admission
                                     SHO and Registrar to review                                          Increased number of weekend              PAS report &                                                  Requires embedding                        Systemic
                                     patients as per list during am/pm                                    discharges                               documentation                                                 and improved
                                                                          91       SL           JC                                                                        Jun-10         Aug-10          A
                                     handovers                                                                                                                                                                   compliance from
                                                                                                                                                                                                                 Medical Teams.
1. Performance Management &          Reduction in LoS by 0.5 days for                                     Reduction in LoS from Jan 2010           Monthly reports                                                                                         Systemic
                                                                          95      DOR           CL                                                                        Jun-10                         G
Improvement                          all physicians                                                       baseline




                                                                                                                                        12 of 29
                    July 10 Completions

Objective                          Action                               Item   Lead   Supported by Measure                                   WSH Evidence          Initial Date   Revised Date     WSH      WSH Evidence           Interdependencies   Impact area
                                                                          #                                                                                                                      Evidence
                                   Scope need for A&E Observation                                   Scoping paper                            Presented to                                                                                              Systemic
                                   area                                 24     SL         AS                                                 Directorate             Jul-10        ON-HOLD          R
                                                                                                                                             Performance meeting
                                   Option appraisal for A&E                                         Option appraisal paper                   Presented to                                                                                              Systemic
                                   Observation area if scoping          25     SL         AS                                                 Directorate             Jul-10        ON-HOLD          R
                                   exercise identifies need                                                                                  Performance meeting
                                   Conduct a review as to how GP                                                                                                                                            Will be addressed by
                                   EAU referrals are                                                                                                                                                        Urgent Care
                                   accepted/redirected to alternative   28     JC         CL                                                                         Jul-10          Oct-10         A       Transformation
                                   routes for accessing care                                                                                                                                                Project - ? Resource
                                                                                                                                                                                                            Hub.
                                                                                                    Model agreed and implementation plan     Business Case - TEG                                            Business Case                              Systemic/EAU
                                                                                                    in place                                                                                                agreed Aug.                                flow
                                                                        31     CL         JC                                                                         Jul-10         Aug-10          G


                                                                                                    Increase in ward/board rounds identified Revised job plans                                                                                         EAU Flow
                                                                        33     CL         JC                                                                         Jul-10         Sep-10          A
                                                                                                    in each plan
                                   Work with clinicians (including                                  Individual patient care plan             Copy                                                           Individual patient                         EAU Flow
                                   Primary Care) to develop and                                                                                                                                             pathways changed -
                                                                        53     CL        JY/SL                                                                       Jul-10          Oct-11         A
                                   implement care plan                                                                                                                                                      MTU rather than
                                                                                                                                                                                                            EAU.
                                   Development of process for
                                   making patients/relatives/carers     62     D'OR       GN                                                                         Jul-10         Sep-10          A
                                   aware of EDD
6. TTOs to be available when the   TTOs to be submitted on EPRO                                     100% compliance                          Monthly report from                                            CL to conduct audit.                       13:00 discharge
patient is ready for discharge     within 2 hours of decision to        77     CL     Consultants                                            EPRO                    Jul-10          Oct-10         R
                                   discharge




                                                                                                                                  13 of 29
            Daily Completions

Objective             Action                                 Item   Lead   Supported by
                                                               #
                      Daily validation of breaches
                                                              2     SL        AS/JC

                      Thrice daily board rounds in A&E
                                                              3     SL         AS
                      Feedback of specialty breaches -
                      those referred to specialists within    6     SL      AS/CL/JC
                      2 hours of arrival in A&E
                      Escalate to COO SMHPT any
                                                             22     JC        COO
                      delays
                      Timely declaration of EAU beds to
                                                             29     SL         CB
                      A&E
Measure                                  WSH Evidence              Initial Date   Revised Date


Standard Operating Procedure dictates    Info team records &
that validation must have occurred       A&E Daily Summary            Daily
before production of evidence
Actions identified during rounds and     Shift Co-ordinators Log
                                                                      Daily
implemented dynamically
Daily record sheet sent to specialties   Daily record sheet to &
appropriately                            response from                Daily
                                         speciality
Email evidence of escalation             Email & response on
                                                                      Daily
                                         file
Identified on traffic lights             Report from T/L
                                                                      Daily
  WSH      WSH Evidence   Interdependencies   Impact area   Updates
Evidence                                                    July


   G


   G


   G


   G

   G
Review process
                   Weekly Completions

Objective                           Action                                 Item   Lead   Supported by
                                                                             #
                                    Weekly monitoring of performance
                                    and identification of breach trends.
                                                                            5     SL        AS/JC
                                    PCT attend alternate weeks

2. Address specific breach causes   Review specialist referral pathways
                                                                            7     AS         SL
                                    to reduce delays
Measure                                  WSH Evidence          Initial Date   Revised Date


Follow up of previous actions. Changes   Notes of meeting
in position noted. Further action
                                                                 Weekly
identified

50% reduction in delays of patients in   Notes of weekly
                                                                 Weekly
specialist pathways i.e.. T&O, Gynae     performance meeting
  WSH      WSH Evidence   Interdependencies   Impact area   Updates
Evidence                                                    July


   G


   G
Review process
                   Monthly Completions

Objective                              Action                          Item   Lead   Supported by
                                                                         #
6. Improve Mental Health services to   Improve response times from
WSH                                    SMHPT. Agree baseline for
                                       response times & incremental    20     JC         SL
                                       improvement. Analysis breach
                                       causes
1. Provide assurance on progress       Medical Directorate monthly
                                       performance meetings & Trust-   101    COO       GM'S
                                       wide Urgent Care meetings
Measure                               WSH Evidence           Initial Date   Revised Date


Improved response time to <2 hours for Achievement of plan
assessment
                                                              Monthly


Agenda Item                           Notes of meeting
                                                              Monthly
  WSH      WSH Evidence   Interdependencies   Impact area   Updates
Evidence                                                    July



   G



   G
Review process
                Post-July 10 Completions

Objective                                Action                                 Item    Lead      Supported by Measure                                    WSH Evidence              Initial Date     Revised Date     WSH      WSH Evidence             Interdependencies   Impact area
                                                                                  #                                                                                                                                 Evidence
                                         Initial assessment of care needs                                                                                 Audit, performance
                                                                                11       AS           SL                                                                              May-10           Sep-10          A
                                         within 15 minutes of arrival                                           Captured on A&E Card                      monitoring                                                                                                        A&E Performance

                                         Initial assessment & ordering of       12       AS           SL                                                                              May-10           Sep-10          A
                                         diagnostics by doctor within 1 hour                                    Captured on PAS & CRIS                    PAS reports                                                                                                       A&E Performance
                                         Review by senior decision maker
                                         within 2 hours - completion of         13       AS           SL                                                                              May-10           Sep-10          A
                                         management plan & pathway                                              Captured on PAS                           PAS reports                                                                                                       A&E Performance
                                         Turnaround time for diagnostics
                                                                                15       AS          SM's                                                                             May-10           Sep-10          A
                                         <30 minutes                                                            Captured on CRIS                          CRIS report                                                                                                       A&E Performance
                                         Revision of internal escalation
                                         processes as a result of trend         16       AS           SL                                                                              May-10           Sep-10          A
                                         identification - current version 1.2                                   Revised process published                 Version control                                                                                                   A&E Performance
                                                                                                                                                                                                                               Awaiting
                                                                                       Internal                                                                                                                                implementation of
                                                                                17                                                                                                    Jun-10           Dec-10          A
                                         External audit of compliance with              Audit                                                                                                                                  revised escalation
                                         escalation processes                                                   Compliance                                Report                                                               policy.                                      Systemic
                                                                                                                                                                                                                               1 Consultant
                                                                                                  AS/HR/Med                                                                                                                    appointed awaiting
                                                                                18       CL                                                                                           May-10           Dec-10          A
                                         Job description, advert, interview,                       Staffing     Full substantive establishment - locums Start date or current                                                  the re-advertisement
4. Recruit 2 Consultants                 appoint                                                                in place if not successful              position identifiable                                                  of 2nd post.                                 A&E Performance
                                                                                                                                                        Presented to
                                                                                                                                                        Directorate
                                                                                19       AS           SL                                                                              Jun-10            Oct-10         R
5. Implement Rapid Assessment &          Scope additional resource                                                                                      Performance                                                            Martin Hunt leading
Treatment (RAT) Model of care            requirements                                                           Scoping paper                           Management Meeting                                                     LEAN event in Sept.                          Systemic
                                                                                                                                                                                                                               Will be addressed by
                                         Conduct a review as to how GP                                                                                                                                                         Urgent Care
                                         EAU referrals are                      28       JC           CL                                                                              Jul-10            Oct-10         A       Transformation
                                         accepted/redirected to alternative                                                                                                                                                    Project - ? Resource
                                         routes for accessing care                                                                                                                                                             Hub.
                                                                                                                Model agreed and implementation plan                                                                           Business Case                                Systemic/EAU
                                                                                31       CL           JC                                                                              Jul-10           Aug-10          G
                                                                                                                in place                                  Business Case - TEG                                                  agreed Aug.                                  flow
                                         Conduct a review of the overnight
                                                                                                                                                                                    3-mth from
                                         'On-Call Take' to determine if a
                                                                                                                                                                                 completion of EAU
                                         Unified Medical take would be          34       CL                                                                                                            Apr-11          R
                                                                                                                                                                                    Consultant
                                         appropriate - links to EAU
                                                                                                                                                                                   development
                                         Consultant development
                                                                                                                Increase in ward/board rounds identified
                                                                                33       CL           JC                                                                              Jul-10           Sep-10          A
                                         #REF!                                                                  in each plan                             Revised job plans                                                                                                  EAU Flow
                                         Work with PBC and LMC to                                                                                                                                                              Emma Derbyshire
                                         develop & implement care               37       CL           JC        Appropriate pathways identified and       Presented to Urgent         May-10           Aug-11          A       identified as lead for
3. Develop ambulatory care pathways      pathways for common conditions                                         programme developed                       Care Group                                                           WSCF.                                        EAU Flow
                                                                                                                                                                                                                               Proposal being put to
                                                                                                   JC/SM's/                                                                                                                    the Emergency
                                                                                49       CL                                                                                           Jun-10           Sep-10          G
                                                                                                  Consultants                                                                                                                  Medicine meeting -
                                         Identify appropriate clinical area                                     Ward identified                           Notes of meeting                                                     August.                                      Systemic
                                                                                                                                                                                                                               Technical issue with
                                                                                                                                                                                                                               EPRO being
                                                                                                                                                                                                                               resolved. LB to
                                                                                51       JY         CB/CH                                                                             May-10           Sep-10          A
                                         Provisional diagnosis to be                                                                                                                                                           attend Emergency
6. Ensure all patients have EDD within   updated onto PAS to generate                                           100% patients have EDD within 12                                                                               Med and Surgery
12 hours                                 EDD                                                                    hours of admission                        PAS report                                                           meetings.                                    Flow
                                                                                                                                                                                                                               Individual patient
                                         Work with clinicians (including                                                                                                                                                       pathways changed -
                                                                                53       CL          JY/SL                                                                            Jul-10            Oct-11         A
                                         Primary Care) to develop and                                                                                                                                                          MTU rather than
                                         implement care plan                                                    Individual patient care plan              Copy                                                                 EAU.                                         EAU Flow

                                                                                                                                                          Report to Discharge                                                  Still embedding,
                                                                                59       LB         Matrons                                                                           Apr-10           Sep-10          A
                                                                                                                                                          Implementation Group                                                 record of daily review
                                         Record of daily review retained                                        100% compliance with daily update         meeting                                                              not being collected.                         Flow
                                                                                                                                                                                                                               Feedback to staff
                                         Results of audits to be given to                                                                                 Report to Discharge                                                  given; still requires
                                                                                61       CL          CD's                                                                             Apr-10           Sep-10          A
                                         medical teams and areas for                                            100% of records checked have clear        Implementation Group                                                 improved
                                         improvement identified                                                 action plan                               meeting                                                              compliance.                                  Flow
                                                                                                                                                                                                                               Process being
                                                                                                                                                                                                                               reviewed through the
                                         Development of process for             62      D'OR          GN                                                                              Jul-10           Sep-10          A       DOG, will agree
                                         making patients/relatives/carers                                                                                                                                                      measures at later
                                         aware of EDD                                                                                                                                                                          date.
                                         Identify teams where improvement
                                         is not taking place and agree                                                                                    Report to Discharge
                                                                                63      DOR          CD's                                                                             Apr-10           Sep-10          A
                                         action needed with individual                                          100% of records checked have clear        Implementation Group
                                         Consultants                                                            action plan                               meeting                                                                                                           Flow
                                                                                                                                               26 of 29
Objective                                 Action                                Item   Lead   Supported by Measure                                          WSH Evidence           Initial Date   Revised Date     WSH      WSH Evidence             Interdependencies   Impact area
                                                                                  #                                                                                                                              Evidence
                                          Review of EDD being completed
                                          on LOS Tracker and that all                            CD's/
                                                                                64     DOR                                                                                           Jun-10         Sep-10          A
                                          patients have EDD within 24hrs of                    Consultants    Patients have EDD within 24hrs of                                                                             RT to make changes
                                          admission                                                           admission                                     Performance Report                                              to LOSPT.                                    Systemic
3. Improve referral to and response for   Review role and function of
                                                                                65     ND         CL/LS                                                                              May-10         Sep-10          A
Psychogeriatric assessment                Complex Care Team                                                   Revision of role & function                   Published
                                          Implement revised process for
                                          Consultant Psychogeriatric referral   66     JC         CL/LS                                                                              May-10         Sep-10          A
                                          & assessment                                                        Revision of process                           Published
                                                                                                                                                                                                                            Trainer and trainees
                                                                                                                                                                                                                            identified awaiting
                                                                                71     NM       IT trainers                                                                          Mar-10         Sep-10          A
                                          IT to provide system training to                                                                                                                                                  dates. JH to check
                                          identified staff                                                    List of staff with training status identified List                                                            on this.                                     Flow
                                                                                                                                                                                                                            Requires improved
                                                                                                 Service
                                                                                                                                                            Report to Discharge                                             consistency.
                                                                                73     JC       Managers/                                                                            Apr-10         Sep-10          G
                                          Escalation of non-compliance to                                                                                   Implementation Group                                            Changed to Green 11
                                                                                                 Matrons
                                          Directors (DOR/ND/NK)                                               Escalation records                            meeting                                                         Aug.

5. Utilise LOSPT information for                                                               SMOC/Bed
                                      Review number of medically fit                                                                                        Report to Discharge                                             Requires embedding
                                                                                74     JC      Management                                                                            Apr-10         Sep-10          A
proactive decision making and improve patients and definite discharges at                                                                                   Implementation Group                                            and improved
                                                                                                  Team
awareness of 'medically fit' patients 09:30 bed meeting                                                       Bed status report                             meeting                                                         compliance.
                                      TTOs to be submitted on EPRO
6. TTOs to be available when the      within 2 hours of decision to             77     CL      Consultants                                          Monthly report from              Jul-10         Aug-10          R
patient is ready for discharge        discharge                                                               100% compliance                       EPRO                                                                    CL to conduct audit.                         13:00 discharge
6. TTOs to be available when the      Turnaround time Prescription                                                                                  Monthly report from
patient is ready for discharge        submitted on EPRO to dispensing           78     SW     Pharmacy Staff                                        Pharmacy, compliance             Jan-10          Oct-10         G
                                      <2 hours                                                               100% compliance, baseline & trajectory with trajectory
                                      Highlight need for medical teams
                                      to prioritise the writing of TTOs in a    80     CL         CD's                                                      Notes of relevant       On-going         Oct-10         G
                                      timely fashion                                                          100% compliance                               physicians meetings
                                                                                                                                                                                                                            Requires embedding
                                          SHO and Registrar to review                                                                                                                                                       and improved
                                                                                91     SL          JC                                                                                Jun-10         Aug-10          A
                                          patients as per list during am/pm                                   Increased number of weekend                   PAS report &                                                    compliance from
                                          handovers                                                           discharges                                    documentation                                                   Medical Teams.                               Systemic

12. Update internal escalation plan to                                          93     AC          SL                                                                                               Aug-10          A
include protocols for patient transfers
                                          Provide data at individual
                                          consultant level to consultants and
                                          managers, to include
                                          * Length of stay - monthly 13 week
                                          rolling average, plotted against
                                          Trust & National average and
                                          National top quartile                 96     DOR         KR                                                                                Apr-10         Aug-10          G
                                          * TTO's in pharmacy by 11am -
                                          monthly rolling 13 week average,
                                          plotted against Trust average                                       * Reduction in LoS by 0.5 days                                                                                Problem with server
                                          * Discharges by 1pm monthly                                         * 40% TTOs in pharmacy by 11am                                                                                retrieval of TTO data.
                                          rolling 13 week average, plotted                                    * Increased percentage of patients                                                                            Changed to Green 11
                                          against Trust average                                               discharged by 1pm                             Monthly reports                                                 Aug.                                         Flow/13:00 disch

                                                                                                                                                                                                                            Requires improved
                                                                                97     JC         SM's                                                                               Apr-10         Aug-10          G       consistency and
                                          Review data & agree actions at                                                                                    Specialty meeting                                               embedding. Changed
                                          Speciality Meetings                                                 Improvement against target/trajectories       notes                                                           to Green 11 Aug.                             Flow/13:00 disch
                                          Review data and agree
                                          actions/targets for discharge                         SM's/Ward                                                                                                                   Requires improved
                                                                                98     JC                                                                                            Apr-10          Oct-10         A
                                          performance column during ward                        Managers                                                                                                                    consistency and
                                          meetings                                                            Improvement against target/trajectories       Notes of meeting                                                embedding.                                   Flow/13:00 disch




                                                                                                                                                27 of 29
            On-going Completions

Objective               Action                                   Item   Lead   Supported by Measure                     WSH Evidence          Initial Date   Revised Date     WSH      WSH Evidence   Interdependencies   Impact area
                                                                   #                                                                                                        Evidence
                        Highlight need for medical teams                                   100% compliance              Notes of relevant
                        to prioritise the writing of TTOs in a   80     CL        CD's                                  physicians meetings    On-going                        G
                        timely fashion




                                                                                                             28 of 29

				
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Description: Management Escalation Plan document sample