TB priorities paper v9 FINAL 30.1 · The Summary Hospital Mortality Index score (SHMI) for the Trust is 118 for the period September 2018 – August 2019 which is in the ‘higher

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NLG(20)014

DATE OF MEETING 4 February 2020

REPORT FOR Trust Board of Directors – Public

REPORT FROM Dr Peter Reading, Chief Executive

CONTACT OFFICER Kathryn Helley, Improvement Programme Director

SUBJECT Progress Against Trust Priorities 2019/20

BACKGROUND DOCUMENT (IF ANY) Relevant Project Highlight Reports

PURPOSE OF THE REPORT: To receive and note progress

EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)

In April 2019, the Board approved the key priorities for the organisation for 2019/20. The priorities are centred around six themes:

o Quality and Safety o Culture and Morale o Money o Staffing o Clinical Leadership o Clinical service Redesign and Service Improvement o

The report outlines progress in the first nine months (April to December).

TRUST BOARD ACTION REQUIRED

The Board is asked to receive and note the progress against the Trust Priorities for 2019 / 20

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IMPROVING TOGETHER

NLAG’s KEY PRIORITIES FOR 2019/20 1. Introduction In April 2019, the Trust Board approved the Trust’s key priorities for 2019/20, centred across six themes, Quality and Safety, Culture and Morale, Money, Staffing, Clinical Leadership and Clinical Redesign and Service Improvement. This report outlines progress up to Q3 against these priorities. 2. Progress Safety Further reduce mortality The Summary Hospital Mortality Index score (SHMI) for the Trust is 118 for the period September 2018 – August 2019 which is in the ‘higher than expected’ bracket. Actions to improve the SHMI include:

o Clinician validation of recording/coding and amendments made in response to improved risk recording within the SHMI numerator. Clinical validation of coding in Medical Admissions Units and in Critical Care is currently being undertaken.

o Development and approval of quality of care screening tool (with embedded coding validation tool) went live in January 2020 with the aim of reviewing a higher proportion of deaths for quality indicators and increasing clinician led validation work with coders.

o There is a focus on recording Charlson comorbidities electronically (within Web-V) to improve risk recording within the SHMI denominator. Ongoing coding/documentation improvement programme.

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Strengthening care for deteriorating patients National Early Warning System (NEWS) scores conducted on time with a 30 min grace period was 86.45% in December 2019. This is a reduction but is within normal variation as demonstrated via the statistical process control chart below which shows improvement over time. The escalation policy including community and in-patient care has been drafted and is currently out for comment. A sepsis and escalation snap shot audit has been carried out in each division. This demonstrated areas where further improvements were required and work is under way with these divisions. Manual review will continue to take place pending further work on the electronic recording system. Further audit is planned.

Improve medication safety including Electronic Pres cribing and Medication Administration (EPMA) Medication Safety This project aims to improve the safety of insulin prescription and administration for patients in the trust. To date, 85 staff have received additional training on insulin presentation and monitoring and insulin incidents continue to be monitored. It is too early to see whether the training has had a positive effect in reducing the number of incidents. EPMA The EPMA project went live in Goole during November 2019 across 4 wards and theatre recovery without any major issues. We are on course to go live in Scunthorpe General Hospital in February 2020.

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Improve patient flow and reduce non-elective length of stay

To support the reduction in length of stay and patient flow the following initiatives have been introduced:-

o An Urgent Treatment Centre was introduced at Scunthorpe General Hospital in March 2019 and received formal designation as a UTC in December 2019. The unit at Diana, Princess of Wales Hospital commenced in March 2019 and is expected to receive designation in February 2020.

o An Acute Assessment Unit was introduced in Medicine at both Scunthorpe General Hospital and at Diana, Princess of Wales Hospital in November 2019.

o The Trust have commenced work with NHS Elect to implement Same Day Emergency Care pathways

These have not yet resulted in a significant reduction in length of stay. To support this work and identify further areas for improvement, a ‘Multi-agency Discharge Event (MADE) is currently being planned for February 2020 which will be the forefront of a ‘perfect week’. The aim of which is to review and adjust working practice to ensure service delivery is streamlined for our patients. Improve cancer services including diagnostic report ing

Cancer

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Average number of days for non elective patients (number of days)

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Whilst the Trust continues to deliver 2 week waits on target, compliance with the 62 day cancer metric remains poor. Tertiary capacity also continues to be insufficient for demand. Key risks include:-

o The 62 day backlog has grown from the beginning of December (111) to 126 at 30 December 2019 and 217 as at 20 January 2020. The greatest increase is in Colorectal, from 47 (2/12/19) to 100 (20/1/20)

o 76.7% of breaches in December 202 were in 3 specialties (Colorectal, Upper GI and Urology – prostate)

o 1st appointments booked by day 7 remains an outstanding issue, particularly in Colorectal (35%), Head & Neck (32%), Upper GI (49%). Lung/Haem/Skin (50-52%)

o Endobronchial Ultrasound (EBUS) is scheduled to commence at NLAG by 31 January 2020

To improve cancer performance, the following improvements have been made: o Improvements in first appointment by Day 7 in Breast (96%), Gynaecology (84%),

and Urology (64%) o Improvements in Radiology waiting times (for requests marked 31/62). Request

to exam at 8.4 days (CT) and 6.0 (MRI); and Exam to report 3.1 days (CT) and 2.4 days (MRI)

o Haematology strategy developed with Hull. o Centralisation of oncology clinics: steering group to oversee the oncology

reconfiguration in place (January 2020). o Joint Cancer Board between HUTH and NLAG – agreed stocktake for Prostate,

Lung, Head & Neck, Upper GI pathways undertaken.

Diagnostic reporting In August 2019 the Trust commissioned additional outsourced support to improve radiology reporting times. This has led to the reporting backlog being recovered and under control. The total unreported cases have reduced from 11,000 to 3,000 and there are less than 30 cases overdue for reporting. The graph below shows this improved position.

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In addition, work continues to improve performance in diagnostics although there are continued pressures across MRI, CT and Non-Obstetric Ultrasound. Key risks include:

o Capacity for CT/MRI o Cancer diagnostics continue to be more than 7 day turnaround although

improvement plans are being developed around a rapid diagnostic centre at HCV level

o Supporting Trust with RTT position (long waiters) is impacting on ability to book diagnostics in chronological order

o Endoscopy rota management. Culture and Morale Pride and Respect 3007 staff have received Pride and Respect training since its launch, including 287 doctors. The Trust uptake rate is 39.54% of current staff having attended the training. 18 further training sessions have been booked to the end of February 2020. 85 staff have accessed the Let's Talk service with a 94% success rate. The recent Staff Survey response rate closed at 39%, just short of the national average, which was an improvement on the previous response rate of 35%. The results are due towards the end of Quarter 4 (2019/20). This will enable the establishment of baselines on questions relevant to culture and morale issues but also allow identification of areas for future focus and action. Medical Engagement Scale Results of the Medical Engagement Scale (MES) were presented to clinicians and managers at an event held in November 2019. Findings clearly demonstrate improvement since the MES was carried out 2 years previously. The highlights below 2017, right 2019) reveal an improvement in engagement scales for specialty grade doctors, with a mix across other grades. This demonstrates an improving picture.

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2017 Findings

2019 Findings

Following the feedback event the Medical Director’s Office (MDO) has identified 3 key priorities to improve engagement:-

• Developing trust • Improving communication • Empowering clinicians

These form the foundations of the Medical Engagement Strategy, and work to improve engagement will closely align with the recent findings of Professor Michael West and Dame Denise Coia (2019) ‘Caring for doctors, caring for patients’. The MDO has engaged and sought feedback from the Divisional Clinical Directors and Clinical Leads, as well as close working with the Organisational Development team within the Directorate of People & Organisational Effectiveness in developing the strategy, which is in the final stages of approval.

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April 2020 will also see the MDO working collaboratively with CCG colleagues to host the delivery of an engagement event to further develop relationships between primary and secondary care. Leadership Development Strategy The first draft of the leadership development strategy is prepared. However work is currently on hold until the release of the National People Plan, which will set the national direction going forward. Money Deliver £20m CIP The December 2019 (Month 9) year-to-date delivery for 2019/20 savings is £15,653.7k against a plan of £14,214.7k. In-month delivery was £1.77m against a plan of £1.88m a shortfall of £114k. Current delivery means that the Trust remains on course to deliver its £20m plan.

Gain Treasury approval for £29.26m capital Work has commenced on the development of the Outline Business Case (OBC) for the Acute Assessment Facilities (AAU) for both Scunthorpe General Hospital and Diana, Princess of Wales Hospital. Sub groups have been established to develop the key aspects of the business case. The OBC is due to be presented at the relevant Trust committees in June 2020 before being taken to Trust Board in July 2020. It will be submitted NHS Improvement/DHSC/HM Treasury Approvals via the STP in July 2020.

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Staffing Ward nursing establishment reviews The Chief Nurse and her team reviewed ward establishments across all adult and children’s wards in spring and summer 2019, presenting a paper to Trust Board in August. Nursing teams across the wards were involved in the review process and the Chief Nurse met with every ward manager to review and discuss the recommendations for investment. In September 2019, the Trust Management Board agreed an initial investment of £1.1 million for the highest risk areas. The £1.1m first phase funds have supported: • Introduction of a twilight shift for registered nurses to help match activity levels

of patient flow into the evening • An increase in staffing at weekends • Better skill mix across wards • Investment in the A&Es during twilight and more senior leadership overnight. Phase 2 Ward Establishment Review process is a high priority in the 2020/21 business plan, which will provide additional funds to support ward establishments. Recruitment has begun, including overseas nurses to ensure rapid appointment to vacancies.

Consultant, middle grade and CNS job plans review

Job planning has been a key priority for 2019/20. The majority of teams have now completed their team job plans, enabling individual consultant job plans to be created. These are going through the sign off process during February 2020 and achievement against this target will be reported in the next update. Awareness sessions were held throughout November and December 2019 as part of continued professional development to help all staff understand the requirements and needs of Medical Job Planning. Sessions were well attended with positive feedback. Quality improvement programme In March 2019, the Trust Board approved its Quality Improvement Strategy which outlined 5 key objectives:-

o Putting patients at the heart of quality improvement o Developing quality improvement leadership o Building and embedding quality improvement skills and competencies o Building a quality improvement culture at all levels o Holistic system adoption of quality improvement

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Actions taken to delivery these objectives include:-

o Establishing a QI Faculty of four experienced Improvement Managers who are all accredited QSIRAs

o Delivery of ‘Plot the Dots’ sessions to Trust Board, members of the senior team and approximately 70 staff from across the health system

o QI training is now embedded in all internal leadership and management training courses with the QI Faculty delivering QSIR training modules with apprenticeship courses.

o The Faculty has created and launched a QI resource centre for leaders and staff on the HUB.

o Formed a dedicated PGME/QI Training Faculty to deliver QI training to F1/F2 doctors. The PGME/QI Faculty is a partnership between QSIRAs and 4x Consultant F1/F2 Programme Leaders

o Delivered three Quality Improvement Sessions to in excess of 200 staff across the Trust as part of the Leadership Conferences running through Autumn and into Winter of 2019. These sessions focused on the Model for Improvement and featured 3 interactive breakout sessions which saw high levels of engagement.

o QI methodology is being used throughout a number of projects taking place within the Trust such as adult and children in-patient establishment reviews, deteriorating patient, development of the AAUs, maternity/neonatal collaborative work, effective rostering for medical staffing, UTC development, CNS, AHP and medical staff job planning, pressure ulcers, falls, improving junior doctor induction, embedding Thomas splint in A&E for femur fractures, compliance with AKI bundle and falls to name a few.

In January, NHSE/I agreed to fund the short term, 3 days per week appointment of a Deputy Improvement Director from outside the Trust, reporting to the Chief Executive, half of whose role is to review the development of QI in the Trust, advise the Executive on how this may be improved, and then support changes to deliver accelerated and deeper delivery of QI. Clinical Leadership Appoint clinical leads 30 clinical leads have been appointed. Clinical Redesign and Service Improvement North Lincolnshire out of hospital transformation p roject Collaboration within North Lincolnshire remains strong but, as yet, with modest outputs.

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Move elective work to Goole Theatre session utilisation at GDH continues to be a priority and there has been a slight improvement in recent months. However, further work needs to be undertaken to ensure in-session utilisation is maximised to increase productivity through all theatre activity at GDH.

Urgent Treatment Centres (UTC) In January 2020, at the request of NEL CCG, the Trust took over leadership of the Grimsby UTC from CCL (Core Care Links). This will be visible in terms of rota consistency from mid-January 2020, using a mix of PCN and bank GPs to deliver the model and the possibility of the Trust itself employing GPs is being worked through. Roll out of NHS 111 pre-bookable appointments is behind plan, however, this is expected to commence in February 2020. The chart below demonstrates that the UTC is consistently seeing more patients than was planned.

137 118 133 140 121 100 118 111 110 129 117 117108 95 99 102 94 76 86 74 89 107 101 9210 5 14 3 7 7 4 2 5 12 3 3118 100 113 105 101 83 90 76 94 119 104 95

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Humber Acute Services Review (HASR) including mater nity service re-design and trans-Humber cardiology and haematology Work continues on the Humber Acute Services Review. The Case for Change has been completed following the clinical design workshops and patient engagement events for:- - Urgent and emergency care, acute assessment, inpatient and critical care - Maternity and Paediatrics - Planned care. The output has created a long list of options for Urgent & Emergency Care and Maternity, Planned Care and Paediatrics. A series of well attended workshops with clinicians from both Trusts have been held looking at each of these areas. Outpatient transformation programme There has been an increase in the backlog of overdue follow-ups due to reduced activity over the Christmas period and cancellations of clinics due to high demand through our non-elective pathways. However, patient numbers without a due date are reducing as seen in the graph below.

The use of virtual clinics is currently being worked through for impact in the 2020/21 operational business plans. Advice and guidance requests from GPs, and responses from the Trust within 48 hours, continue to increase. The Trust was successful in being accepted to take part in the ‘100 day challenge programme’ supported by NHSE/I and a launch event took place on 18 December 2019. This is a regional programme which offers health systems the opportunity to implement and test interventions in rapid ‘sprints’, completing the programme within 100 days and then bring together information and case studies to allow others to learn from their experience.

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The plan for the transformation programme for 2020/21 is out for discussion with all system partners. Fractured neck of femur The Trust performance on treatment for fractured neck of femur continues to exceed the target of patients receiving surgery within 36 hours from arrival in an emergency department, or time of diagnosis if an inpatient, to the start of anaesthesia. The graphs below show that this has been achieved consistently on both hospital sites since April 2019.

Scanner programme Magnetic Resonance Imaging (MRI) Scunthorpe: Work has commenced with NHSI/E to fast track through the full business case to address the capacity pressures the Trust currently faces. It is anticipated that the new Magnetic Resonance Scanner (MRI) will be fully operational in 2021. Grimsby MRIs: The full business case was approved at Trust Board in December 2019. Construction commences on 10 Feb 2020.

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Computerised Tomography (CT) The first cut of the Business Justification Case was approved at Trust Board in December 2019 following a procurement and market test through the NHS Supply Chain for the options of a lease or purchase of the CT modular. The approval of the case has enabled the design team to work with the Supply Chain and the Division to finalise the detail on the design incl. groundworks. The programme is aiming for the modular to be installed and operational by late Autumn 2020. Refurbish ward 29 The Royal Institute of British Architects (RIBA) stages 1-4 are already complete - full business case is already approved, the admin move is complete and the contract has been awarded. Construction is under way and remains on track for completion in June 2020. A number of works stoppages have taken place, the contractor is stating a one week delay, however this does not affect the programme and completion date. No over-40 week waiters and reduce (incomplete) waiting list by 2,500 Despite good progress, the number of patients waiting more than 40 weeks increased in December 2019, as seen in the graph below. This was due to operational pressures and cancelling of some elective surgery. This group of patients is monitored on a weekly basis. The target of eliminating over 40 week waiters by the end of March 2020 remains and is a national requirement.

Conclusion and Recommendation As shown above, strong progress has been made across many, but not all priorities. The Board is asked to note and comment on progress. Peter Reading Chief Executive 30 January 2020