1 Action Plan Arising from RCPCH Evaluation Recommendation Actions to be taken Timeline Responsible Person Monitoring Progress / Current Status Obstetric, Maternity and Gynaecology Services Strategy and Patient safety 1 Expedite the ‘Phase Two’ business case and commence development to provide a high quality environment for consultant-led maternity care and compliant facilities for neonates. Formally establish Phase 2 project and develop business case for Welsh Government consideration. Initial business case by Spring 2016 Chief Executive (as SRO of Phase 2 Project Group) BP&PAC Phase 2 Project Group established November 2015. Clinical User Groups and Project Team currently developing design specification for individual elements of project. 2 Develop a clear sustainable strategy for obstetric, midwifery Multi-disciplinary clinical group to September 2016 General Manager, W&C Directorate BP&PAC Multi-disciplinary clinical group
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1
Action Plan Arising from RCPCH Evaluation
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
Obstetric, Maternity and Gynaecology Services
Strategy and Patient safety
1 Expedite the ‘Phase Two’
business case and commence
development to provide a high
quality environment for
consultant-led maternity care and
compliant facilities for neonates.
Formally establish Phase 2 project and develop business case for Welsh Government consideration.
Initial business case by Spring 2016
Chief Executive (as SRO of Phase 2 Project Group)
BP&PAC Phase 2 Project Group established November 2015. Clinical User Groups and Project Team currently developing design specification for individual elements of project.
2 Develop a clear sustainable
strategy for obstetric, midwifery
Multi-disciplinary clinical group to
September 2016 General Manager, W&C Directorate
BP&PAC Multi-disciplinary clinical group
2
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
and gynaecology services,
prioritising patient safety, patient
access and quality of care,
building on and completing the
changes of services introduced in
August 2014. New ideas,
perhaps from a ‘task and finish’
innovation group can refresh the
team, harnessing external
support to examine new ways of
working with the support of the
local clinicians and women
be established involving consultant, midwifery and Gynaecology staff to develop strategy and prioritise innovation ideas and new practice. (Task & Finish groups to be agreed for specific projects).
established 6th January 2015.
3 Identify clinical line
management for the Directorate
to provide visible and robust
professional support, mentoring
and development to the clinical
leads for obstetrics and
paediatrics and the Head of
Midwifery. An independent
member at Board level should
have a remit of responsibility for
women's and children's issues
Acute Service operational structure to be reviewed. Independent Board member with lead responsibility as Children’s Champion to be confirmed
March 2016 In Place
Director of Operations Mr Mike Ponton
BP&PAC BP&PAC
Acute Service operational structure under current review. Proposals currently being developed. Achieved (Independent Board member identified as Children’s Champion)
4 Expand community based Plan for September 2016 General Manager, BP&PAC Multi-disciplinary
3
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
consultant and midwifery based
services at Withybush,
developing more comprehensive
EPU, EGU, day theatre, and
clinical community based
services there in line with RCOG
standards1
expansion of community based consultant and midwifery services to be developed by multi-disciplinary clinical group (referred to above).
W&C Directorate clinical group established 6th January 2015.
5 Retain provision of dedicated
transport facilities
Renew SLA for DAV for 2016/17
March 2016 Executive Director of Commissioning
BP&PAC Health Board agreement to retain DAV for 2016/17
6 Rationalise major in patient
gynaecological surgery onto one
site, if accommodation allows.
Clinical Task & Finish Group to be established (involving Directorate & GGH / WGH site representation) to undertake review of capacity and service implications
Review of capacity and service implications by June 2016
BP&PAC Clinical T&F Group to be established February 2016 to assess clinical and service implications.
7 Phase out the obstetric and Clinical Task & Finish Group to
Review of capacity and
Clinical Lead, O&G (via multi-disciplinary
BP&PAC Clinical T&F Group to be
1 2013 Good Practice 15 Reconfiguration of women’s services n the UK RCOG
4
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
gynaecology out of hours
consultant rota at Withybush with
a target date of April 2016,
integrating and strengthening the
obstetric and gynaecological
consultant team at Glangwili.
be established (involving Directorate & GGH / WGH site representation) to undertake review of capacity and service implications
service implications by June 2016
clinical group)
established February 2016 to assess clinical and service implications.
8 Review of the uptake of midwife
led care, and plan to expansion
of use by women who have been
appropriately risk assessed.
Unified patient pathways,
guidelines and clinical
governance structures must be
incorporated into all units within 6
months
Promote awareness of All Wales MLU guidelines amongst all midwifery staff. Monthly monitoring of MLU usage via Directorate. Establish database of all women who are suitable for MLU care and audit of outcome Review all supporting pathways,
March 2016 February 2016 March 2016 June 2016
Senior Midwife MLU / Community Senior Midwife MLU / Community Senior Midwife MLU / Community Senior Midwife MLU / Community
QSEAC Current MLU Utilisation Jan – Dec 2015 (22%)
5
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
guidelines and unit governance structures
9 Assurance to public of the safety
of birthing in MLU’s in line with
the All Wales Pathway for
Maternity Care; community
midwives should take a stronger
lead in this. A band 7 midwife
should be appointed to champion
a team to develop each of the
MLUs in terms of increased
usage, active birth supporters
and midwives competence and
confidence in supporting active,
non pharmacological birth.
Develop communication strategy to engage with women across Hywel Dda to promote MLU as a viable option for giving birth Responsibility of Band 7 Community midwives to be confirmed.
April 2016 March 2016
Senior Midwife MLU / Community Senior Midwife MLU / Community
BP&PAC Communication strategy to be developed by April 2016. Role and responsibilities of Community midwives to be confirmed by March 2016.
Staff Team and Leadership Development
10 Conduct medical staff job
planning to provide a unified safe
service which delivers
professional satisfaction to staff
Review and update all job plans
March 2016 General Manager W&C Directorate/Clinical Lead O&G
BP&PAC All job plans to be reviewed by March 2016
6
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
across both sites.
11 Develop a programme of
opportunities for midwifery
development that reflects the
aspirations of service
developments – these should be
achieved within a 12 month
period
To be progressed in parallel with multi-disciplinary clinical group and midwifery OD programme.
December 2016 Head of Midwifery BP&PAC Multi-disciplinary clinical group established 6th January 2015. Midwifery OD programme commenced December 2016.
12 In order to meet RCoA standards
and secure future allocation of
anaesthetic trainees further
additional sessions are needed
on the labour ward.
Anaesthetic workforce development plan to be produced in parallel with HB IMTP.
Workforce Development Plan by March 2016 (Implementation plan subject to IMTP)
Service Delivery Manager, Anaesthetics
BP&PAC Priority identified via IMTP / Clinical Strategy development sessions held 14/15th January 2016
13 The multi-disciplinary training
opportunities for doctors, nurses
and midwives are considerable
and need further development. A
training lead should be identified
to ensure training is carried out
across all groups including
simulation and skills/drills.
Multi-disciplinary clinical group to review current multi-disciplinary training plan to ensure availability of appropriate skills. Identify a training lead to coordinate training
June 2016 April 2016
Clinical lead O&G / Head of Midwifery Head of Midwifery
QSEAC Multi-disciplinary clinical group established 6th January 2015. Training lead to be confirmed
7
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
programme across multi-disciplinary team.
14 A programme of organisational
development should be
instigated to build team working
and a sense of ‘one service’;
across all staff groups from all
three sites including community.
This could be informed by the
Fundamentals of Care audit, and
include encouragement and time
to nurture potential future
medical leaders
Implement programme of Organisational development for clinical staff, commencing with midwifery teams before consideration of roll out to medical staff and neonatal / paediatric teams.
Commenced December 2015
Head of Midwifery QSEAC OD programme commenced.
Governance and Accountability
15 The new Band 7 maternity risk
manager should administer the
clinical governance programme
including three monthly reports
with action plans to the Trust
Board and clinical directorate
meetings
Confirm substantive appointment of interim Band 7 postholder within current resources
March 2016 General Manager QSEAC Quarterly reports to be considered via HB Q&S structure from March 2016
8
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
16 The maternity dashboard, should
be reviewed by the directorate
Quality and Safety Committee
quarterly for review and
appropriate action. Review of
compliance with the RCOG
Maternity Standards should be
undertaken immediately and
upon publication of the new
standards expected during 2016
Ensure implementation of new All Wales Maternity Network Dashboard and include as standing agenda item at Directorate Q&S meeting. Review compliance of new standards once published
January 2016 Once published
Head of Midwifery O&G Clinical Lead/General Manager W&C directorate
QSEAC
All Wales Maternity Dashboard report to be considered at W&C Directorate Q&S Committee in January 2016. Publication of new standards awaited.
17 Review of the midwifery
workforce establishment using
Birthrate Plus acuity tool should
be completed immediately and at
least every 2 years.
Confirm HOMS recommended Birthrate Plus assessment tool BR+ exercise to be conducted following confirmation of recommended tool.
March 2016 To commence upon confirmation of HOMS recommended assessment tool.
Head of Midwifery Head of Midwifery
QSEAC
Confirmation of recommended assessment tool awaited via HOMS. To commence upon confirmation of HOMS recommended assessment tool.
9
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
18 Quality Improvement projects
such as the Productive Ward,
Releasing Time to Care should
be used to involved all groups of
staff in the quality improvement
programme
Quality improvement projects to be prioritised by multi-disciplinary clinical group.
From February 2016.
Head of Midwifery QSEAC
Multi-disciplinary clinical group established 6th January 2015.
Public Engagement
19 The Maternity Service Liaison
Committee should be re instated
with membership drawn from
local recent service users.
Additionally the service should
seek out ways to engage with the
local families living in the three
counties.
Programme of MLSC meetings to be re-established. Women & Children’s Communication & Engagement Strategy to be developed.
April 2016 April 2016
Head of Midwifery Head of Communications & Engagement
QSEAC Programme of MLSC meetings to be confirmed. W&C Communications & Engagement Group established 14th December 2015.
20 A social media campaign should
promote positive birth
experiences / normal birth in
various media and establish a
user group to provide feedback
and advice on improving take-up
of the MLU
Women & Children’s Communication & Engagement Strategy to be developed.
May 2016 Head of Communications & Engagement
QSEAC W&C Communications & Engagement Group established 14th December 2015.
10
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
21 Ensure all staff in contact with
expectant parents are fluent in
the service arrangements,
choices available for women,
thresholds for transfer and
outcomes.
Refresher training /update on services to be provided to all midwives and Health Visitors
March 2016 Head of Midwifery BP&PAC W&C Communications & Engagement Group established 14th December 2015. Revised communications pack to be prepared.
22 Facilities for birth partners,
whose partner may not be in
established labour, to rest and
obtain a hot drink should be
available 24 /7 at Glangwili.
Establish an interim facility pending Phase 2 redevelopment.
March 2016
Senior Midwife Acute
QSEAC Interim facility identified (pending Phase 2 redevelopment). Minor refurbishment works being undertaken.
Neonatal Service
Strategic Planning and patient safety
23 Implement the ‘Phase 2’
developments to provide
adequate accommodation for
neonates and families.
Formally establish Phase 2 project and develop business case for Welsh Government
Initial business case by Spring 2016
Chief Executive (as SRO of Phase 2 Project Group)
BP&PAC Phase 2 Project Group established November 2015. Clinical User
11
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
consideration.
Groups and Project Team currently developing design specification for individual elements of project.
24 Gain commitment and support
from the Health Board and The
Wales Neonatal Network for a
strategic plan for neonatal care
towards designation of the unit
as an LNU.
Agree a joint development plan with the Wales Neonatal Network
Agreement of plan by May 2016
Clinical Lead, Children’s Services
QSEAC All Wales Neonatal Standards Compliance Report (as at Sept 2015) published Dec 2015. Wales Neonatal Network Annual Compliance Visit 8th January 2016 – report awaited. Further All Wales Neonatal Standards Compliance Report (as at Dec 2015) expected March 2016 – will inform joint
12
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
development plan.
25 Conduct a training needs
analysis amongst medical staff
for competencies pertinent to
operation as an LNU and a plan
to meet those needs
Training needs analysis to be undertaken as per Wales Neonatal Standards. Outcome to inform joint development plan with Neonatal Network as above
April 2016 May 2016
Neonatal Clinical Lead
QSEAC To commence February 2016.
26 With facilitated OD, continue to
develop team cohesion and a
sense of ‘one service’
Extend Organisational Development programme to Neonatal Service clinical staff, following initial phase with midwifery teams.
September 2016 Directorate Nurse QSEAC Neonatal Organisational Development programme to commence September 2016.
27 Include EMRTS procedures into
MLU protocols at WGH
MLU protocol to be revised to reflect EMERTS availability.
February 2016
Head of Midwifery
QSEAC
Policy currently being reviewed for operational approval via
13
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
Directorate Q&S Committee February 2016.
28 Strengthen and formalise clinical
meetings with Singleton,
reviewing all cases weekly and
documenting discussions and
actions
Programme of review meetings with Singleton NICU to be arranged.
Ensure availability of Wales Neonatal Network Guidelines via shared drive on the Neonatal Unit.
January 2016 Senior Nurse (Quality Assurance), Neonates
QSEAC Achieved (guidelines available via shared drive).
30 Review protocols and skills for
emergency out of hours
stabilisation given that CHANTS
is not a 24-hour service.
Review protocol(s) for emergency out of hours stabilisation to support management of babies pending arrival of CHANTS retrieval service.
January 2016 Neonatal Clinical Lead / Senior Nurse (Quality Assurance), Neonates
QSEAC Achieved (Neonatal Network protocols for premature babies available on Unit. All supporting resuscitation guidelines are current).
14
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
31 Initiate and support opportunities
for the neonatal leads to join
sessions at the Singleton to help
sustain and further develop their
neonatal expertise.
Agree programme of joint rotations / visiting sessions with Singleton NICU team.
April 2016 Neonatal Clinical Lead
QSEAC Initial discussions commenced between Medical Directors. Further discussion scheduled between joint Neonatal teams 12th February 2016 (Joint HDd / ABM Neonatal review meeting).
32 Ensure that all consultants
providing out of hours cover have
some daytime involvement on
the neonatal unit which could be
attendance at the weekly grand
round as a minimum
Remove all Community Paediatricians from acute on-call rota.
December 2015 Clinical Lead Children’s Services
QSEAC Achieved (all consultants providing out of hours cover of Neonatal Unit have planned daytime sessions on Unit as part of Consultant of the Week rota)
33 Revisit the BLISS audit with
service users and develop an
action plan ‘you said-we did’
Parent Support Group to be established to review audit and develop supporting action plan.
April 2016 Senior Nurse (Quality Assurance), Neonates
QSEAC Parent Support Group to be established by April 2016.
15
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
34 Improve accommodation
arrangements for parents and
communicate them clearly,
perhaps utilising the CHC to
audit awareness
Promote availability of current facilities / services for all parents pending improvement of facilities as part of Phase 2 re-development.
Immediate
Senior Nurse (Quality Assurance), Neonates
QSEAC Achieved (profile of parents’ accommodation / transport needs included in Unit and handover meetings and awareness raised re supported transport arrangements).
Paediatrics and Emergency care
Emergency Pathway
35 Clarify the governance, decision
making and pathway
arrangements for paediatric
attenders out of hours,
particularly the relationships
between paediatrics, ED and the
Out of Hours GP service so
patients, public and referrers are
clear about whom to refer to at
different times of day. and what
telephone support is available
Review current policies and protocols
December 2015
Clinical Lead, Children’s Services.
QSEAC Policy review meeting held 18th December 2015. Policy amendment to be considered via W&C Directorate Q&S Committee.
16
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
from the Glangwili paediatricians
to diagnose, treat and discharge
locally where safe and
appropriate.
36 Continue with the relocation of
the Withybush PACU nearer to
the ED
Progress PACU relocation in parallel with redevelopment of WGH.
Spring / Summer 2016
General Manager / WGH Clinical Lead
BP&PAC PACU Relocation plans being progressed via WGH CDU / Ward 10 Project (relocation expected late Spring / early Summer 2016)
37 Audit WAST out of hour
paediatric decisions around 999
destination, with a group
including anaesthetists, WAST,
paediatric and ED staff and
revisit criteria/refresh training as
necessary
Undertake audit in conjunction with WAST and relevant clinical teams
July 2016
Clinical Lead, Children’s Services
QSEAC Audit specification to be agreed by March 2016.
38 Provide a further 12 month
extension to the DAV to March
2017 reviewing again once other
changes have been made
Renew SLA for DAV for 2016/17
March 2016 Executive Director of Commissioning
BP&PAC Board agreement to retain DAV for 2016/17
39 Ensure there are adequately
qualified staff with paediatric
resuscitation skills available at all
Training / Skills development programme to be
From April 2016 Clinical Lead WGH (with support from HB Resuscitation
QSEAC Programme to be agreed from April 2016.
17
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
times at WGH, perhaps through
a programme of training and
skills development for the
anaesthetic team with rotation to
other units to maintain skills. The
paediatric team should play a
leading role in overseeing
arrangements
arranged
Training Team & Paediatric Team)
40 Strengthen nurse staffing in ED
through urgent appointment of
Registered Children’s Nurses
(one per shift) to provide general
paediatric expertise. Longer
term consider development of
Emergency Nurse Practitioner
(ENP) roles, including nurse
prescribers, and a 5-year plan for
training and retention.
ED workforce development plan to be produced in parallel with HB IMTP.
Workforce Development Plan by March 2016 (Implementation Plan subject to IMTP)
Joint planning required between:
• Lead Nurse, WGH site
• Directorate Nurse, Children’s Services
• Lead Nurse, Unscheduled Care
BP&PAC Priority identified via IMTP / Clinical Strategy development sessions held 14/15th January 2016
41 Ensure that all staff who advise
members of the public are aware
of the correct clinical pathway to
access early treatment and safe
transfer.
Review current policies and protocols and communicate to relevant staff.
December 2015
Clinical Lead, Children’s Services.
QSEAC Policy review meeting held 18th December 2015. Policy amendment to be considered via W&C Directorate Q&S Committee and updated policies to be re-
18
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
issued with supporting communications / information.
Paediatric Care
42 Formally merge the paediatric
consultant team and remove the
out of hours cover for Withybush
with a target date of April 2016
once the paediatric, nursing and
management team are sure that
appropriate emergency
arrangements (training access
transfer) are in place. This
assurance should be supported
by monitoring of all attendances
out of PACU operating hours to
ensure appropriate case
management occurred, and
identify any incidents resulting
from the changes.
Clinical Task & Finish Group to be established (involving Directorate & GGH / WGH site representation) to undertake review of capacity and service implications
Review of capacity and service implications by June 2016
BP&PAC Priority identified via IMTP / Clinical Strategy development sessions held 14/15th January 2016 Recruitment efforts continuing. Locum appointment
2 RCPCH/PICS Time to Move On 2015
3 NHS At Home – developing Community Children’s Nursing DH England 2011
4 Facing the Future Together for Child health – RCOCH 2015
21
Recommendation
Actions to be taken
Timeline Responsible Person
Monitoring Progress / Current Status
vacancies. scheduled to commence January 2016.
50 Develop the roles of specialist
nurses, for example in epilepsy,
asthma/ respiratory.
Review current profile of specialist nurses and identify priority areas for development
March 2016 Directorate Nurse Children’s Services
QSEAC Priority identified via IMTP / Clinical Strategy development sessions held 14/15th January 2016
51 Review scope of on-call activity
and maximise the role of nurses
to help reduce pressure on
doctors, including development
of a criteria led nurse discharge
programme.
Review on call activity and demand Identify opportunities for extended roles for nursing staff in support of medical teams and discharge pathways.