Clinical Support Services

workplan

2021/22

Our vision is to be the best rural District General Hospital for patient and staff experience

STRATEGIC OBJECTIVE

To consistently provide safe and compassionate care for our patients and their families.

Executive Lead - Chief Nurse

STRATEGIC OBJECTIVE

Modernising our hospital (estate, digital infrastructure and medical equipment) to support the delivery of optimal care.

Executive Lead - Director of Finance

STRATEGIC OBJECTIVE

Strengthening staff en-gagement to create an open culture with trust at the centre.

Executive Lead - Deputy CEO

STRATEGIC OBJECTIVE

Working with patients and system partners to improve patient pathways and ensure future financial and clinical sustainability.

Executive Lead - Director of Strategy

STRATEGIC OBJECTIVE

Supporting our patients to improve health and clinical outcomes.

Executive Lead - Medical Director

STRATEGIC OBJECTIVE

Maximising opportunities for our staff to achieve their true potential so that we deliver out-standing care.

Executive Lead - Director of People

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Our strategic objectives Our Corporate Strategy includes six clear strategic objectives, each with Executive Director leads (see below).

Each of the overarching strategic objectives has a range of underpinning Key Performance Indicators (KPIs).

We will publish progress reports on a quarterly basis, to be open and transparent with our patients, partners and staff about ‘how we’re doing’.

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About us With over 4,000 staff (known as Team QEH), we are one of the biggest employers in West Norfolk, supporting the health and wellbeing of our local community. We are fortunate to be supported by 300 dedicated volunteers. QEH has circa 500 beds, 28 wards, a budget of circa £220m and serves a population of around 331,000 people who live in the three counties of Norfolk, Cambridgeshire and Lincolnshire.

We have begun our journey of improvement, to turnaround the Trust from one with an ‘Inadequate’ rating (and requiring ‘intensive support’) from the CQC, to one our local communities can be proud of for the high standards of care we consistently deliver to our patients and their families. We play a leading role in research and innovation, being one of the most research-active NHS Trusts in the country compared to similar-sized hospitals.

The Clinical Support Services Division have worked together to develop a workplan for the year ahead, encompassing all departments and specialities.

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About us Clinical Support Services is a diverse division of 18 departments which provides pharmacy services, diagnostic screening, testing and imaging, therapies, laboratory services and business support to the hospital. We have 650 staff made up of a wide range of healthcare professionals who interact directly with inpatients and outpatients at multiple stages in their treatment pathway, and are integral to providing high quality diagnosis, treatment and care.

Audiology

Breast Unit

Cardio-respiratory

Dietetics

Main Outpatients

Mortuary

Neurophysiology

North Cambridgeshire Outpatients

Occupational Therapy

Phlebotomy

Pharmacy

Physiotherapy

Point of Care

Radiology

North Cambridgeshire Phlebotomy

Speech & Language Therapy

Transfusion

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About usClinical Support services came together as a single division in September 2019 and we are on a journey to deliver the highest quality support services to our patients and colleagues as a cohesive team.

PHARMACY - provides a clinical and dispensing service to all inpatients; this includes Medicines Reconciliation on admission, clinical review by a pharmacist and assessment of Patients’ own Drugs for use as an inpatient. Teams deliver pharmaceutical care using the principles of Medicines Optimisation to ensure effective use of medicines for all patients and the opportunity for patients to ask questions about their medicines. Pharmacy also has an aseptic production unit which supplies chemotherapy and biologic drugs in a safe and ready-to-administer form for patients.

DIAGNOSTICS - provides a wide variety of diagnostic imaging and interventional radiology; breast screening; hearing tests and audiology care for all ages; cardiac and respiratory diagnostic testing and monitoring and diagnostic investigations, monitoring and management for neurological conditions. The departments provide a service for both inpatients and outpatients.

THERAPY SERVICES - includes physiotherapists, occupational therapists, dietitians, speech and language therapists. The services support patients at many stages of their pathway including urgent and emergency care, planned surgery and supporting patients as they leave hospital. In addition to inpatient support, they also offer a range of outpatient services.

OUTPATIENT TEAM - provides support to all clinical specialisms, ensuring each clinic is provided with the right input to provide care to patients. The service also provides outpatient treatments and procedures at QEH and North Cambridgeshire Hospital, Wisbech.

LABORATORY SERVICES - QEH is part of the Eastern Pathology Alliance which provides microbiology and pathology services across the region; histopathology services are contracted to Cambridge University Hospital. We have developed an excellent Point of Care Testing and Transfusion service and our Phlebotomy team supports direct access from GPs, clinical services and outpatients.

MORTUARY - provides after-death care for all patients who pass away in the hospital and facilitates their release to their designated funeral director in a timely fashion. The department also acts as a public mortuary to admit sudden deaths from the local community for the Norfolk Coroner’s Service.

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PRIORITY 1 - Quality

STRATEGIC OBJECTIVE 1: To consistently provide safe and compassionate care for our patients and their families. Executive Lead – Chief Nurse

We will optimise and reduce variation in patient flow through the hospitalWe will do this by:

• Working with other Divisions to optimise access to and input by clinical support services at each stage of the patient journey

• Reducing unnecessary diagnostic imaging and tests by implementing clinical vetting of requests by September 2021

• Participating in the Better Hospital “Patient Flow: Ward & Discharge Improvement Programme” workstreams and implementing resulting changes in practice

We will deliver high standards of support services to patients on a Cancer pathwayWe will do this by:

• Delivering Breast Screening services to National KPIs reporting to the Divisional Monthly Management Board from July 2021

• Development of a dedicated point of contact and one-stop diagnostic imaging to reduce time to diagnosis by October 2021

• Working closely with cancer teams to deliver chemotherapy, aiming to supply 95% of treatments within one hour of scheduled appointment time reporting to the Divisional Monthly Management Board from July 2021

• Supporting the development and implementation of the Diagnostic Assessment Centre (DAC) by ensuring senior management attendance at project team meetings and engagement with project development work during 2021/22

We will ensure best use of medicines for patientsWe will do this by:

• Delivering excellent pharmaceutical care for all patients using the principles of Medicines Optimisation

• Developing opportunities for increasing aseptically prepared products for patients from the pharmacy aseptic unit, initially by assessing the costs/benefits of a Central Intravenous Additive Service (CIVAS) by December 2021

• Delivering an effective programme of Antimicrobial Stewardship; reducing the incidence of hospital acquired Clostridioides Difficile infections to meet national targets

• Reducing incidents associated with harm from anticoagulants to meet targets in the Quality Priorities for 2021/22

We will improve the discharge processWe will do this by:

• Working with wider system partners and the Better Hospital Team to deliver ‘Discharge to Assess’ (D2A) by March 2022

We will optimise our Clinical Governance processes across the DivisionWe will do this by:

• Standardising our governance processes across the Division by July 2021

• Encouraging shared learning from incidents

• Responding promptly to and learning from complaints

• Managing risk effectively in the Division to improve quality of care

• Completing an annual programme of clinical audit

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PRIORITY 1 - Quality

STRATEGIC OBJECTIVE 2: Modernising our hospital (estate, digital infrastructure and medical equipment) to support the delivery of optimal care. Executive Lead – Director of Finance

We will enhance our Digital MaturityWe will do this by:

• Implementing Electronic Prescribing and Medicines Administration (EPMA) across the Trust in September 2021

• Implementing Radiology Information System/Patient Archiving Communications System (RIS/PACS) by August 2021

• Supporting the submission of an updated business case for Chemotherapy Electronic Prescribing system in conjunction with the Division of Medicine by March 2022

We will develop a programme of equipment replacementWe will do this by:

• Capital planning for equipment replacement in all departments by January 2022

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PRIORITY 2 - Engagement

STRATEGIC OBJECTIVE 3: Strengthening staff engagement to create an open culture with trust at the centreExecutive Lead - Deputy CEO

We will develop the workforce within Clinical Support ServicesWe will do this by:

• Working with external education partners such as the University of East Anglia (UEA) and Health Education England (HEE) to increase the availability of training courses for Allied Health Professionals (AHPs) in line with the Divisional Workforce Plan

• Developing leaders who are confident, inspiring and empowering

• Promoting a culture of openness and kindness

• Strengthening staff engagement in continuous quality improvement; nominate three staff from within the Division to attend each QSIR course

• Increasing opportunities for communication across the Division by introducing a newsletter and staff forum from June 2021. Improving the National Staff Survey result for Shared Objectives from 73% to 80% for the Division

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PRIORITY 2 - Engagement

STRATEGIC OBJECTIVE 4: Working with patients and system partners to improve patient pathways and ensure future financial and clinical sustainabilityExecutive Lead - Director of Strategy

We will strengthen our engagement with external partnersWe will do this by:

• Being active partners in external alliances and working partners, including the Integrated Care System (ICS), Eastern Pathology Alliance (EPA), Regional Imaging Alliance and Integrated Pharmacy and Medicines Optimisation Leaders group

• Implementing the Norfolk and Waveney Centralised Therapy Transformation Programme across West Norfolk by December 2021

We will ensure future financial sustainabilityWe will do this by:

• Delivering Divisional CIP targets by March 2022 and supporting the wider organisational delivery

• Managing Divisional finances within our available budgets

We will improve our patient experienceWe will do this by:

• Launching the ‘first 15-steps’ programme in outpatients by June 2021 to report into Divisional Management Board

• Learning from Friends and Family feedback by discussion at monthly Governance meetings from June 2021

• Encouraging shared learning from incidents to continuously improve our services for our patients and their families at monthly Governance meetings from June 2021

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PRIORITY 3 - Healthy Lives

STRATEGIC OBJECTIVE 5: Supporting our patients to improve health and clinical outcomesExecutive Lead - Medical Director

We will enable patients to access information on healthy lifestyles and recovery supportWe will do this by:

• Aligning services such as Dietetics and Occupational Therapy to support the Cancer Health and Wellbeing Centre from September 2021

• Supplying ‘Healthy Living’ leaflets to >90% of patients on discharge to report through monthly Governance meetings from July 2021

We will further improve the care of older people by developing pathways of care for frailtyWe will do this by:

• Identifying key staff to represent the Division in the development stage of pathways of care

• Supporting the Trust’s aim to maintain an A rating for stroke services supported by Therapy services by delivering rehabilitation and Early Supported Discharge to locally defined targets by March 2022

We will support the Trust to create a Smoke-free siteWe will do this by:

• Encouraging staff who wish to stop smoking to access advice and support

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PRIORITY 3 - Healthy Lives

STRATEGIC OBJECTIVE 6: Maximise opportunities for our staff to achieve their true potential so that we deliver outstanding careExecutive Lead - Director of People

We will maximise opportunities for staff to reach their potential and deliver excellent patient careWe will do this by:

• Delivering the Divisional workforce plan to enable staff to have a positive work-life balance monitored through the Divisional Management Board

• Supporting staff to reduce sickness absence associated with workplace stress and anxiety and provide psychological support if needed; consistently meet Trust’s target for sickness absence (<4%) and improve associated score in the next National Staff Survey

• Encouraging relevant educational, training and research opportunities

• Enabling staff to access leadership development

• Using technology to support new ways of working and remote working

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The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust

Gayton Road, King’s Lynn, PE30 4ET01553 613613