Congestive Hospital Failure - Avoiding the Heart Attack

1. Congestive Hospital Failure - Avoiding the Heart Attack Felicity Cox Matthew Drinkwater Elliot Howard-Jones

2. Kent and Medway Acute Hospital Sites H H H H H H H

3. Overview The Secretary of State got on the phone:- • A&E performance deteriorated significantly across England over December 2012 to April2013. • Recovery plans to ensure that the operational standard for A&E set out in the NHS Constitution is met. • East Kent Hospitals FT called an ‘Internal Major Incident’ due to pressure in A&E without following an agreed escalation process

4. Hospitals in the Kent and Medway System routinely go into business Continuity

5. Reduce the number days on black alert in Kent & Medway to a maximum of 12 days between June 2013 and April 2014. The Objective

6. Root Cause Analysis People: • Have changed and newer recruits in the system no longer have the relationships or experience •Staffing levels and skill mix in all organisations has become less rich Process/Policies • New organisational policy no longer followed the pattern of system escalation policies • System escalation polices have been over time and were no longer consistent • Other policy targets & PbR militate against stepping down routine work to enable urgent care to work • Ambulance internal policies were not synchronised with provider policies. Equipment • Equipment to safely take people home was not immediately available Environment • National data shows that A&E 10/11 or 11/12 didn't recover from winter as normal in February • National data shows no correlation between attendances & 4 hour waits • Increase in total numbers attending happened when we started counting walk in centres and urgent care centres, major setting type1 units show a flat to decreasing trend • There has been a 1.2% increase in admissions in 4% reduction in beds although no change in acuity identified • Significant reductions in social care funding

7. agency responsibility common language agency language agency event trigger agency policy defines multiagency policy role has responsibility for action log informs activity gives informs action local objects shared objects process process data data ownership person Individualresponsibility gives accessto updates multiagency responsibility

8. Benefits of Shrewd 1. A NATIONAL real time view of hot & cold system pressures . 2. A REGIONAL real time view of hot & cold system pressures . 3. A LOCAL AREA TEAMreal time view of hot & cold system pressures Access to the detail in box 4 is a maximum of 3 clicks away from the LOCAL AREA TEAM, REGIONAL & NATIONAL views 4. Access down to single hospital indicator level for granular detail 5. A nationally benchmarked data set and EPRR system

9. Strategy Selection • Facilitate CCGs to produce a system wide plan to improve A&E performance. Challenge the CCGs to cover four areas:- • Appropriately understand and diagnose issues in urgent care performance • Have appropriate escalation procedures in place following Emergency Planning Response and Resilience (EPRR) principles • Ensure that our urgent care system is efficient – as per King’s Fund report • Urgent care system redesign for long term sustainability • NHS England has lead responsibility for EPRR and therefore would operationally lead this as part of contributing to the programme.

10. Implementation

12. Evaluation • Three of four have stayed out of business continuity so far • No further major incidents called • One Trust remains on black - bigger issue related to Keogh Review, Culture & Medical Leadership

14. Learning through the process • It is hard to reduce the problem to a simple statement • Naming and defining the problem collectively developed shared understanding • In addressing the simple problem other things improved – what is measured changes? • Analysing the root cause identified it wasn’t the reason being described • Many alternatives identified are still being pursued so process useful • It is all about relationships

15. Commissioning together