elective care conference: recovery planning & trajectory development
TRANSCRIPT
Addenbrooke’s Hospital I Rosie Hospital
RTT Recovery Planning and
Trajectory Development:
“A Cambridge Tale”
Linda Clarke
Head of Operational Performance
The need for RTT Recovery at CUHFT
• The Trust had a background of delivery of the RTT Incomplete Standard,
averaging 97% against the 92% standard.
• The Trust has failed to achieve the RTT performance standard since
December 2014.
• Less than half the reportable specialties were achieving the required 92%
standard.
9
7.8
%
98
.0%
97
.9%
97
.4%
97
.2%
97
.5%
96
.2%
92
.1%
89
.2%
83
.5%
84
.0%
84
.7%
88
.9%
90
.3%
90
.5%
90
.6%
89
.6%
89
.3%
88
.2%
89
.0%
88
.1%
88
.5% 8
9.9
0%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
Ap
r 2
01
4
May
20
14
Jun
20
14
Jul 2
01
4
Au
g 2
01
4
Sep
20
14
Oct
20
14
No
v 2
01
4
De
c 2
01
4
Jan
20
15
Feb
20
15
Mar
20
15
Ap
r 2
01
5
May
20
15
Jun
20
15
Jul 2
01
5
Au
g 2
01
5
Sep
20
15
Oct
20
15
No
v 2
01
5
De
c 2
01
5
Jan
20
16
Feb
20
16
Referral to Treatment Incomplete Standard (92% < 18 weeks)
Causes of the deterioration in performance We engaged the Elective Care Intensive Support Team to help us with recovery planning in March
2015. Below was their assessment of the causes of our position:
• Data quality – Despite significant preparatory work at CUHFT, the introduction of a new clinical
information system has led to reductions in data quality as far as waiting times reporting is
concerned.
• Planned activity reductions associated with new EPR implementation – CUHFT quite correctly
took the decision to reduce activity immediately prior to, during, and after the implementation of
Epic. However, this has necessarily contributed to the increase in the number of patients waiting.
• Continuing pressure on resources – as with any health system, if capacity does not match or
exceed demand, then waiting times and numbers will increase. CUHFT has clearly encountered
issues with both sides of this equation: referral demand has increased beyond expected levels in a
number of specialties; capacity has been constrained, particularly in terms of admitted care as a
consequence of the emergency demand on bed capacity from the frail elderly population, which has
led to higher levels of elective cancellations.
In addition to these issues, in order to support the financial challenges facing the Trust, in June
2015 a reduction in premium rate payments to staff was implemented. This reduced the volume of
waiting list initiatives undertaken, and impacted on Theatre’s ability to staff all elective capacity
whilst faced with high vacancy rates.
Overview of Session
Why are we failing?
Action planning
Trajectory Setting
Financial Consequences
Stakeholder Agreement
Monitoring the plan
Why are we failing?
Action planning
Trajectory Setting
Financial Consequences
Stakeholder Agreement
Monitoring the plan
Why is the Trust not delivering referral to treatment
(RTT) in 18 weeks?
You cannot begin to outline your recovery plan until you
know what the causes of your underperformance are:
• Which specialties are not consistently delivering the 92%
standard?
• For those that are not:
– Is capacity and demand in balance in those
specialties (sub specialties)?
– Are the pathways deliverable in 18 weeks?
– Are the waiting lists a manageable size?
Is capacity in balance with demand?
Using the NHS IMAS Intensive Support Team Capacity and Demand
Models you can identify if there is an imbalance in your services.
Models are available for the different stages of the pathway:
Outpatients, Inpatients and Diagnostics.
In the summary of the outputs from the models below, which service is
more sustainable?
Urology Inpatient Model
ENT Outpatient Model
Per
Week
193
50
64
79
11.4
3.4
8.0
0.0
163
0
163
+33
Mean DNAs (routine referrals)
Indicator
Mean referrals Received
Of Which Urgent
Routine Paper/Fax
Routine Choose & Book
Net Weekly PTL Size Change
Of Which Reappointed
Of Which Discharged
Mean Rearranged Slots
Mean Core Capacity
Mean Ad-hoc Capacity
Mean Total Capacity
Per Week
70
Mean Decisions to Admit 79
34
46
9
0
75
91
Indicator
Mean Net Change on Waiting List
Mean Capacity
Of Which Urgent
Of Which Routine
Mean Removals without Treatment (ROTT)
65th Percentile of DTAs - ROTT
85th Percentile of DTAs - ROTT
Are the pathways deliverable in 18 weeks?
For common high volume conditions you should have a clear idea of
what a typical pathway should look like. In simple terms this should set
out what should happen to the patient and in what order.
There should also be clarity as to the required timing of the following
“events”:
– First outpatient appointment;
– Diagnostic test;
– Decision to admit;
The capacity and demand models require these parameters to help
determine the appropriate waiting list size. For example, in general we
recommend to our surgical specialties to work to a 5 week maximum
outpatient wait, and to allow a maximum of 8 weeks for treatment
following decision to admit.
Sustainable Waiting list size
More patients waiting means a longer waiting time, and if the number waiting is
too large then the standard cannot be achieved even if capacity and demand
are in balance.
Based on the demand profile and the desired waiting time, the IST Models can
advise on maximum waiting list size and therefore what reduction is required.
Below is the output from the Urology Inpatient model which had shown the
demand and capacity had been in balance. However, the waiting list was too
large to deliver a maximum inpatient wait of 8 weeks:
337 to 373
677
304 to 340
WL consistent with RTT delivery
Required reduction in backlog
Indicator
Current waiting list size
Outputs of our Capacity and Demand Modeling
The outputs of our work identified:
• Of the 19 services we modelled, 10 had an underlying imbalance in
demand and capacity that if left would lead to ever increasing waiting
times. These specialties required recurrent actions to be included
within their recovery plans, not just backlog reduction.
• The extent of this was surprising, and reflects the level to which the
Trust had become reliant upon additional adhoc waiting list initiative
activity to prop up core scheduled capacity.
• Across the specialties we identified a need to reduce outpatient
waiting lists by 8,000 patients, and inpatients waiting lists by 2,000 in
order to achieve maximum waiting time parameters consistent with
sustainable delivery of an 18 week wait.
Why are we failing?
Action planning
Trajectory Setting
Financial Consequences
Stakeholder Agreement
Monitoring the plan
Drivers for identifying Appropriate Actions
Capacity and demand shortfall versus waiting list reduction
• Specialties with a capacity and demand imbalance require Recurrent actions. Without
them, when fixed term actions cease, the waiting list will increase again.
• If the service only needs to reduce a backlog then actions should be fixed term or you
may be left with costs / resources that are not required.
Financial Drivers
• We all have a responsibility for NHS finances and should seek the most cost effective
actions to support recovery.
• Actions to increase productivity to deliver more activity for the same cost are more likely
to be supported, and will be in line with Cost Improvement Programmes.
• The financial cost to the whole local health system should be considered e.g.
Significantly increasing activity may be unaffordable for commissioners, there could be
commissioned capacity that is underutilised in other parts of the health system; or there
could be initiatives to reduce real demand.
• Premium rate actions such as agency pay rates and outsourcing to the independent
sector would be less favourable. If sufficient actions cannot be found from more cost
effective solutions, then it can be helpful to present high cost actions as an optional
additional scenario, outlining the cost versus the benefit to the recovery trajectory.
Principles of Action Planning
• Needs to contain an appropriate level of detail to explain what the action involves. Useful to highlight which pathway stage the action is targeting: outpatient, diagnostic , admitted.
Detailed
• Each action should quantify the effect that it will have i.e. how many additional cases per week will be undertaken. Quantitative
• The role of the individual responsible for the action should be clear, and the responsible Organisation Owner
• From what date will the action start to deliver benefit. It is also useful to define if this is a recurrent action or time limited
Implementation date
• Key potential risks to the actions should be identified and the scale of risk. High risk actions might require mitigation plans from the outset.
Risk Assess
• Actions require the support and ownership by Clinical teams and commissioners to be credible. Supported
Themes of Actions
Recovery Plan
Increase Capacity /
Improve productivity
Demand Management
Data Quality
Actions to support RTT recovery planning fall into one of the following themes.
Fit to refer
De-
commission
services
Advice
and
Guidance
Patient
choice
hub
Clinic
outcome
capture
Transfer
to other
NHS
providers
Expand
physical
capacity
Length of
Stay
Improvement
Clinical
thresholds
Community
providers
Referral
re-
direction
Theatre
efficiency
Nurse /
AHP led
clinics
Telephone
follow up
7 day
services /
extended
days
Outpatient
template
reviews
Reduce
DNA rates
Job Plan
reviews 1st /FU
ratio
Ring fence
elective
capacity One-stop
clinics
Recruit
medical /
nursing
Waiting
list
initiatives
Outsource
Independent
sector
Waiting
list
validation
Adhere to
Access
Policy
Pathway
Trackers
Clock
start
capture
Referral
guidelines
Why are we failing?
Action planning
Trajectory Setting
Financial Consequences
Stakeholder Agreement
Monitoring the plan
Recovery Trajectories
• As Recovery Actions are quantitative, with implementation dates, they can
define numerically when the waiting list reductions will have achieved the
recommended target waiting list size.
• The IST capacity and demand models support you to record the quantitative
impact of your actions
• This should be operationally realistic – for example don't forget that elective
activity is always lower at Christmas, and when bank holidays fall.
From the examples on your tables, when would the Urology and
ENT plans achieve the target waiting list size?
You will notice:
• Each action has it’s own planned implementation / start date
• ENT has split their actions into 2 scenarios:
Scenario 1 with all the actions to address the recurrent shortfall in capacity v
demand
Scenario 2 with additional actions to reduce the waiting list size.
Recovery trajectories cont..
0
500
1000
1500
2000
2500
21
/9/1
5
5/1
0/1
5
19
/10
/15
2/1
1/1
5
16
/11
/15
30
/11
/15
14
/12
/15
28
/12
/15
11
/1/1
6
25
/1/1
6
8/2
/16
22
/2/1
6
7/3
/16
21
/3/1
6
4/4
/16
18
/4/1
6
2/5
/16
16
/5/1
6
30
/5/1
6
13
/6/1
6
27
/6/1
6
11
/7/1
6
25
/7/1
6
8/8
/16
22
/8/1
6
ENT Outpatient Actual PTL Against Plan
Scenario 1 Plan Scenario 2 Plan Lower Target PTL Upper Target PTL Actual PTL
The models also graphically present the trajectory, and allow you to record
your actual progress
Summary of Recovery Trajectories Service Incomplete
> 18 wks
Sept 15
Recurrent
Shortfall In
Capacity
Sustainable RTT 92%
Trust Total 3907 Mar-16
Ophthalmology 480 No Feb-16 Feb-16
Dermatology 289 Yes Jun-16 May-16
Rheumatology 115 Yes May-16 Apr-16
General Surgery 140 No Feb-16 Feb-16
Paediatric Urology 52 Yes Feb-16 Jan-16
Gastroenterology 89 No Nov-15 Achieving
Orthopaedics 499 No Not achieved Jun-16
Urology 195 No Aug-16 May-16
ENT Incl Paediatric 636 Yes Aug-16 Jul-16
Oral Surgery & Maxillo-
Facial
206 Yes May-16 Apr-16
Cardiology 118 Yes Mar-16 Mar-16
Paed Orthopaedics 111 Yes Not achieved Nov-16
Paediatric Surgery 107 Yes Apr-16 Mar-16
Vascular Surgery 89 Yes No recovery* No recovery*
Pain Management 78 Yes May-16 Mar-16
HPB Surgery 47 Yes May-16 Apr-16
Gynaecology 103 No Mar-16 Achieving
MRI 301 Yes Jan-16 Jan-16
Neurophysiology 250 No Feb-16 Feb-16
Can achieve recovery by end
Quarter 4 with no additional
cost
Sustainable core capacity but
high proportion of overall Trust
backlog
Significant shortfall in
capacity to meet demand and
require investment to prevent
them from further deteriorating
as well as to reduce backlog
Diagnostic 6 week wait
Recovery
Why are we failing?
Action planning
Trajectory Setting
Financial Consequences
Stakeholder Agreement
Monitoring the plan
Financial Consequences
• Work with your finance managers and commissioning team to cost
the actions in your plans.
• Consider:
– Whose cost will it be? Trust or Commissioner?
– If activity is going to be undertaken by another provider is that a loss of
income your Trust has assumed in their financial planning?
– If the activity is in the activity plan, and budgets have already been set
to deliver that at standard cost, are your plans now suggesting you need
exceptional / premium rate funding to deliver?
– If activity is above the agreed activity plan, will the commissioner pay for
it, and will the income cover the Trust costs?
– If you are on a block contract is it assumed the activity volumes have
already been paid for. If so, is the full cost to the Trust?
– Will the cost be recurrent or fixed term?
– Will the cost span financial years?
– What is your process to get Board approval for any recovery costs?
– What are the contractual financial consequences of not recovering?
Summary of Financial Consequences
Service Incomplete
> 18 wks
Sept 15
Recurrent
Shortfall In
Capacity
Sustainable RTT 92% Recovery
Cost
2015-16 £
Recovery
Cost
2016-17 £
Recurrent
Cost
£
Trust Total 3907 Mar-16 £2,252,401 £2,137,860 £871,356
Ophthalmology 480 No Feb-16 Feb-16 £15,349 £0 £0
Dermatology 289 Yes Jun-16 May-16
Rheumatology 115 Yes May-16 Apr-16
General Surgery 140 No Feb-16 Feb-16
Paediatric Urology 52 Yes Feb-16 Jan-16
Gastroenterology 89 No Nov-15 Achieving
Orthopaedics 499 No Not achieved Jun-16 £489,253 £297,229 £0
Urology 195 No Aug-16 May-16 £92,412 £30,222 £0
ENT Incl Paediatric 636 Yes Aug-16 Jul-16 £929,854 £926,207 £0
Oral Surgery & Maxillo-
Facial
206 Yes May-16 Apr-16 £107,298 £175,886 £176,000
Cardiology 118 Yes Mar-16 Mar-16 £46,357 £120,000 £120,000
Paed Orthopaedics 111 Yes Not achieved Nov-16 £91,990 £225,236 £225,236
Paediatric Surgery 107 Yes Apr-16 Mar-16 £48,803 £65,000 £65,000
Vascular Surgery 89 Yes No recovery* No recovery* £70,582 £0 £0
Pain Management 78 Yes May-16 Mar-16 £64,803 12960
HPB Surgery 47 Yes May-16 Apr-16 £78,000
Gynaecology 103 No Mar-16 Achieving £6,500 £0 £0
MRI 301 Yes Jan-16 Jan-16 £178,200 £285,120 £285,120
Neurophysiology 250 No Feb-16 Feb-16 £33,000 £0 £0
* Costing includes the transfer of activity required to recover but alternative provider not yet identified.
Can achieve recovery by end
Quarter 4 with no additional
cost
Sustainable core capacity but
high proportion of overall Trust
backlog
Significant shortfall in
capacity to meet demand and
require investment to prevent
them from further deteriorating
as well as to reduce backlog
Diagnostic 6 week wait
Recovery Cost £
Why are we failing?
Action planning
Trajectory Setting
Financial Consequences
Stakeholder Agreement
Monitoring the plan
Stakeholder Agreement
• Key stakeholders include:
Clinical Teams
Trust Board
Commissioners
Regulators (Monitor / TDA / Care Quality Commission)
• Engage stakeholders during the development of the plan, do not just present
a fait accompli
• Prepare an RTT Improvement Plan document that can be shared with all
stakeholders for agreement. Ours included the following section headings: -
Executive Summary
Background Data Quality Current Position Mitigating Patient
Harm
Approach to Recovery Planning
Summary of Specialty Action
Plans
Financial
Implications
Contractual Consequences
Risks Monitoring and
Governance
Why are we failing?
Action planning
Trajectory Setting
Financial Consequences
Stakeholder Agreement
Monitoring the plan
Monitoring and Governance Arrangements
• Weekly PTL Meeting – Patient level discussion of longest waiters, Chaired by Head of Operational Performance
– Frequency: weekly
– Attendees : Head of Operational Performance, Divisional Operations Managers
• Operational Taskforce – overarching group, Chaired by Chief Operating Officer
– Frequency: weekly
– Attendees : COO, Dir. of Operations, Associate Directors of Operations, Head of Operational Performance
• Divisional / Executive Performance Meetings:
– Frequency: monthly
– Attendees : Executive Board Members, Senior Divisional Management teams
• RTT Recovery meetings:
– Frequency: bi-weekly
– Attendees : Lead CCG, COO, Dir. Of Commissioning, Head of Operational Performance, Divisional Teams as
required
• Finance and Performance (Board sub-committee)
– Frequency: monthly
– Attendees - Non- Executive Chair, Executive Board Members
• Monitor Improvement Board
– Frequency: monthly
– Attendees: Executive and Non- Executive Board Members, Monitor, NHS England, Commissioners, CQC,
35083
3788
3000
3500
4000
4500
5000
5500
6000
6500
7000
7500
8000
8500
30,000
32,000
34,000
36,000
38,000
40,000
42,000
44,000
To
tal S
till
Wia
itin
g
RTT Backlog & Still Waiting Volumes - Weekly performance 89.2% (Backlog target <2807, 981 over tolerance to achieve 92%)
Total incomplete
Total backlog
KPIs Using data from the Weekly UNIFY returns
2000
2500
3000
3500
4000
4500
5000
-100
0
100
200
300
400
500
04
/10
/20
15
11
/10
/20
15
18
/10
/20
15
25
/10
/20
15
01
/11
/20
15
08
/11
/20
15
15
/11
/20
15
22
/11
/20
15
29
/11
/20
15
06
/12
/20
15
13
/12
/20
15
20
/12
/20
15
27
/12
/20
15
03
/01
/20
16
10
/01
/20
16
17
/01
/20
16
24
/01
/20
16
31
/01
/20
16
07
/02
/20
16
14
/02
/20
16
21
/02
/20
16
28
/02
/20
16
06
/03
/20
16
13
/03
/20
16
20
/03
/20
16
27
/03
/20
16
03
/04
/20
16
Ne
t ch
ange
s to
nu
mb
er
of
pat
ien
ts o
ver
18
we
eks
Week
Trends in Over 18 week waiters
Adm Backlog movement
Non Adm Backlog Movement
Total Net change to Backlog (>18
weeks)
Total Backlog
DOH Group
Breach
Tolerance
for 92% 03/0
1/2
016
10/0
1/2
016
17/0
1/2
016
24/0
1/2
016
31/0
1/2
016
07/0
2/2
016
14/0
2/2
016
21/0
2/2
016
28/0
2/2
016
06/0
3/2
016
13/0
3/2
016
20/0
3/2
016
27/0
3/2
016
03/0
4/2
016
Variance in
last week
X-Other 991 1237 1215 1190 1315 1258 1224 1211 1267 1152 1097 1103 1079 1113 1131 18
Trauma & Orthopaedics 191 656 656 616 601 605 594 606 571 569 536 545 562 574 619 45
ENT 203 689 689 661 687 683 690 708 772 652 593 559 556 572 564 -8
Ophthalmology 195 468 416 384 347 315 301 289 287 275 262 235 240 255 224 -31
Dermatology 159 253 253 237 222 181 168 166 177 180 188 166 166 185 221 36
Rheumatology 70 93 81 77 90 92 88 107 95 95 79 61 53 57 71 14
Urology 106 233 221 232 228 208 201 209 204 188 186 176 172 169 184 15
Gastroenterology 154 100 115 73 54 58 40 43 33 27 29 26 37 46 63 17
Cardiology 104 115 141 166 153 136 159 126 131 144 140 162 143 163 118 -45
General Surgery 86 197 151 116 107 107 101 105 103 107 95 84 81 89 92 3
Oral Surgery 71 205 213 205 218 207 194 197 202 222 234 238 227 243 247 4
Gynaecology 83 36 35 42 42 43 41 25 26 30 35 38 43 46 49 3
Plastic Surgery 63 170 160 168 134 132 142 144 135 126 124 123 128 127 135 8
Neurosurgery 93 105 94 83 95 77 103 120 95 109 120 85 94 106 121 15
Neurology 108 41 46 44 49 59 78 105 103 30 46 60 48 27 19 -8
Thoracic Medicine 41 13 10 3 4 7 8 16 17 17 20 26 24 25 31 6
General Medicine 8 14 8 12 13 8 7 9 9 7 0 1 2 2 2 0
Geriatric Medicine 7 5 4 3 2 2 1 2 5 5 3 3 4 2 -2
Grand Total 2705 4630 4508 4312 4361 4178 4139 4187 4229 3935 3789 3691 3658 3803 3893 90
"Other" Top Specialties
Pain Management 92 200 191 181 217 220 170 158 151 108 78 72 76 83 89 6
Maxillo-facial Surgery 81 144 138 123 121 123 130 130 138 155 155 189 146 170 196 26
Paediatric Orthopaedics 26 119 123 105 112 101 110 106 113 100 102 103 98 93 110 17
Vascular Surgery 34 110 101 95 91 96 85 77 78 70 63 60 60 60 66 6
HPB Surgery 18 105 106 114 122 124 118 122 121 115 115 118 125 115 118 3
0
20
40
60
80
100
120
Over 40 Weeks
52 week +
Over 40 wk
Action Plan Monitoring
Quantitative Monitoring
• Waiting List sizes against trajectory using the IST Models
• Actual weekly activity compared to plan
• Actual demand compared to plan
• Actual removals compared to plan
Action Plan Progress Update
• Narrative action plan to provide assurance and explanation on
progress with individual actions.
• Summary of Specialty Plans
• Each Individual Specialty Plan
• Risk and Issues Log
• Quality Impact Assessment
Further Information:
Contact details:
NHS IMAS Elective Intensive Support Team models &
Elective Care User Guide can be found at:
www.nhsimas.nhs.uk/ist