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Velindre NHS Trust DELIVERING EXCELLENCE: OUR THREE YEAR
PLAN
2014/15 -2016/17
FINAL DOCUMENT 14 March 2014
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Contents Page
Introduction How to use the plan 1 Engaging with our commissioners 5 Our role in public health 5 Where are we now The services we provide 7 Understanding our strengths, weakness, opportunities 15 and threats Our vision for the future Our vision and goals 17 Our strategic objectives 18 Towards 2017: achieving excellence National strategic direction and policy 19 Key issues on the horizon 25 The Planning Process 32 Improving the quality of Cancer Services Where do we want to be in 2017 35 Forecast demand for our services 36 Our priorities 37 Radiotherapy: our performance and quality ambitions 38 Our plan of action for radiotherapy 40 Chemotherapy: our performance and quality ambitions 50 Our plan of action 53 Improving quality, safety and our staff: our performance 59 ambitions Our plan of action 62 Research and development: our plan of action 72 Improving the quality of Blood and Transplant Services Where do we want to be in 2017 76 Benchmarking our services 77 Forecast demand for our services 81 Our priorities 85 Our performance and quality ambitions 86 Our plan of action 88 Developing a culture of high quality and continuous improvement Supporting our staff to excel 110 Our approach to organisational development 119 Our approach to quality improvement 124
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Page Enabling Transformation to happen: improving the infrastructure Information, communication and technology plan 130 Capital developments and resources plan 145 Spending our resources effectively Our financial strategy and plans 152 Managing the delivery of our plan Commissioning arrangements 161 Integrated performance, risk and assurance framework 161 Performance Management and Quality Improvement System 163 Governance arrangements 164 Measuring our success 167 Risks to delivery Risk register 170
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Introduction
Patients, donors, carers and their families are at the centre of everything we do and their needs can only be met if we are able to create an environment which supports our staff in achieving their potential.
We are therefore delighted to present ‘Delivering Excellence: 2014/15 – 2016/17’ which sets out our plan for the next three years. It is intended to tell a clear and uncomplicated story about our priorities, the actions we wish to take and the improvements and benefits we expect to see for patients, donors, carers, families, our staff and our partners.
The foundation for this plan is our five year framework, ‘Delivering Quality, Care and Excellence’ which set out a clear vision for the Trust and a set of aims focused on improving the quality and outcomes of our services for those people who use them and the environment and job satisfaction for the staff who provide them. We have used this, together with a range of national policy and service standards, to develop a clear set of actions for the next three years.
It is important to recognise at this point that the three-year plan will constantly change during the 2013 – 2017 period as a result of a range of factors, some of which we know about and some which will emerge. Therefore, this plan is intended to provide a direction of travel for the Trust which will evolve as we work through its implementation.
How to use the plan
Our aim is to make this plan clear and easy to understand. In order to achieve this we have set out the plan in the following way:
Section 1: Where are we now: we set out the current range of services we provide and the demand on these services from patients, donors and families/carers.
Section 2: Our vision and goals: we set out our vision for the Trust and our strategic objectives up to 2017.
Section 3: Towards 201; achieving excellence: we set out the big challenges and opportunities we have identified over the next three years.
Section 4: Improving the quality of Cancer Services: our priorities and action plan: we set out our vision of cancer services by 2017; our priorities, performance expectations and the key actions we will take to achieve them.
Section 5: Improving the quality of the Blood and Transplantation Services: our priorities and action plan: we set out our vision for blood and transplantation services by 2016, our priorities and performance expectations, and the key actions we will take to achieve them.
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Section 6: Developing a culture of high quality and continuous improvement: we set out our organisational development and quality improvement plans which will enable us to put quality at the heart of everything we do. Section 7: Enabling Transformation to happen: improving the infrastructure: we set out our plans for improving the infrastructure and environment within the organisation. Section 8: Spending our resources effectively: we set out our financial plans which will support the delivery of the service priorities and performance expectations.
Section 9: Managing the delivery of our plan: we set out the arrangements we have in place to support us in delivering our plan.
Section 10: Risks to Delivery: we set out the main risks we have identified in delivering our plans and the actions we are taking to effectively manage them.
Engaging with our Commissioners
As one of three NHS Trusts’ within Wales we provide services to the population of Wales on behalf of the Local Health Boards. The commissioning process in Wales is being developed through a range of forums and activities which will take some time to come to fruition. All Local Health Boards and Welsh Health Specialised Services Committee (WHSSC) received a copy of our draft plan in November 2013 to enable feedback and further discussion in advance of the finalisation of the plan.
We received a number of comments from Local Health Boards and these are reflected in the plan.
Looking to the future, we will continue to work with the Local Health Boards, WHSSC and the Welsh Government to further strengthen the planning and commissioning arrangements to ensure that the services we deliver.
Our Role in Public Health
We, together with all public services in Wales, have a vital role to play in improving public health in Wales. We are in an excellent position as we have a very talented group of staff, a very strong reputation and recognisable brand, and provide a range of services which allows us to come into contact with a wide range of patients, donors, families and carers at different stages in their lives.
We are extremely excited by the potential that this offers us and believe that we could make a significant and sustained contribution to public health across the whole of Wales
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and a real difference. In the first instance, we are keen to identify what our particular role is within the wider system and develop a clear understanding with our partners about the contribution we could make. This will allow us to develop a clear plan of action and ensure our staff have the appropriate skills and knowledge to enable them to make a difference. Importantly, it will ensure that we are able to contribute effectively and in an integrated manner. We will take this issue forward as part of our discussions with our commissioners and partners.
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Section 1: Where are we now?
The services we provide
We provide a number of services within the Trust which are described below.
Velindre Cancer Centre
This is a specialist treatment, teaching, research and development centre for non-surgical oncology. It treats patients with chemotherapy, Systemic Anti-Cancer Treatments (SACTs), radiotherapy and related treatments, together with caring for patients with specialist palliative care needs.
Specialist teams provide care using a well established network multi-disciplinary team (MDT) model of service for oncology and palliative care, working closely with local partners and ensuring services are offered in appropriate locations in line with best practice standards of care. Whilst radiotherapy services are currently centralised at Velindre Hospital, chemotherapy/SACT and Outpatients services also run on an outreach basis with services delivered in facilities around South East Wales, including District General Hospitals.
The aim is to improve and extend life, with quality of life at the forefront of all treatment and care.
The Welsh Blood Service This service plays a fundamental role in the delivery of healthcare in Wales. It works to ensure that the donor’s gift of blood is transformed into safe and effective blood components which allow NHS Wales to improve the quality of life and save the lives of many thousands of people in Wales every year. The Welsh Blood Service:
• recruits blood and stem cell donors from the public in south, mid and west Wales and through voluntary donations encourages them to continue to support the provision of a wide range of specialist clinical services to NHS Wales.
• manufactures those donations into safe blood components. • provides blood and stem cell components to hospitals, where they will be transfused
to patients. • supports patient care in a range of clinical specialities, for example in the selection
and provision of blood components for patients with specific needs, and in the selection of compatible stem cells and kidneys for transplant patients.
• Provides professional support for both UK and International laboratories as part of the UK National External Quality Assessment Scheme for Histocompatibility and Immunogenetics.
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Hosted Organisations The Trust hosts a number of organisations on behalf of Welsh Government and NHS Wales:
NHS Wales Informatics Service (NWIS)
NWIS is responsible for both the strategic development of Information Communications Technology (ICT) and the delivery of operational ICT services and information management. NWIS has a national remit to support NHS Wales, make better use of scarce skills and resources, and facilitate a consistent approach to health informatics and the implementation of common national systems.
Shared Services
The NHS Wales Shared Services Partnership (NWSSP) is an organisation owned and directed by NHS Wales. It was established in 2011 and supports NHS Wales through the provision of a comprehensive range of high quality, customer focused support functions and services. The range of services include E-Business, Employment, Facilities, Legal and Risk, Primary Care, Procurement, Welsh Risk Pool and Workforce, Education and Development
NISCHR Clinical Research Centre (NISCHR CRC)
The National Institute for Social Care and Health Research Clinical Research Centre (NISCHR CRC) was established in 2010 and brings together all-Wales research networks in health and social care and cancer (the former Clinical Research Collaboration Cymru and the Wales Cancer Trials Network, now Wales Cancer Research Network).
National Collaborating Centre for Cancer (NCC-C)
The NCC-C was established in April 2003. The centre is funded and commissioned by the National Institute for Health and Clinical Excellence (NICE) to develop evidence-based clinical guidelines for the NHS in England, Wales and Northern Ireland on treating and caring for people with cancer. Velindre NHS Trust is directly involved in the governance of this UK-wide organisation for improving the care of patients with cancer.
Cancer National Specialist Advisory Group (CNSAG)
CNSAG is an all-Wales NHS organisation based in Cardiff. It works with the Welsh Government and the Cancer Networks to ensure delivery of high quality, up-to-date care for cancer patients and their carers. In collaboration with the All Wales Cancer Steering Groups, it provides expert clinical advice to the Welsh Government regarding the strategic development of cancer services in Wales. It also supports the development and work of the Cancer Networks in Wales.
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Demand for our Services
Cancer
The incidence of cancer is increasing in Wales by approximately 1.5% per year. In real terms, we expect 1 in 3 people to be diagnosed with cancer before the age of 75 and around 40% of the population of Wales to be diagnosed with cancer during their lifetime.
Due to improvements in outcomes people are living with and beyond cancer (survivorship). Currently 120,000 people in Wales are living with or after cancer (approximately 4% of the population) and by 2030 it is forecast this figure will almost double.
The demand and complexity of radiotherapy treatment is rising at a significant pace and is often not accounted for in future service planning.
The pace of clinical and technological change and innovation in cancer services is rapid and this can often lead to misunderstanding when trying to plan services. Traditionally, current and future referrals and activity levels are used to assess whether a service has sufficient capacity and capability to achieve the required standards and outcomes. However, whilst important this does not provide a comprehensive picture with regard to cancer services. With regard to radiotherapy services a better currency is the time taken to provide the service. Over the past decade there has been a shift from “conventional” to “technical” radiotherapy. This will continue over the following decades and represents a step-change in the way that radiotherapy is planned and delivered. For example, in 2013 radiotherapy is mainly 3D, computer-aided and digital. It is vastly more sophisticated and complex than 10 years ago. The majority of radiotherapy planning is done using imaging information from a 3D CT scanner. The oncologist, using computer treatment planning software, manually contours the tumour and the treatment volumes on the planning CT scans, a process that may take 3 hours for a particularly complex case compared to 15 minutes a decade ago. A physicist may require a day to produce an acceptable plan. Treatment itself commonly involves multiple bespoke radiation beams and requires rigorous quality assurance. This can significantly extend the standard 15 minute treatment delivery slot. The increase in complexity and related human resource requirements are particularly noticeable when radiotherapy departments start to use IMRT routinely. It is probable that this will be the biggest service change over the next 5 years. Other developments, such as those related to IGRT, will be no less complex but allowing for the usual learning curves, are likely to be introduced more incrementally than will be the case with IMRT. It is probable that some of the time consuming work involved in planning complex radiotherapy will become more automated over the next few years. An example of this is the increasing sophistication of automatic segmentation software which can, to a variable extent, automatically contour body organs in a planning CT scan. This is currently a manual procedure which can take hours per case. To date, the automatic segmentation systems on the market do not meet the aspiration of being fully automatic and operators are still required to review and edit contours generated by these systems.
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The complexity of radiotherapy treatment will continue to increase and hence the time taken to image, plan and verify. There are 3 components to this complexity:
(i). target volume definition: this will increasingly involve co-registering of diagnostic imaging such as MRI and PET-CT and multi-disciplinary input into RT radiotherapy planning from radiology.
(ii). dosimetric treatment planning: this is increasingly using computer software to sculpt
radiation delivery to treat the target volume and spare normal tissues at risk. This may allow higher dose delivery to the target and improve cure rates or reduce toxicities from radiotherapy by sparing normal tissues. Planning may also take into account temporal changes in shape or movement of the target volume in the form of ‘4D CT’ planning, which requires more extensive imaging procedures to record and account for motion effects.
(iii). Treatment set up, verification and radiotherapy delivery: this will be affected by the complexity of beam arrangements, new technology to accurately image during treatment what is actually being treated and adapting the treatment delivery to changes in target volume shape or position either by resetting fixed treatment fields, ‘tracking’ in real time or ‘adapting’ to changes of tumour position or shape identified by repeated imaging during treatment.
The increasing complexity of radiotherapy treatment delivery has resulted in a requirement to increase the routine appointment slot duration for radiotherapy attendances. IMRT planning has also had an impact on the demand for medical physics planners. Audits have demonstrated that a conventional conformal plan would take approximately 3.5 hours to produce. The IMRT planning process was recently mapped and demonstrated a time requirement of up to 11 hours to produce and check an IMRT plan. This is reflected in appointment times as in 2007/08 over 80% of referrals were allocated a 10 minute slot. By 2012/13 this had reduced to less than 22% of attendances. When predicting the required daily LINAC machine time for radiotherapy in the future the known changes to the service have been considered and have been included as additional hours per working day. The impact of changes to be implemented in the coming three years is relatively well understood and has formed the basis of the modelling.
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Fig. 1 Current and ppredicted hours of LINAC daily machine time required up to 2025 Initial forecasts suggest a 48% increase in LINAC machine time between 2013/2014 and 2024/2025, which equates to approximately 35 hours per day of LINAC machine time. It is expected that the LINAC machine time predictions set out in Fig. 1 will be understated as new and increasingly complex technology is introduced into the service.
Fig. 2 Current and predicted referrals and LINAC machine time required to treat them by 2025
Whilst a 1.5% annual increase does not initially seem significant, it represents a major challenge when converted into LINAC machine time hours required to treat patients. Fig. 2 illustrates this as whilst the predicted number of radiotherapy referrals increases steadily over the next 10 years, the amount of daily LINAC machine time required to meet the increase in referrals rises significantly as a result of the increase in complexity of treatments. It is clear that the improvements to planning and treatment regimes will lead to significant increases in the amount of time it takes to treat each patient with more sophisticated
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clinical and technological procedures. This should be partially offset by a reduction in the number of episodes of treatment that patients receive, although the expected gains have not yet been fully evident in SBRT and IMRT. This additional element of complexity is often not understood sufficiently when planning service levels and is expected to grow exponentially.
Chemotherapy attendances
Fig. 3 Actual and predicted referrals and SACT/Supportive care up to 2025
The picture is similar for chemotherapy treatment with a steady increase in referrals over the next decade. However, in real terms this will require an additional increase in activity of 16%.
Blood and Transplantation Services
The demand for red blood cells has fallen consistently over the last decade for a number of reasons. These include improved clinical practice in theatres, more effective stock management and more effective usage and reduced levels of waste. This is in contrast to the demand for platelets which has increased steadily over the past decade as a result of higher standards relating to the quality of blood products.
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testing 409 325 405 321 317
Fig.4. Red Blood Cells (RBC) issued to customer hospitals
Fig.5 Platelets issued to customer hospitals
Fig.6 Stem cell and Transplant Immunology Services
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Welsh Bone Marrow Donor Registry (WBMDR)
The increase in testing for kidney transplantation has risen as a result of UK initiatives to decrease waiting lists. As such, this leads to improved quality outcomes for patients as well as being more a cost effective treatment.
There has been a considerable drive to increase liver transplant donors in the last few years as these are associated with enhanced outcomes for patients. Stem cell provision has also increased as a result of an increase in demand for stem cell transplants on a global basis. In particular, technological advancements have enabled this to become a more viable option for older patients.
Fig. 7 Welsh Bone Marrow Registry
There has been a global increase in demand for transplants and due to the availability of high resolution typing of WBMDR donors this enables faster identification of suitable matched donors.
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Understanding our services
We have undertaken a SWOT (strengths, weaknesses, opportunities and threats) analysis of our two main services to inform the development of our strategic plans. These are set out below.
Cancer Services
Strengths
Weaknesses
High quality of care Hospital is 60 years old and the age of the estate impacts on the quality of care and patient experience
Very good reputation Increases in referral and demand may outstrip capacity
High / positive brand recognition Lack of physical space to meet need Committed clinicians, staff and volunteers
Challenge to keep pace with advances due to limited resources
Strong patient facing culture Limited space available to progress research and development agenda
Very high patient experience and satisfaction ratings
Increases in referrals and demand result in significant pressures on clinical workforce
International reputation for some areas of research and development
No established capital programme for replacement of essential equipment and technology e.g. LINACS
Partnerships with Local Health Boards still in development stage
Opportunities
Threats
Development of new treatments and technologies in Wales
Further reduction in capital resources from Government
Ability to repatriate patients receiving treatment in England/other countries back into Wales as wider range of services and treatments are offered
Reduced funding from Local Health Boards
Development of a new cancer campus in South East Wales
Inability to keep pace with advances in treatment and technology which could impact on patient care and also the recruitment and retention of staff
Increase fundraising activities to support further developments in treatment and technology
Patient satisfaction and experience ratings fall as a result of the poor environment
Further development of research and development activities e.g. Phase 1 clinical trials
Develop strategic relationships with other tertiary cancer service providers to share learning
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Blood and Transplant Services
Strengths
Weaknesses
High quality of care Transformation programme encountering some difficulties with the up-skilling of staff
Very good reputation Difficulties in retaining existing donors may result in under-supply; similar to the picture across the United Kingdom
High / positive brand recognition Limited resources to actively market services Committed clinicians, staff and volunteers Lack of capital resources Strong patient, donor facing culture Extended timeframes for implementing key
technology and information systems High patient, donor experience and satisfaction ratings
Partnerships with Local Health Boards not sufficiently mature or effective
International reputation for some areas of research and development
Lack of national blood stock system
Opportunities Threats
Development of new treatments and technologies in Wales
Inability to fully introduce a modern service model
Provision of all-Wales service by acquiring North Wales services from 2015/2016
Donors do not commit to a modern service model i.e. planned appointments
Develop lean culture and ways of working to ensure effective use of resources
Cost of supply increases and results in significant financial risk
Increasing attraction and retention of donors reduces the amounts of blood imported
Reduced funding from Local Health Boards
Increase research and development activities to improve quality of service, reputation and generate additional income
Reduced capital resources from Government
Improved marketing and communications to increase donor attraction and retention
Inability to keep pace with advances in treatment and technology due to resource constraints
Development of recruitment strategy for bone marrow donors and creation of single point of contact within the UK for Transplant Centres
Patient, donor satisfaction and experience may reduce as a result of the changes to service provision
Development of strategic relationship by joining the National Marrow Donor Programme (NMDP) as a donor centre
Increasing regulation may have additional cost impacts on the service
Potential to extend services into the wider public health agenda on behalf of Local Health Boards.
Collaborative work with NHSBT needs to be agreed to support development of plan to uplift short fall in collection against demand in north Wales pre-transition. Failure to achieve this will restrict WBS ability to meet clinical demand at go- live.
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Section 2: Our vision and goals
We have developed an uncomplicated vision and set of goals to guide our development.
- - high quality outcomes.
Velindre NHS Trust will be recognised locally, nationally and internationally as a renowned organisation of excellence for patient and donor care, education and research.
Our Vision
Improved well being and quality of life for
our patients and donors
Excellent care for our
patients, donors,
families and carers
World class research and development
Organisational excellence
Our Goals
High Quality Outcomes
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Our strategic objectives
In order to achieve our vision we have identified a small set of objectives.
Equitable and timely services: providing
patients and donors with access to services
according to their clinical needs in a fair way
Safe and reliable services: prevent all avoidable harm
to patients and donors
Providing evidence based care and research which is
clinically effective: identifying and using the most effective treatment, drugs and technology to
get the best outcome
First class patient /donor experience: providing the
care to patients and donors that we would
want for our family and friends
Supporting our staff to excel: providing our staff
with the support, encouragement and
environment to achieve their potential
Spending every pound well: ensuring everything
we do adds value for patients, donors and
partners
EXCE
LLEN
CE
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Section 3: Towards 2017, achieving excellence
National Strategic Direction and Policy The focus and direction of the Trusts’ three year plan is determined by a range of drivers which bring together national policy, Local Health Boards local needs assessment (in their capacity as commissioners of our services) and the need to comply with statutory requirements. National Policy Drivers There are a number of important national strategies and policies which guide the development and delivery of the services we provide. Together for Health was launched in November 2011 and sets out the Government’s aspirations for a high quality, safe, effective and person-centred health system. Its aims are for: • Health to be better for everyone – meaning that more children will have a good start
in life and more people will enjoy a long and healthy life. • Access and patient experience to be better – meaning that people will be able to
access primary care more easily, will have more services delivered locally (e.g. through pharmacies) and more services will be available 24 hours a day, 365 days a year. In addition, more information and advice will be available by telephone and on-line.
• Better service safety and quality will improve health outcomes – meaning that we can safely sustain a network of care, with partners, which assures high quality care and is resilient to manage future need. This network will be able to meet patients’ justified expectations in terms of safety, quality, access, communication and respect leading to improved health outcomes for people.
To achieve this requires sustained and long term change to account for the advances in medicine, new technologies and a population that is ageing and living much longer. This means a reconfigured health system fit for today and future years that is built on prevention, self-management and home-based services, recognising the important role carers play in helping maintain independence at home integrated health and social care centres, partnerships and teams, hospital clusters, networks and regionally based services, planned specialisation and consolidation of care into centres of excellence. These are supported by a range of cross-cutting policies which are set out in table 1.
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Table 1 Strategic drivers within Wales
Policy Document
Direction and objectives Working Differently, Working Together
This document focuses on the vital role that all staff play in delivering safe and effective care for the people of Wales. It recognises that the NHS in Wales is working within a changing environment in challenging times. It is therefore important that staff are supported by the best in employment practices. This framework will support the development of the right staffing model in order to continue to transform the way we deliver healthcare.
Safe Care, Compassionate Care
This governance framework builds on previous work set out by the WG and describes the assurance systems which should be in place to ensure organisations have a robust, transparent approach to quality care.
Together for Mental Health - A Strategy for Mental Health and Wellbeing in Wales
The strategy aims to improve the lives of people using mental health services, their carers and their families. At the heart of the Strategy is the Mental Health (Wales) Measure 2010, which places legal duties on Health Boards, Trusts and Local Authorities to improve support for people with mental ill-health. The strategy is structured around six key themes: promoting mental wellbeing, partnership with the public, delivering a well-designed, integrated network of care, addressing the factors which affect mental wellbeing and action planning.
Rural Health Plan
The plan aims to ensure that the future health needs of rural communities are met in ways which reflect the particular conditions and characteristics of rural Wales.
More Than Just Words – the Welsh Government’s strategic framework for Welsh language services
This document provides a clear framework for the continued development of the Welsh Language and the provision of all services in the language of choice.
Our Healthy Futures: a range of Health Improvement documents
This strategy sets out a clear direction and programme for improving public health in Wales.
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The additional range of strategies and documents also contribute to the strategic direction and plans of the organisation (this is not an exhaustive list):
• Sustainable Development Charter • One Wales: One Planet • Doing Well, Doing Better: Standards for Health Services in Wales • Delivery Plan for the Critically Ill 2013 • The Francis Report • National Dementia Vision for Wales 2011 • 1000 Lives / 1000 Lives Plus • The NHS Wales Quality Delivery Plan
Government priorities and health targets The Welsh Government also has a range of national Tier 1 targets which the Trust is required to meet. Cancer Policy Drivers Cancer is one of the two biggest causes of premature death in Wales. With our ageing population the demand for cancer care is increasing. For this reason tackling cancer is one of the Welsh Government’s top priorities. In 1995, a report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales (known as the Calman-Hine Report) recommended a restructure of services to create a network of care in England and Wales to enable a patient, wherever he or she lives to be sure that the treatment and care received is of a uniformly high standard. Fundamental to this was the development of a structure of cancer centres in a hub and spoke arrangement with smaller cancer units. The application of these principles in Wales was set out in the Cameron Report, 'Cancer Services in Wales' which laid down the foundation for the development of cancer services in Wales, with services based around three cancer centres. The development of the National Cancer Standards (2005) helped to define the core aspects of the service that should be provided for cancer patients in Wales. These National Cancer Standards take account of the evidence-based Improving Outcomes Guidance series published by the National Institute of Health and Clinical Excellence (NICE). Designed to Tackle Cancer in Wales (2008 – 2011) published by the Welsh Government continued the development of a strategic framework for tackling cancer with the emphasis on action based around four themes:
(i) more prevention; (ii) early detection; (iii) improved access; and, (iv) better services.
The current strategy, Together for Health: Cancer Delivery Plan 2012 – 2016 was launched in 2012 and sets out a clear vision for cancer services in Wales:
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• People of all ages to have a minimised risk of developing cancer and, where it does
occur, an excellent chance of surviving, wherever they live in Wales. • Wales to have cancer incidence, mortality and survival rates comparable with the
best in Europe. The Delivery Plan sets out the strategic themes and actions required to improve outcomes in the following key areas:
• Preventing cancer: people live a healthy lifestyle, make healthy choices and minimise risk of cancer.
• Detecting cancer quickly: cancer is detected quickly where it does occur or recur. • Delivering fast, effective treatment and care: people receive fast, effective
treatment and care so they have the best chance of cure. • Meeting People’s Needs: people are placed at the heart of cancer care with their
individual needs identified and met so they feel well supported and informed, able to manage the effects of cancer.
• Caring at the End of Life: people approaching the end of life feel well cared for and pain and symptom free.
• Improving Information: providing improved analysis and information which is available at the right time to the right person.
• Targeting research: to support improvements in cancer treatment and care. The Trust is working with Local Health Boards and a wide range of partners to implement this plan. Welsh Blood Service Policy Drivers The Welsh Blood Service is charged by Welsh Government to be the supplier of blood components for customer hospitals across NHS Wales. This means it must ensure that supplies are sufficient to meet demand in compliance with relevant regulatory and statutory requirements. Regulation and compliance in healthcare continues to develop both in terms of stringency and increased frequency of change. The introduction of the EU Blood Directive was transposed into UK law in 2005 as the Blood Safety and Quality Regulations (BSQR). This has resulted in a phased shift in the extent and stringency of achieving regulatory compliance. As a result, all UK Blood Establishments became subject to regular inspection against the BSQR by the Medicines and Healthcare products Regulatory Agency (MHRA), on a minimum of 2 yearly cycles to ensure regulatory compliance. The diagnostic services provided by the WBS are also subject to a variety of regulatory authorities/organisations, including the Human Tissue Authority, Clinical Pathology Accreditation UK Ltd and the European Federation for Immunogenetics.
These developments have meant that the standards of premises in which blood component collection and manufacturing take place and the quality systems and resources required to support this activity and maintain its Blood Establishment License have significantly increased. Furthermore the emergence of new infectious agents that can be transmitted by
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blood and new technologies that improve blood safety has led to the need to introduce new tests and technology to keep the blood supply safe. Not surprisingly, this continually drives up the cost of blood and related services whilst driving down operational flexibility.
The Joint UK Blood Transfusion Services and National Institute of Biological Standards and Control Professional Advisory Committee (JPAC) prepare detailed service guidelines, known as the ‘Red Book’ for the UK Blood Transfusion Services and act in concert through the UK [blood services] forum, a body which co-ordinates UK wide inter-service activity. Further advice for the UK Blood Services may be given by external bodies such as the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) who in turn provide expert advice and recommendations to the four UK Health Departments; SaBTO also formally considers cost-effectiveness of transfusion strategies. Recent recommendations, which may become mandatory requirements by the Health Departments, include the need for prion filtration, the restricted use of UK plasma and the preferred use of pooled platelets.
Non-mandatory guidelines and recommendations also have an impact on the Welsh Blood Service. Perhaps the most visible are those contained in the Health Service Circulars that lay down clear guidance for hospital laboratories on the appropriate use of blood (Better Blood Transfusion). The Welsh Blood Service has been very proactive in supporting hospitals and this support will continue to be expected. Other examples include recommendations from the Serious Hazards of Transfusion (SHOT) team, the National External Quality Assurance (NEQAS) Steering Groups and the British Committee for Standardisation in Haematology (BSCH) all of which influence hospital and blood service practice. Professional bodies such as the Institute for Biomedical Science (IBMS) and British Blood Transfusion Society (BBTS) are also influential in transfusion practice. Other professional bodies e.g. those for nursing and obstetrics produce guidelines that affect the work of the WBS. Summary
The strategic and policy framework in Wales, together with the various clinical and professional standards and guidance have a number of common principles at the heart of them, which the Trust has at the centre of its thinking. These are summarised as:
• Putting citizens and patients at the centre of service design and delivery; • Providing services of the highest quality which meet the needs of individuals consistently; • Improving the quality of services; • Delivering outcomes which are comparable with the best elsewhere; • Reducing all avoidable waste, harm and variation; • Providing care at home or within the local community wherever and whenever possible; • Developing a system which is based upon the principle and practice of co-production; • Uses resources in a sustainable way; • Treating people individually with dignity and respect;
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• Ensuring that every Welsh pound is spent efficiently and effectively; and • Providing a first class experience for everyone who uses services.
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KEY ISSUES ON THE HORIZON There are a number of challenges and opportunities which have been at the forefront of our thinking during the development of the plan.
Generic Issues
Our population is growing: The Welsh Government have predicted that the population of Wales will increase by 5% to 3.17 million by 2020 and by 12% to 3.37 million by 2035. This will increase the demand for services across the NHS (National Population Projections for Wales 2010)
Our population is ageing: we are facing an increase in the number of older people across Wales. This is illustrated in Fig. 8 which shows that the number of people in Wales aged 65 and over is projected to increase by around 365,000, approximately 55%, between 2010 and 2035. This will place an increasing demand on our services given the link between age and the incidence of cancer and the need for blood services.
Fig. 8 Population aged over 65 projections
Funding is decreasing in real terms: the funding position within the NHS in Wales is extremely challenging with the medium term outlook likely to see little or no growth in cash terms. This presents significant pressure for all NHS organisations given the increasing costs of providing health care against ever increasing demand for services, rising costs of medicines and technology as a result of innovation and advances in clinical practice and unavoidable cost increases such as pay inflation.
We need to keep pace with clinical advances and technology: the main services we provide are non-surgical oncology, blood donation and support for transplantation, and these are largely dependent on cutting clinical services and technology. The pace of technological advancement is extremely rapid and our ability to keep pace is driven by the availability of
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capital resources, which are significantly constrained within Wales. We need to overcome this to achieve our ambitions.
We need to continuously improve the quality of care, patient and donor experience: the public quite rightly expect us to continuously improve the quality of services they receive and their experience of it. This is at forefront of our thinking and has been accentuated by the unacceptable themes identified within the Francis Review into Mid Staffordshire NHS Foundation Trust. We currently provide high quality services but fully believe that they can always be improved.
We need to continue to reduce inequalities in health: whilst we do not have a statutory responsibility for improving population health we believe we have an integral role to play in reducing inequalities in health within South East Wales. There is significant variation in the life expectancy for people in different communities in Wales, many of whom receive our services. The causes of this are complex and related to many factors including lifestyle, soci-economic factors (such as unemployment and poverty) and access to services (the Inverse Care Law which identifies the fact that those who least need services access them more than those with the greatest need). We have the opportunity to reverse this unacceptable trend.
We need to continue to improve the safety and outcomes of the care we provide: we are proud of the quality of care we provide and the patient outcomes we achieve. We, like all ambitious organisations, are focused on continually improving the quality of services we provide and the outcomes they produce. There are a number of areas where we believe further improvements can be made regarding improved safety and enhanced clinical outcomes to enable us to be an organisation that is identified around the United Kingdom and the world as being synonymous with excellence.
Specific to Cancer Services
Incidence of cancer is increasing: more people in Wales are being diagnosed with cancer than ever before. The incidence of cancer is increasing annually by approximately 1.5% in Wales with the most commonly diagnosed cancers (breast, lung, bowel and prostrate) accounting for over half of all new cases. This is particularly relevant given the relationship between an ageing population and the increased likelihood of having cancer. This presents a challenge for services as more patients require treatment and ongoing care than ever before.
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Fig. 9 Average Number of New Cases per Year (All Cancers Excluding Non-Melanoma Skin Cancer) in the UK from 2008 – 2010 and Age-Specific Incidence Rates per 100,000 Population
The relationship between deprivation and cancer incidence for the South East Wales population that the Velindre Cancer Centre serves: The Welsh Cancer Intelligence and Surveillance Unit report, ‘Cancer Incidence, Mortality and Survival by Deprivation in Wales’, highlights the relationship between cancer incidence and relative areas of deprivation and affluence. There is a high concentration of deprived areas within the Cancer Centres catchment population of South-East Wales as illustrated in Fig. 10. This disparity is further exemplified by the fact that cancer incidence in the most deprived areas is 21% higher for men and 14% higher for women than reported for men and women from affluent areas.
Treatments are becoming more complex and taking more time to plan and administer: research and development is supporting the advancement of cancer care at a rate unsurpassed. This is enabling more sophisticated treatments to be provided to patients which have improved clinical effectiveness and survival rates. These advanced treatments require greater amounts of time to plan, prepare and administer and this causes pressure as there are more patients requiring treatment which often take longer to provide. We therefore have to find sustainable ways to ensure that patients are still able to access care at the right time.
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Fig. 10 Deprivation in Wales
Survivorship has increased and the proportion of the population living with cancer in remission or with managed relapses will continue to rise: the increasing effectiveness of cancer treatment has seen a significant increase in the number of patients surviving the disease. At the end of 2009, almost 85,000 people were living after a prior diagnosis of cancer during the previous 15 years (just under 3% of the population). Macmillan have forecast that this figure is set to double to about 7% of the population by 2030. For many people cancer is now considered to be a chronic condition which requires a new approach to supporting people living with the disease. We therefore need to continue to develop services and support mechanisms which enable people to effectively manage their condition and live happy and fulfilled lives.
Developing a cancer campus in South East Wales: the increasing demand for services, the ageing condition of the cancer centre, the lack of physical space to treat people, and the need to keep pace with advances in treatment and technology have made the development of a new facility a high priority for the Trust. We want to develop a set of services which are fit for the 21st Century and support them with a world class cancer campus which brings together the best possible patient care and environment with the voluntary sector, and
5 4 3 2 1 Affluent (376) Quintile 2 (378) Quintile 3 (373) Quintile 4 (377) Deprived (392)
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leading edge research and development with academia. This will provide the basis for excellence and be future proofed for decades to come.
The current patient environment is poor and does not provide a high quality experience for patients, families and carers. The Velindre Cancer Centre was built in 1956 and has been extensively developed in an incremental fashion. The hospital is widely acknowledged as having a ‘Velindre Way’ which is embodied by a culture where patients are at the centre of everything, the environment is a compassionate and caring one and where staff consistently ‘go the extra mile’ to meet the needs of patients, families and carers. Notwithstanding this, there are large parts of the hospital which do not comply with statutory requirements such as Health Building Notes. The site also presents a significant challenge with regard to energy and environmental management with the building design constraining the potential gains that could be made. Of greater importance is the impact the environment has on patients and the service they receive. In general, the hospital is not fit-for-purpose to provide cancer services for a population of 1.5 million people in the 21st century. This is illustrated in a number of ways: Physical
• Two out of the three inpatient wards are well below the required standard for modern healthcare;
• Space is cramped with the majority of inpatients having insufficient space; • The majority of circulation routes are too narrow for the volume of traffic and
patients and staff/families have to stand tight to the wall in the main corridor if a trolley or wheelchair is passing as there is insufficient room for two-way traffic;
• The outpatients department is too small to cope with current demand and in desperate need of modernisation;
• Patients, staff and services have to cover too much distance due to the poor adjacencies that have resulted from piecemeal design e.g. the pharmacy is at the furthest point away from the outpatients department;
• The hot and cold water infrastructure is insufficient to support the showers and washing facilities on the First Floor inpatient wards due to the incremental development of the building.
• The existing working environment often causes staff to make compromises as they deliver care. For example, using smaller hoists in patient rooms due to the limited space.
Patients and families
• The facilities do not always provide patients with their basic and fundamental needs. For example, there are frequent occasions when inpatients on the First Floor ward
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are unable to have a shower as the pressure is insufficient to get water to the showers and as it cannot be controlled safely; it is either very hot or very cold.
• The dignity of patients is compromised due to the lack of space and privacy for inpatients. For example, there is little space between beds on the First Floor. There is a similar picture for outpatients where the design of the consulting rooms does not allow for total privacy.
• The majority of the inpatient, outpatient and therapies environments are not synonymous with a cancer centre which supports well-being and healing.
• There is insufficient car parking available for patients and their families and they often have to spend too long waiting for a space or finding a car parking space outside the hospital in a built up and busy residential area.
While quality of the service provided to patients is rated very highly, we fully recognise that the environment that it is provided in is not fit-for-purpose and does not provide patients, their families or our staff with the experience they deserve. This particular issue is perhaps the biggest risk to the reputation of the Velindre Cancer and will reduce our ability develop our reputation nationally and internationally and provide the highest quality patient care to which we aspire.
Specific to Blood and Transplantation Services
The donor pool is shrinking: an ageing population means today’s donors are tomorrow’s recipients and the potential pool of donors is shrinking, creating an inverse relationship between supply and demand. Life is getting busier and time is precious and more and more people are travelling further to exotic destinations that may exclude them from blood donation.
Keeping pace with a social media and communications: reliance on conventional communication channels will not suffice if we are to attract and retain the donor base of the future. Smart phone technology and social media platforms have revolutionised the way in which we interact on both a personal and business level. Our ability to provide modern donor interfaces that utilise up-to-date technology is vital if we are to future proof the service.
Supporting the fluctuating demand for blood: differences between the population blood group profile and demand patterns necessitate ever more sophisticated donor marketing tools. The ability to successfully employ blood group targeted communications and collection programmes represents a significant challenge for the Welsh Blood Service in achieving effective donor relationship and supply chain management.
Retaining a sufficient and loyal donor panel with the optimum spread of blood groups by improving the donor experience: we have the opportunity to personalise the donor service in order to make it a more enjoyable and attractive experience.
Reducing waste: we are in an environment where donor attraction and retention is more challenging than it has ever been. We need to do all we can to reduce any waste within the
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service and ensure that all the blood and bone marrow we do collect is used as effectively and efficiently as possible.
Meeting increasingly stringent blood selection guidelines and regulatory requirements. The requirements for blood services increase annually, which we fully support. We therefore need to ensure that we are an organisation that is at the forefront of driving continuous improvement and quality of service.
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The Planning Process
Translating Strategic Direction and Policy into Action within Velindre NHS Trust We are committed to developing an integrated strategic and service planning approach which is clinically led. In support of this we have introduced a clear planning framework based upon the best practice identified by Welsh Government which is set out below.
Fig. 11 Welsh Government Planning Cycle
We have slightly amended this as an LHB commissioned service, and use Stage 1 (understand your population/healthcare environment) in two distinct elements:
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1. understand LHB commissioners intentions and requirements for blood and cancer services at the respective population level; and
2. take a clinical and professional view in respect of the required advances in each of the services.
The Trusts’ planning and assurance processes are set out below.
Fig. 12 Trust Planning Framework
Trust Board
Sets strategic direction and goals
Planning and Performance Committee
Provides assurance to the Board on planning and performance issues
Other Trust Committees e.g. Quality and Safety
Provides assurance to the Board on a range of specific/cross-cutting issues
Trust Planning Group
- Clinical representation - Functional representation e.g. human
resources, information communication and technology
Velindre Cancer Centre Senior Management Team
Co-ordinate the VCC planning process
Welsh Blood Service Senior Management Team
Co-ordinate the WBS planning process
Site specific clinical groups for each cancer site
Clinical leadership of the planning process
WBS Service specific clinical groups
Clinical leadership of the planning process
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Section 4: Improving the quality of Cancer Services: Priorities and Action Plan 2013 - 2017
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Where do we want to be in 2017: our vision of excellence
Provide leading cancer care:
- we want to be in the top five cancer centres in the UK as determined by key quality measures.
- we want to be recognised internationally as a centre of excellence for non-surgical care; - we want to be the hospital of choice for patients requiring specialist non-surgical cancer
care in Wales. - we want to be recognised as a leader of research and development in the United
Kingdom with a strong international reputation and to develop a programme of activities to be considered world class.
Delivering the Velindre experience
- we want patients, families and carers to continue to feel the warmth and compassion within the care we provide.
- we want to attract and retain the best staff who share our values and ethos. - we want our staff to continue to work as teams and provide services which are designed
and delivered around individual patient need. - we want to continue to work with Third Sector to develop a range of new services.
Meeting the needs of patients
- we want to ensure all patients have the right level of access to non-surgical oncology care, enabling patients to receive the best treatment in specialist areas.
- we want to provide treatments using cutting edge technology. - we want to provide our services at home or as close to home as possible by giving
patients greater flexibility and choice regarding their treatment and any follow-up care; - we want to have achieved the relevant approvals and be well on the way to developing a
new cancer campus which has the latest clinical services, treatments and technology necessary to be a leader in cancer care.
- we want to work with the Maggie’s to provide a Maggie’s centre on the new cancer campus which provides holistic support to patients through their journey.
Outcomes comparable with the best elsewhere
- we want to have clinical outcomes that are outstanding and compare with the best in the world. This will see continued improvement in survival rates so that more patients diagnosed with cancer survive for five years or greater.
- we want to develop better information systems to measure our clinical outcomes and share information with our partners and patients.
- we want to prevent and eliminate all avoidable harm to patients.
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Forecast Demand for Services
Fig. 13 Forecast radiotherapy referrals and LINAC machine time required to treat them
Fig. 14 Forecast chemotherapy attendances
Note: there are two different unites used to determine future projections (i) referrals: the number of patients referred to the service (ii) LINAC machine time: the total number of hours of treatment that will be required for each patient referred. This approach is used as the complexity of treatment has increased significantly over recent years. This has an exponential affect ion the service i.e. a small increase in referrals has a significant impact upon the capacity of the service due to the sharp growth in the amount of time required to treat each patient today compared with previous years.
14000
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Curent and predicted attendances for SACT/Supportive care
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Our Priorities for the Future. By 2017, our cancer service will...
Equitable and timely services
• achieve all national waiting times targets and seek to achieve waits less than the targets
• work with Local Health Boards to assess the need to increase access to radiotherapy for patients with cancer within our resident population
• Increase the provision of IMRT/IGRT/SBRT/SRS to patients in South Wales
• reduce outpatient waiting times within the centre • increase the number of patients receiving chemotherapy in outreach
and homecare settings
Safe and reliable services
• reduce healthcare associated infections to zero (MRSA, MSSA and C.Difficile)
• reduce hospital acquired inpatient pressure ulcers to zero • reduce the number of patients discharged with a deep vein
thromboembolism (DVT) to zero • improve the management of septicaemia • prevent patient harm • reduce medication errors • reduce treatment errors • comply with all national, professional and clinical requirements
and environmental agency, Health and Safety and other regulatory bodies
Providing evidence based care and research which is clinically effective
• improve performance against deaths within 30-days for patients receiving chemotherapy
• improve performance against deaths within 90-days for patients receiving radical radiotherapy
• increase the number of clinical trials and the number of patients accessing them
• increase the number of patients recruited to Phase 1 clinical trials • provide care in line with NICE guidelines and NICE/AWMSG appraisals
First class patient experience
• increase the number of patients able to access their preferred place of care
• increase the number of patients able to access their preferred place of death
• respond to all complaints within 20 days • have made significant progress in developing a world class
cancer campus • modernise out patients services to reduce ‘on the day’ waits
Supporting our staff to excel
• support staff to receive all required statutory and mandatory training • ensure all staff have a PADR • support attendance at work • improve staff work/life balance • develop a flexible workforce which can respond to changing clinical
needs • develop capacity, capability and leadership to deliver strategic change • develop talent management and succession planning within the service • continue to work in partnership with staff and their representatives • continue to embed a learning culture within the service • encourage all staff to be trained in service improvement techniques
(IQT)
Spending every pound well
• Improve levels of efficiency and productivity • Improve quality and reduce waste • reduce energy consumption and associated costs • seek to develop high quality services in new and innovative ways • Increase income generation from research and development • continue to participate in strategic joint procurement opportunities
with UK health organisations
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Our performance and quality ambitions by 2017
Dimension Ambition Equitable and timely access to services
- 98% patients commencing radical radiotherapy within 28 days - 98% patients commencing palliative radiotherapy within 14 days - 100% patients commencing emergency radiotherapy within 2
days - 98% of patients commencing non-emergency chemotherapy
within 21 days - 98% of patients commencing emergency chemotherapy within 5
days - 35% of patients treated with radical radiotherapy receiving
intensity modulated radiotherapy - 300 patients receiving SBRT/SRS including patients in clinical
trials - 90% patients waiting 20 minutes or less when they attend the
cancer centre - increase the number of patients receiving outreach
chemotherapy to 45% - Work with LHBs to increase access to radiotherapy
Safe and reliable services
- 0 cases of MRSA - 0 cases of MSSA - 0 cases of C.Difficile - 0 cases of hospital acquired pressure ulcers - 0 cases of Hospital Acquired Thrombosis - 100% compliance with sepsis 6 bundle - Reduce the rate of patient harm - Reduce medication errors - Reduce treatment errors - 0 major non compliance in respect of external regulators - Accreditation retention (MHRA etc) - Maintain compliance with Health and Safety and Environmental
Agency regulations Providing evidence based care and research which is clinically effective
- Improve performance against deaths within 30 days of chemotherapy
- Improve performance against deaths within 90 days of radical radiotherapy
- Increase in number of clinical trials open and number of patients recruited
- Increase the number of patients recruited for Phase 1 trials First class patient experience
- 100% patients satisfied - 100% of staff who would recommend Velindre to friends and
family needing care - Increase the number of patients able to access their preferred
place of care - Increase the number of patients dying in their preferred place
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Supporting our staff to excel
- 100% of statutory training delivered - 100% of staff to receive PADR - Sickness absence rate of 3.5% or less - 25% of staff trained to Silver level of IQT
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Cancer Services Plan for 2013/2014 – 2016/2017
Radiotherapy
Quality and Performance Ambitions over the next 3 years
Strategic Theme
Objective Key Actions
Baseline 2012/2013 2013/2014 2014/2015 2015/2016 2016/17 Equitable and timely access to services
98% of patients commencing radical radiotherapy on 28 day pathway
• 94% • 98%
• 98%
• 98% • 98% minimum, to be reassessed
98% of patients commencing palliative radiotherapy within 14 days
• 94% • 98% • 98% • 98% • 98% minimum, to be reassessed
100% of patients commencing emergency radiotherapy within 2 days
• 99.5% • 100% • 100% • 100% • 100%
Increase radiotherapy access to the appropriate rate for patients with
• 37% assumed from RCR
• Establish realistic performance ambitions with LHBs and develop implementation plan, if required, to increase access to radiotherapy for population of South East Wales
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cancer within our resident population
Increase provision of IMRT to 35% of radical plans
• 15% • 24% • 35% • 35% by October 2015
• Reassess target figure
• Identify new target e.g. 50% of radical treatments delivered by inverse planned IMRT)
Develop use of IGRT techniques across tumour sites
• Development of CBCT
• Review IGRT plan to establish baseline clinical need for different imaging techniques by tumour site
• Increase provision over baseline for appropriate sites, in line with IGRT plans
• Develop online imaging provision
Repatriate activity from England and increase the provision of Stereotactic Body Radiotherapy and Stereotactic Radio surgery to 300 patients per annum by 2017
• 24 (12 NSCLC, 12 palliative neurology)
• 36 (18 NSCLC, 18 palliative neurology)
• 50 (20 NSCLC, 20 palliative neurology, 10 others)
• Implementation of full year effect of business case = 220 patients
• 300 patients per annum
Safe and reliable services Reduce treatment
incidents and errors
• Establish baseline and continue to collect incident data
Establish realistic performance ambitions and benchmark with national figures where possible
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First class patient experience
Evaluate current waiting times targets based on clinical need with a view to establishing reduced waiting times for radical specific patient groups including lung and radical neurology patients. Reassess general targets and establish whether JCCO guidelines are still appropriate
• As per Joint Council for Clinical Oncology (JCCO) guidelines
• 14 day pathway for selected H&N cases
• With Service Improvement team develop new pathways for selected lung and neuro cases
• Agree new waiting times targets
• Consolidate new pathways
• Implement new targets
Implementation of RCR guidance on management of interruptions for category 2 patients
• < 5 days • < 5 days • < 2 days for pilot site
• < 2 days for all category 2 patients depending on available resources
• < 2 days for all category 2 patients
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How will we achieve it
Radiotherapy
Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 Equitable and timely access to services 98% of patients commencing radical radiotherapy within 28 days
• Explore service delivery model to ensure optimum use of resources
• Review servicing provision to minimise interruption for patients
• Identify operational service efficiencies and implement
• Develop radiotherapy strategy • Calculate requirement for additional
equipment • Develop business case for additional
LINAC /equipment
• Secure approval /funding for additional equipment
• Develop LINAC/equipment implementation plan and begin implementation
• Develop long term site expansion programme including interim plans for waiting times compliance
• Recruit additional staff
• Site expansion plans to include bunker solution for LA6 replacement
• Further implementation of Linac /equipment plan
• Site expansion plans • Further
implementation of Linac /equipment plan including replacement of LA6 98% of patients
commencing palliative radiotherapy within 14 days 100% of patients commencing emergency radiotherapy within 2 days
• Undertake pathway analysis to maximise staff potential in developed and enhanced roles • Ensure most appropriate servicing model, balancing service needs and financial
considerations
Increase radiotherapy access to the appropriate rate for patients with
• Establish actual baseline for radiotherapy access utilising Malthus programme
• Undertake analysis of each Site Specific Team (SST)
• Identify areas of variation • Collaborate with LHBs and other
cancer centres via COSC to establish an All Wales position for access rates Access Malthus Cymru
• Identify areas of low access across
• Implement plan (if funded)
• Develop business case to improve access
• Secure any additional
• Rerun Malthus to ensure figures continue to be accurate in light of changing practice
• Either maintain current
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cancer within our resident population
SE Wales, South Wales and all Wales and develop plans for resolution with networks, LHBs and COSC
funding required rates or investigate ways to deliver new rates
• Ensure equity Develop a strategic plan for radiotherapy services
• Baseline information and evidence gathering
• Visit Clatterbridge and other centres for benchmarking/ learning
• Engage patients/LHBs/WHSSC • Develop SACT strategy • Consult and secure support/funding • Commence implementation
• Full implementation of strategy
• Further development implementation of next phase of strategy
Embed ongoing strategic development plans for radiotherapy into practice
Evaluate current waiting times targets/ JCCO targets and establish (i). reduced waiting times for tumour sites where there is a clinical benefit e.g. radical lung, radical neuro patients (ii). whether guidelines are still appropriate for all tumour sites and for both radical and palliative patients
• Consolidate new 14 day H&N pathway
• Discuss with SST leads re appropriate pathway for other SST (such as lung/neurology)
• Work with relevant SSTs and staff groups to develop new radical pathways for lung and neurology cases
• Discuss options for new waiting times standards based on clinical need
• Develop proposed new waiting times standards and engage with COSC/networks/Welsh Govt/LHBs
• Discuss any funding requirements with LHB/WHSSC
• Secure funding
• Roll out new pathways at VCC
• Implement new standards
• Influence colleagues in other centres to adopt new standards
• Re-evaluate waiting times targets in light of changing clinical practice and clinical trials results
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Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 Providing evidence based care and research Increase provision of IGRT and adaptive radiotherapy techniques across tumour sites
• Evaluate CBCT requirements for prostate cancer patients
• Establish baseline clinical need for different imaging techniques by tumour site
• Review the need for H&N ART • Develop online imaging for
bladder cancer patients in line with HYBRID protocol
• Review IGRT plan in light of increased demand for online imaging
• Evaluate online imaging requirements including resources
• Develop business case for additional resources required e.g. fiducial marker service) if appropriate
• Secure commissioner support and funding for service development
• Identify priorities for adaptive radiotherapy
• Develop adaptive pathways including review of resources required
• Develop online imaging provision
• Implement in phased approach
• Ensure 4D adaptive radiotherapy available for all patients who would benefit
Increase provision of IMRT to 35% of radical plans
• Implement year 3 of IMRT BC • Implement year 4/5 of IMRT BC • Agree final position for IMRT
Explore ways in which to implement final position if different from IMRT business case
Attain new target figure (?50% of radical treatments delivered by inverse planned IMRT)
Increase the provision of Stereotactic Body Radiotherapy and Stereotactic Radio surgery to 300 patients per annum by 2017
• Commence project for implementation of SRS/SBRT service
• Develop scope of SBRT liver project
• Recruit additional staff required (from CF)
• Implement SBRT lung and SRS/SRT as per stereotactic Business Case
• Work with WHSCC to establish funding stream implementation
• Implement SBRT liver pilot project • Prioritise clinical trials involving SBRT • Ensure representation from VCC at all key
SBRT/SRSD national meetings
Increase SBRT/SRS provision to 220 patients (first full year numbers) to be confirmed by the clinical implementation group
Fully implement BC Reassess total in light of changing clinical practice and available clinical trials
Develop strategic plan for the implementation
• Undertake strategic review of radiotherapy services
• Continue to implement IMRT/IGRT as per RDG approved
• Develop an annual plan through Multi-Disciplinary working and with RDG approval to include IMRT, IGRT, SBRT and SRS/SRT
• Multi-Disciplinary working groups to engage the relevant SSTs to ensure updated and accurate plan reflecting service changes and clinical requirements
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of advanced radiotherapy techniques
plans
Implement Image Guided Brachytherapy for the appropriate gynae cancer patients by 2016
• Explore potential improvements to current pathway
• Development business case and secure funding for Levels 2-4
• Commence implementation of level 3 service
• Implement level 4 service
Action to be removed if plans have been fully implemented
Implement HDR brachytherapy for prostate cancer patients
• Commission HDR Brachytherapy equipment
• Establish baseline clinical need and service ambition
• Establish project group to identify scope of need and resources required
• Identify resource implications • Agree sole treatment/boost/
both and prioritise
• Develop business case and identify/secure revenue funding as required
• Develop pathway for prostate cancer boost treatment
• Implement for pilot group
• Increase provision in line with clinical need and available funding
• Implement HDR for all appropriate prostate cancer patients
• Action to be removed if plans have been fully implemented
Assess clinical need for contact radiotherapy for lower GI patients
• Develop understanding of clinical case/need for development
• Develop clear clinical direction • Develop business case and engage with
LHBs/WHSSC to secure support/ funding if approved
• Implement service / contact radiotherapy plan if approved to progress
• Action to be removed if plans have been fully implemented
MDT development
• Collate development requirements – supra regional for metastatic prostate ca, colorectal multidisciplinary forum
• Work with network and other stakeholders to develop MDT development plan
• Identify priorities and adopt phased approach
• Implement first phase
• Action to be removed if plans have been fully implemented
Analysis of management of
• N/A • Review current management of patients who experience interruptions and compare
• Fully implement plan in accordance
• Action to be removed if plans have been
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interruptions to treatment for all categories of patients in line with RCR guidance
to guidance • Assess practicalities and resource
implications of implementing guidelines • Develop plan to introduce for pilot site • Develop implementation plan for other
sites, as required
with RCR guidance fully implemented
Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 Safe and reliable services Reduce treatment incidents and errors
• Establish baseline of treatment incidents/errors
• Trend analysis undertaken and actions from investigation followed up
• Establish service improvement programme
• Develop systems to review incident and error rates
• Increase number of staff able to investigate incidents
• Benchmark current practice , targets and levels nationally where possible
• Establish performance ambitions • Implement service improvement actions
identified
• Evaluation and agree further action
Review system for reporting and investigating incidents with a view to ensure it is still fit for purpose
Implement Organ Motion Management (OMM) for appropriate patient groups
• Establish scope, timelines and targets for OMM techniques for appropriate SSTs
• Agree clinical priorities giving consideration to respiratory motion management for breast and lung ca patients and OMM for liver, gynae & prostate ca patients
• Develop scope of need and resources required
• Introduce OMM based on clinical priorities and available resources
• Identify resources for OMM based on clinical priorities
• Implement OMM where resources are available for selected patients
• Develop OMM capabilities • Develop business case to secure
support/funding for wider range of OMM application
• Fully implement all OMM techniques in accordance with agreed clinical priorities and available funding
• Review OMM practices to ensure they result in the expected benefit for patients
• Ensure all patients who would benefit from OMM access the appropriate technique/equipment
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Increase provision of advanced “in vivo” dosimetric (IVD) verification
• IVD on 2 Linacs • Assessment and development of
business case to determine way forward for advanced verification through IVD or portal dosimetry
• Evaluate technology options for diode and portal dosimetry verification
• Identification of required equipment and resources • Obtain support/approval from LHBs/stakeholders • Implement according to resource provision
Fully implement advanced verification Ensure that all new and replacement equipment BC considers IVD needs
Introduce functional imaging in radiotherapy planning
• Develop understanding of need • Collaborate with PETIC on future
development plan
• Set up MD working group including PETIC to establish the way forward
• Incorporate functional imaging into radiotherapy planning protocols across VCC
• Develop BC and secure support/funding • Begin implementation for specific tumour sites • Review progress against the agreed plan
• Complete roll out of functional imaging plan
Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 First class patient experience Improve “on the day” waiting times for patients attending the radiotherapy department
• Establish baseline data for patients waiting in the radiotherapy department • Determine service improvement plan • Implement plan – possibly pilot group if appropriate • Audit on the day waits in radiotherapy to ensure average is less than 20 minutes • Work to understand outliers and what can be done to improve these cases
• Ensure waiting times are routinely monitored and maintained
Introduce Holistic Needs Assessment (HNA)for all patients undergoing radiotherapy
• Pilot study in collaboration with Macmillan • Analyse pilot and establish need for roll out
• Develop business case and engage with Welsh Govt/LHBs/ stakeholders to secure ongoing support/funding
•
• Roll out HNA use for appropriate patients in accordance with funding
• Complete roll out of HNA
• Review benefits of HNA
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Develop improved working relationships with HBs to better understand and support referral pathway problems
• Develop links with HBs • Identify key individuals and groups within HBs and across network • Support and aid improvement of referral pathways to ensure patients are referred in the most timely and
efficient manner
• Review current practice to ensure still fit for purpose
Develop a world class cancer campus
• Secure support for cancer campus
• Identify and purchase land
• Undertake feasibility study
• Develop and submit Strategic Outline Programme
• Develop Strategic Outline Case
• Develop Full Business Case (subject to approval of SOC) • Potential enabling works
• Further building works
• Recruit staff • Ensure staff
development continues in line with future needs
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Systemic anti-cancer treatments
Quality and Performance Ambitions over the next 3 years
Strategic Theme
Objective Performance Ambitions
Baseline 2012/2013
2013/2014 2014/2015 2015/2016 2016/17
Equitable and timely access to services 98% of patients
commencing emergency chemotherapy within 5 days
• 93% • 98%
• 98% • 98% • 98%
98% of patients commencing non-emergency chemotherapy within 21 days
• 93% • 95.5% • 98% • 98% • 98%
Increase provision of chemotherapy to patients in an outreach setting
• 32% • 40% • 45% • To be confirmed following development of chemo strategy
• To be confirmed following development of chemotherapy strategy
Safe and reliable services
Reduce medication errors
• No baseline
• Establish realistic performance ambitions
• Achieve agreed targets
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Reduce the post 30 days mortality rate for patients receiving chemotherapy and benchmark against NICE/other organisations
2.5% <2% <2%
First class patient experience
Reduce on-the-day waits in chemotherapy areas
• No baseline • Establish realistic performance ambitions and develop plans to achieve the target
Achieve agreed targets
Further develop Non medical prescribers ensuring that patients receive the most efficient and effective service delivered by appropriate clinical professional
• 24 qualified NMPs in a variety of different roles
• Establish realistic performance ambitions
Achieve agreed targets
Improve patient education and information
• N/A • Review methods of patient education to establish most appropriate
Achieve agreed targets
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methods and then establish current practice in each tumour site and venue
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How will we achieve it
Systemic anti-cancer treatments
Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 Equitable and timely access to services 98% of patients commencing emergency chemotherapy within 5 days
• Link with outreach project to ensure that access is not adversely affected by the increase in demand for services
• Embed the 36 hour rule into service
• Continue to incorporate service improvements into SACT pathway
• Ensure that the chemotherapy services review develops plans to manage the demand
• Once service improvements embedded at VCC, roll out to outreach settings in a controlled way
• Work with SSTs to improve and achieve appropriate medical availability across all SACT pathways
• Ensure that ability to comply with targets is embedded into clinical practice
98% of patients commencing non-emergency chemotherapy within 21 days
Ensure ongoing access to NICE & AWMSG approved drugs
• Continue to ensure all NICE/AWMSG approved new drugs are available to our catchment population
• Engage with WG and LHBs to ensure ongoing equitable access for all approved drugs
• If appropriate develop business case for funding for new NICE/AWMSG approved drugs
• Extend engagement to include all other drugs
Ensure ability to comply with standards is embedded into clinical practice
Develop strategic plan for SACT services
• Baseline information and evidence gathering
• Visit Clatterbridge and other centres for benchmarking/ learning
• Engage patients/ LHBs/WHSSC • Develop SACT strategy • Consult and secure support/funding • Commence implementation
• Full implementation of strategy
Review SACT strategy and update to reflect changing clinical practice
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Increase patients receiving outreach chemotherapy to target in line with the “25 minute travel time” target
• Review outreach services in order to inform and develop appropriate targets
• Develop a sustainable plan to move services
• Work towards agreed targets with LHBs
• Review of services to ensure correct balance between centre and outreach
Ensure appropriate balance is maintained
Increase provision of homecare services
• Analyse implications of WG policy direction
• Review current contracts for homecare provision
• Engage with appropriate stakeholders to establish optimum configuration
• Develop/agree service model with LHBs and secure required funding
• Develop implementation plan
• Implement plan
• Review provision of homecare in light of changing patient needs and clinical practice
Review optimum venue for administration of blood transfusions (BTs)
• Undertake a review of current venues (centre and outreach)
• Establish pathway for current practice
• Agree optimum configuration of transfusions undertaken between centre and outreach
• Engage with LHBs to agree a way forward for the administration of BTs to ensure the best service for patients
• Develop SLAs to allow implementation in outreach clinics
• Repatriate patients to host LHB as per agreed plan
• Review progress and sustainability to ensure safety and patient satisfaction
Action to be removed if plans have been fully implemented
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Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 Safe and reliable services Establish an e prescribing system which allows transfer of patient care across organisational boundaries and implement an e prescribing solution for solid tumours at VCC
• Complete review of current e-prescribing processes
• Establish if there is a need for a BC to support a single e-prescribing system across South Wales
• Configure and test third party solution
• Schedule a pilot at VCC
• Implementation of the solution into the VCC live environment • Roll out solution across the network in agreement with stakeholders • Engage with external partners to ensure that the system will enable patients to receive their anti
cancer treatments closer to their homes, across LHB boundaries where necessary • Rationalise services to ensure joined up care for patients within and out with our catchment area
Engage in network wide chemo project
• Development of agreed standards for chemotherapy across the network
• Work with HBs/WG to ensure that VCC is able to implement the new standards
• Ensure standards are embedded into clinical practice
Implement the Welsh Clinical Portal to include Medicines Transcribing and electronic Discharge within VCC
• Identify scope of project with key personnel including IT
• Liaise with colleagues at NWIS to agree an implementation date
• Identify dependencies and schedule accordingly
• Undertake process mapping exercise to establish workflow
• Engage with stakeholders at VCC to ensure seamless roll out
• Determine actions required to implement plan
• Implement plan such that MTeD is utilised for 100% of patients discharged
Action to be removed if plans have been fully implemented
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Reduce medication errors
• Establish baseline of medication errors
• Trend analysis undertaken and actions from investigation followed up
• Establish service improvement programme
• Develop systems to review incident and error rates
• Increase number of staff able to investigate incidents
• Benchmark current practice, targets and levels nationally where possible
• Establish performance ambitions to include medicines reconciliation within 24 hours, reduction in omitted or delayed pharmacy doses and dispensing errors
• Implement service improvement actions identified
• Evaluation and agree further action
• Achieve agreed targets
Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 First class patient experience Reduce on-the-day waits in chemotherapy areas
• Gather baseline data ‘wait times’ for each area
• Trend analysis undertaken and actions from investigation followed up
• Engage with patients to gain views on standards / areas for improvements
• Establish service improvement programme
• Establish waiting times internal standard
• Develop and implement service improvement plan
Assess effectiveness of improvements
Ensure waiting times are routinely monitored and maintained
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Further develop Non medical prescribers ensuring that patients receive the most efficient and effective service and maximising skill set of different clinical professions
• Identify resources required to undertake a project to review current service, optimum numbers and configuration of NMPs
• Ensure project scope includes future needs and sustainability
• Address the gaps in service where there is no or low NMP cover
• Identify forecasted increase in demand and reflect this in the new NMP configuration
• Identify sources of funding to implement findings of the review
• Ensure that all NMPs have appropriate job planning to address areas of need
• Review provision of NMPs to ensure best outcomes for patients
Assess and provide appropriate patient education
• Review group education sessions for capecitabine and other general chemotherapy education groups
• Undertake scoping exercise to establish gaps in current service and next steps
• Agree a preferred model of provision with patients and staff • Ensure phone service for concordance included in revised model • Identify additional resource requirement and secure funding • Develop implementation plan • Implement model • Review and evaluate practice to ensure patients receive and understand their instructions
Review clinical workforce for prescribing/delivery of chemotherapy/SACT
• Undertake pathway analysis to ensure optimum roles across the SACT pathway
• Agree optimum model for clinical staff
• Develop additional/ appropriate roles and role development
• Work with senior management to ensure all opportunities for role
• Ongoing review to ensure best clinical model for patients
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• Review workforce in terms of skill mix
redesign and improved skill mix are realised
• Indentify resource implications and secure funding
• Implement improvements • Evaluation of improvements
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Improving quality, safety and our staff
Quality and Performance Ambitions over the next 3 years
Strategic Theme
Objective Key Actions
Baseline 2012/2013 2013/2014 2014/2015 2015/2016 2016/17 Equitable and timely access to services Secure ongoing
funding for “at risk” posts e.g. CNS
• Multiple posts across VCC being funded by non establishment means
• Identify the posts at risk and establish the loss to service if funding ceases
• Ensure all essential posts at VCC have secure funding
Safe and reliable services
Reduce healthcare associated infections to zero
• C diff full year actual = 12
• MRSA full year actual = 0
• MSSA actual = 7
• C diff target = 10 • MRSA = 0 • MSSA target = 0
• C.diff = 0 • MRSA = 0 • MSSA target = 0
• C.diff = 0 • MRSA = 0 • MSSA = 0
• C.diff = 0 • MRSA = 0 • MSSA = 0
Reduce Velindre acquired pressure ulcers to zero
• 0 • 0 • 0 • 0 • 0
Reduce the number of patients discharged with hospital acquired thrombosis
• Not available • 0 • 0 • 0 • 0
Reduce incidents of patients with septicaemia to zero
• Not available • 0 • 0 • 0 • 0
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Undertake mortality review of all deaths at VCC
• 100% • 100% • 100% • 100% • 100%
First class patient experience
Increase the number of patients that die in their preferred place
• Baseline not available
• Establish realistic performance ambitions
Achieve agreed target
Increase the number of patients who access their preferred place of care
• Baseline not available
Establish realistic performance ambitions
Achieve agreed target
Increase patient satisfaction
• 95% • 100% in key areas • 100% in key areas • 100% in key areas
• 100%
Reduce “on the day” waiting times within the centre to less than 20 minutes or as appropriate dependent on service
• N/A • Establish realistic performance ambitions
• 20 minutes in pilot area
• To be confirmed following results of pilot
• <20 minutes
Supporting our staff to excel Increase the % of
staff who would recommend Velindre to friends and family needing care
• N/K • 65% • 70% • 75%
• 80%
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Support staff to receive all required statutory and mandatory training: ≥95% statutory training ≥95% mandatory training
To be confirmed when ESR data is robust
• Establish realistic performance ambitions
95%
Ensure all staff have a PADR
30% 50% 70% 90% 100%
Reduce sickness absence levels to improve staff attendance:
- sickness absence rate of 3.5% or less
4.01% 3.5% 3.4% 3.3%
3.3%
Develop capacity, capability and leadership to deliver strategic change
N/A N/A Roll out IQT Training initiative: Bronze Level – Staff Silver Level – Managers
Roll out IQT Training initiative: Bronze Level – Staff Silver Level – Managers
Roll out IQT Training initiative: Bronze Level – Staff Silver Level – Managers
Develop talent management and succession planning within the service
N/A Review Pilot outcomes of VCC talent management initiative
Review PADR arrangements dependent on Pilot outcomes
Consider full roll out of revised PADR dependent on Pilot outcomes
Consider full roll out of revised PADR dependent on Pilot outcomes
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How will we achieve it
Improving quality, safety and our staff
Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 Equitable and timely access to services Secure ongoing funding for “at risk” posts e.g. CNSs
• Establish number of at risk posts • Confirm posts are essential to ongoing
patient care
• Engage with LHBs to ensure that essential roles are appropriately funded in order to continue the Trust’s standards of care
• Establish ongoing secure funding for all essential roles within the Cancer Centre
• Establish ongoing secure funding for all essential roles within the Cancer Centre
Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 Safe and reliable services Reduced healthcare associated infections to zero (MRSA, MSSA and C.Difficile)
• Continue with education and awareness programmes
• Focus on increasing compliance with hand hygiene bundle
• Work with colleagues throughout VCC to establish further mechanisms for preventing C diff including improving hand hygiene compliance
• Review prescribing of antibiotics to minimise the risk of C. diff
• Routinely screen all patients admitted to VCC for MRSA
• Develop pathway to ensure that screening is undertaken and acted upon where appropriate
• Continue to monitor
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Development of the Acute Oncology Service across SE Wales
• VCC establish AOS ‘hub’ • Evaluate pilot • Provide support for development
of AB spoke
• Based on outcomes of the Aneurin Bevan pilot, engage with the network to agree next steps for further spoke services
• Develop business case and secure support/funding from LHBs/stakeholders
• Support other Health Boards to develop AOS for their populations, linking to unscheduled core agenda as appropriate
• Support development of further spoke services if funded
• Ensure that plan encompasses VCC catchment population such that AOS are equally available
Action to be removed if plans have been fully implemented
Reduce Velindre acquired pressure ulcers to zero (national target)
• Continue to utilise care bundles / audit use of care bundles
• Develop wider information/ awareness across the hospital
• Work with colleagues across region to shared/learn from best practice in preventing pressure ulcers
• Work with primary care providers through the HBs to identify at risk cancer patients to support the reduction of pressure ulcers experienced at home
• Continue to monitor
Reduce the number of patients discharged with HAT
• Undertake RCA of patients diagnosed with HAT
• Implement best practice across wards
• Audit practice to ensure that: • 100% of patients who have risk assessment
completed • 100% of patients considered high risk who have had
appropriate thromboprophylaxis prescribed
• Continue to monitor
Reduce the rate of patient safety incidents
• Define terms and targets for this measure across the different services
• Ensure accurate and complete data collection is possible
• Work across the Division to improve the incident rate through RCA, analysis of trends and shared learning
• Benchmark with similar organisations where possible to ensure robust targets are in place
• Achieve targets • Continue to improve rates
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Improve management of septicaemia by achieving 100% compliance with the response to the bundle for sepsis
• Audit of NEWS and sepsis bundle • Enhance clinical leadership / focus
on sepsis • Continued focus / audit of CAUTI
insertion and maintenance bundles • Continue to publicise/champion
the sepsis care bundle • Improve communication with LHBs
for patients with sepsis • Audit compliance with bundles
• Explore benchmarking with other LHBs etc
• Continue to identify, share and implement best practice from around the world
• Conclude work on bed criteria with possibility of introducing step-up beds to support patients with sepsis on-site
• Continued focus / audit of CAUTI insertion and maintenance bundles
• Audit compliance with bundles
• Assess if further action is required as a result of the audit
• Evaluation of progress
Objective Key Actions
2013/2014 2014/15 2015/16 2016/17 First class patient experience Increase the number of patients who can access their preferred place of care
• Establish baseline within the end of life priorities
• Work with partners to establish appropriate data capture for all patients
• Engage with patients /families/carers • Develop plan with LHBs/third sector to ensure that the
plan is integrated and that patients discharged from VCC to their preferred place of care are referred to specialist palliative care in that setting if appropriate and needed
• Finalise plan and resourcing • Implement plan
• Evaluation and review
Increase the number of patients that die in their preferred place
• Establish baseline within the end of life priorities
• Work with partners to establish appropriate data capture for all patients
• Engage with patients /families and carers
• Develop plan with LHBs/third sector such that patients with “Welsh integrated care priorities at the end of life” documentation
• Evaluation and review
• Investigate areas of non compliance to ensure all
• Continue to monitor and achieve targets
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in place can access their preferred place of death
• Finalise plan and resourcing • Implement plan
stakeholder organisations meet the requirement
Ensure that 100% of palliative care patients have an POS-S or equivalent assessment within 24 hours of referral
• Establish a baseline of current assessment
• Develop a plan to ensure that the palliative care team are available to undertake the assessments
• Implement plan to ensure that all patients have a POS-S assessment
• Introduce monitoring/audit of POS-S
• Re-audit practice to ensure compliance
• Establish plan for remedial action if areas of audit show non compliance
• Continue to monitor and achieve targets
Improve support for patient’s carers and their families
• Develop and implement Carer’s strategy, including processes for identification of carers and training for them
• Develop carer’s information pack • Develop and implement Carer’s
awareness Training
• Increase the number of staff who attend Carer’s awareness training
• Establish a new post to support the supportive care team in the provision of services and support to meet the needs of carers
• Roll out the carer’s information pack
• Continue to monitor and achieve targets
To implement the Trust’s action plan for “Together for Mental Health” and ensure patients and staff receive the care/support they require to ensure mental well being
• Trust will aim for Platinum award for corporate health standard
• Embed the excellent work undertaken by the “Dementia and cognitive impairment nurse” across the Division, including picture menus, environmental improvements
• Continue to offer complementary therapies to patients, carers and staff
• E-hna pilot to become embedded
• Continue work, led by the clinical psychologist, on the project re holistic needs assessments for patients; rolling out to other cancer sites where possible
• Develop pathways for inpatients who have a co-morbid drug and /or alcohol problem
• Review the action plan and update to reflect changing priorities to meet the requirements/needs against this strategy
• Achieve actions contained within revised plan
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Increase patient satisfaction
• Develop and introduce routine patient satisfaction recording as follow up of national pilot
• Explore with patients, carers and patient representatives the causes of any dissatisfaction experienced at VCC
• Utilise lessons learned from concerns procedure to support satisfaction scores
• Identify key areas for Cancer Centre • Develop appropriate improvement plans / secure
resources and implement improvements • Re-audit to ensure patient satisfaction is attained/
maintained
• Continue to monitor and achieve targets
Ensure that people living with and beyond cancer have a personalised assessment, information and care plan and are empowered to manage their condition
• Continue to work towards patients who are better informed and prepared for the long term effects of living with and beyond cancer
• Raise patient and public awareness of available programmes and support • Work with internal and external colleagues to ensure a full understanding that survivorship and
rehabilitation for people with cancer begins at diagnosis and continues with regular reassessment throughout their journey
• Continue to monitor and achieve targets
Reduce “on the day” waiting times within the centre to less than 20 minutes
• Establish project group • Undertake data capture exercise for on the day waits in key areas within VCC e.g. OPD • Utilise IQT methodology to identify areas of concern and possible changes to secure
improvements • Develop a business case to introduce automated check in facilities for patients at VCC and s
secure funding • Share learning from different areas to maximise the improvements
• Ensure waiting times are routinely monitored and maintained
Stratify follow up for breast cancer patients
• Establish a Network wide project in liaison with Macmillan
• Clearly identify scope, deliverables and
• Identify recommendations and development of an action plan
• Develop plan • Ensure all relevant
findings from
• Identify other SSTs where follow up could be improved in this way
• Identify other tumour sites that would benefit • Develop plan and begin roll out to other tumour
sites
• Action to be removed if plans have been fully implemented
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timescales project implemented by SST
• Consider VIP event for breast cancer services at VCC
Further develop “key worker” concept
• Work with CIG/network project to approve definitions and establish baseline
• Develop partnerships with LHBs to identify any gaps, new roles and resource requirements
• Develop plan to increase the number of patients with key workers • Implement plan with key worker concept/roles going across
organisational boundaries • Further engage with LHBs and 3rd sector to ensure patient pathways
have an identified key worker
• Evaluate and review project • Identify if any areas of non
compliance and plan remedial action
Improve the patient environment where necessary
• Undertake urgent compliance work
• Prioritise patient areas for improvement beginning with first floor ward • Undertake improvements in other patient areas – wards, OP, theatres • Review patient environment with external partners and patient/carer
representatives • Work with HBs to provide the most appropriate accommodation for
patients in an outreach setting
• Incorporate into ongoing site development plans
Establish ‘step-up fed facility’ at VCC
• Establish need/requirement for step-up facilities including identification of resource
• Develop and implement the step up facility
• Work with Health Board critical care colleagues to assess VCC’s requirement for step-up facilities (now and in future)
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Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 Providing evidence based care and research Develop a system for accurate and complete collection of toxicity data
• Identify scope of project in collaboration with SACT, IT and RDG
• Utilise SABR implementation project to highlight issues with IT solutions for toxicity data
• Ensure acute data collected by any method
• Identify long term solutions available for data collection including appropriate IT support
• Secure necessary funding
• Work across network to ensure IT solutions available in each OP setting
• Ensure that each SST undertakes detailed and accurate acute & late toxicity data collection for use in assessment of patient outcomes
• Review process for data collection and ensure still fit for purpose
Develop performance information for post 90-day mortality rates for patients receiving radical radiotherapy
• New measure • Establish baseline • Agree collection methodology /
definitions
• Test data quality with peers
• Publish data • Utilise data to inform
ongoing improvement clinical/ technological programme
• Utilise data to inform ongoing improvement clinical/ technological programme
Reduce the post 30 day mortality rates for patients receiving chemotherapy
• Establish baseline • Agree collection
methodology / definitions
• Test data quality with peers • Publish data • Utilise data to inform ongoing
improvement clinical/ technological programme
• Ensure ongoing programme of improvement is embedded in day to day practice
• Utilise data to inform ongoing improvement clinical/ technological programme
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Objective Key Actions 2013/2014 2014/2015 2015/2016 2016/17 Supporting our staff to excel Increase the % of staff who would recommend VCC to friends and family needing care
• Establish reasons why some staff would not recommend VCC
• Establish project group across professions and work areas
• Work with staff across the Division to respond to concerns regarding recommending VCC
• Ensure staff concerns are addressed
• Re survey staff on this particular question
• Develop a plan for any outstanding remedial actions
Support staff to receive all required statutory and mandatory training: ≥95% statutory training ≥95% mandatory training
• Develop robust training schedule
• Appointment of Trust-wide statutory and mandatory trainer
• Core skills matrix: e-learning to be promoted and rolled out from 2013 onwards
• MSS/ESS rollout for OLM in 2013/14 enabling employees to self-book onto courses
• Proactive monitoring • Review of training resource • Ensure departments/ services have a
training plan to ensure that compliance is attainable
• Proactive monitoring • Adjust training plans to
reflect changes in practice or evidence
• Review compliance and create plan to rectify any areas of concern
• Adjust training plans to reflect changes in practice or evidence
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Ensure all staff have a PADR
• Appraiser training
• Monthly monitoring with departments
• Preparation of progress statistics
• Reports and feedback on progress to SMT
• Updated PADR paperwork
• Monthly monitoring with departments • Preparation of progress statistics Reports and feedback on progress to SMT
• Reports and feedback on progress to SMT
• Ensure that ongoing department and service plans include workforce, training and reflect PADR outcomes
Reports and feedback on progress to SMT Ensure that ongoing department and service plans include workforce, training and reflect PADR outcomes
Reduce sickness absence levels to improve staff attendance to 3.5% or less
• Return to work interviews
• Use of Occupational Health assessments
• Sickness audits • Stress risk
assessments • Use of sickness
policy • Promotion of
Health and Wellbeing initiatives
• Return to work interviews • Use of Occupational Health
assessments • Sickness audits • Stress risk assessments • Use of sickness policy • Promotion of Health and Wellbeing
initiatives
• Return to work interviews • Use of Occupational Health assessments • Sickness audits • Stress risk assessments • Use of sickness policy • Promotion of Health and Wellbeing initiatives
Manage staff work / life balance
• Consider applications in line with the Work-life Balance Policy
• Provision of support services
• Consider applications in line with the Work-life Balance Policy
• Provision of support services e.g. advice and counselling through Employee Assistance Programme (EAP)
• Provision of childcare vouchers, holiday child subsidy scheme
• Consider applications in line with the Work-life Balance Policy
• Continued provision of support services, childcare vouchers, holiday child subsidy
• Review compliance and create plan to rectify any areas of concern
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e.g. advice and counselling through Employee Assistance Programme (EAP)
• Provision of childcare vouchers, holiday child subsidy scheme
scheme • Review supportive
structure and identify areas for further development
Develop capacity, capability and leadership to deliver strategic change
N/A • Roll out IQT Training initiative: Bronze Level – Staff Silver Level – Managers
Develop talent management and succession planning within the service:
• Explore with NLIAH funding for scientific training post in line with modernising scientific careers
• Review Pilot outcomes of VCC talent management initiative
• Develop succession plan and business case for NEQAS H&I Director post
• Review PADR arrangements dependent on Pilot outcomes
• Consider full roll out of revised PADR dependent on pilot outcomes
Provide and support advanced technical training
• Assess training needs of the appropriate staff groups
• Identify training opportunities to ensure advanced techniques, technologies and ways of working can be implemented in a timely manner
• Secure funding stream
• Ensure plan is robust, flexible and sustainable to adjust to changing needs
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Research and development
The Trust’s vision for research states that we will accelerate “bench to clinic” development of innovative treatments, provide state of the art facilities to attract and retain world leading staff and create a vibrant research hub. Velindre Cancer Centre wants to provide the required resources and technology to facilitate the delivery of evidence based care and research that is at least comparable with the best in the world.
Objective
Key Actions
Baseline 2013/2014
2014/2015 2015/2016 2016/17
Increase recruitment to radiotherapy clinical trials
All appropriate NCRI radiotherapy trials open with VCC within acceptable timeframe
• Regular review of NCRI trial portfolio by RT Trials group to ensure VCC is open to all appropriate trials
• Technical requirements for upcoming trials identified and prioritised within RDG and associated working groups
• Local RTTQA requirements completed without incurring delaying the opening of trials
Evaluate practice for establishing clinical trials and ensure that it is still fit for purpose
Increase early phase/locally funded/ ’pathway to portfolio’ trial activity
FIGARO and BIOPROP to open and recruit to target
• Technical requirements for FIGARO and BIOPROP supported by RT Trials group and associated working groups
• Technical requirements for upcoming ‘pathway to portfolio’ trials considered by RT Trials group and associated working groups and submitted to RDG for approval
Ensure recruitment targets are met through active monitoring and engagement
Increase national RTTQA activity
Annual strategic plan for expansion of Cardiff RTTQA approved by R&D committee
• RTTQA management group to develop a strategic plan for expansion of trial work and associated research
• RTTQA management group to manage trial specific work: development of RT protocol, RTTQA programme, pre-trial and on-trial work, presentation and publication of results
• RTTQA management group to support appropriate funding for novel research concepts
Ensure recruitment targets are met through active monitoring and engagement
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Increase tissue collection for the Wales Cancer bank
• Upper GI/lung • Charitable funds support
for tissue collection post
• Establish need in each tumour site
• Collaborate with Local Health Boards to achieve 20% of patients consenting to donate tissue to the Welsh Cancer Bank.
• Collaborate with Local Health Boards to achieve 20% of patients consenting to donate tissue to the Welsh Cancer Bank.
• Ensure targets are met • Review targets in line
with changing clinical priorities
Increase recruitment into clinical trials activity in line with and beyond national targets where possible
• Target = 10% of newly diagnosed cancer patients recruited into well designed cancer studies
• Actual = 18%
• 10% • Increase the number of patients recruited into interventional clinical trials, contributing to the overall NISCHR target of 7.5%.
• 20% of patients each year recruited into clinical trials, contributing to the overall NISCHR recruitment target of 10% of patients into clinical trials.
• Patients entered into all national cancer trials in the UK (subject to national approval).
• 5% of all national cancer trials in the UK to have a Velindre principal investigator.
Ensure maximum possible portfolio of clinical trials across tumour sites
• Establish baseline • Identify areas of growth and opportunity • Achieve 30% of disease groups to include national or
international leaders
• Review targets in light of changing priorities
Further develop capability and capacity to provide phase 1 trials across the disciplines
• Establish Early Phase research team
• BC for ongoing funding for phase 1 trials
• Identify areas of growth and opportunity • Set realistic but challenging targets for numbers of trials
across a range of tumour sites and disciplines
• Assess capability and capacity to ensure no areas of concern
Develop an interventional radiology programme
• New measure • New measure • Engage with stakeholders to establish strategy and
appropriate measures
• Implementation of strategy
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Review space and accommodation issues connected to progressing the R&D agenda
• Cancer Centre wide accommodation project
• Develop a plan to highlight issues of accommodation and R&D in line with other infrastructure demands
• Engage with external partners and stakeholders to explore innovative ways in which to deal with this issue
• Review current plan and ensure it remains fit for purpose
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Section 5: Improving the quality of Blood and Transplantation Service: Priorities and Action Plan 2013 - 2017
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Where do we want to be by 2017: Our Vision of Excellence
Provide leading blood services:
- we want to be recognised as a blood service of excellence. - we want to provide leading edge services and technology which advance best practice
in blood, blood components, stem cell donation and transplant immunology services. - we want to continuously improve the standard, safety and compliance of the service.
Delivering the Welsh Blood Service experience
- we want to provide donors with the best care and experience possible. - we want donors to routinely recommend us to friends and family without second
thought. - we want donors to feel part of our family, enjoy the time they spend with us and feel
fully valued for their life saving contribution. - we want to attract and retain the best staff who share our values and ethos. - we want to extend our work with local communities and educational providers to
develop and improve our services. - we want to improve the standard of premises where donors donate. Meeting the needs of donors and partners - we want to continue to modernise services to provide improved access at a time and a
place that is convenient to donors and is balanced with the needs of the service. This will support us in developing a donor base that meets future needs.
- we want to attract more donors, and particularly those aged between 18 and 30. - we want to recruit new donors who are able to increase the number of Bone Marrow
Volunteer samples (BMV). - we want to tailor our offering to provide donors with more opportunities to donate - we want to further develop our expertise and portfolio of diagnostic and transplant
immunology services to meet both the needs of patients in Wales and our international customers.
- we want to work with key stakeholders to achieve the maximum benefit from the establishment of an all-Wales Blood Service.
- we want our partners to rate our service as excellent.
Outcomes comparable with the best elsewhere
- we want to have clinical outcomes that are comparable with the best elsewhere. - we want to develop better information systems to measure our clinical outcomes and
share information with our partners and donors. - we want to work across Wales to promote best practice in blood supply management
and operate supply chain models that are the most efficient and effective possible making sure every ‘drop’ counts
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NIBTS NHSBT SNBTS WBS IBTS Average2004/05 83.80% 88.00% 84.80% 84.28% 79.80% 84.14%2005/06 83.01% 86.86% 82.12% 82.06% 80.67% 82.94%2006/07 82.33% 85.43% 80.78% 83.84% 79.64% 82.40%2007/08 81.62% 85.35% 80.40% 85.26% 80.09% 82.54%2008/09 81.25% 85.78% 81.77% 84.59% 81.26% 82.93%2009/10 81.01% 86.44% 83.44% 84.74% 83.98% 83.92%2010/11 83.27% 87.15% 84.27% 81.48% 84.60% 84.15%2011/12 83.65% 88.24% 85.41% 85.20% 84.37% 85.38%Effect of Best Practice (Additional Donors Bled)
3,254 NA 6,871 3,484 6,708 20,316
Benchmarking our service
The Welsh Blood Service has a strong tradition of benchmarking with all UK blood services and in 2002 a subcommittee of the UK Forum was established to help enhance inter-blood service communication on a range of financial and non performance related issues, thereby identifying future risks, opportunities and service improvement requirements.
A range of key performance indicators have been agreed between the four UK and the Irish Blood Services. By measuring relative performance, services have the opportunity to identify areas of improvement and learn from the best practices of others.
The Welsh Blood Service is able to evidence positive improvement over the years in many of these indicators.
Donations/Donors Attending
Fig. 15 Number of whole blood donations recorded per 100 attending donors
Average deferral rates improved for the 5th year in succession to a record 85.38% (from 84.15%). All countries, with the exception of Ireland, saw reduced levels of donor deferral in 2011/12. The level of deferral is now slightly above that seen in 2004/05 although this disguises the fact that the introduction of several more stringent eligibility measures has had to be recovered. The Welsh Blood Service showed a marked increase in the year which is related to a re-introduction of Malaria and Hep B core testing.
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Apheresis NIBTS NHSBT SNBTS WBS IBTS Average2005/06 13.50% 8.40% 9.70% 8.40% 9.40% 9.88%2006/07 8.71% 8.98% 8.66% 6.04% 8.62% 8.20%2007/08 5.70% 8.13% 9.90% 4.50% 8.90% 7.43%2008/09 10.18% 9.20% 10.50% 5.13% 11.77% 9.36%2009/10 12.15% 8.71% 10.98% 7.45% 17.28% 11.31%2010/11 9.01% 7.99% 16.87% 8.28% 14.56% 11.34%2011/12 5.70% 6.05% 14.59% 4.52% 11.50% 8.47%
NIBTS NHSBT SNBTS WBS IBTS Average2004/05 94.30% 94.30% 93.20% 95.60% 92.90% 94.06%2005/06 94.70% 95.12% 92.98% 95.41% 94.10% 94.46%2006/07 94.17% 95.18% 93.60% 96.23% 94.25% 94.69%2007/08 93.80% 95.42% 93.72% 95.78% 94.66% 94.68%2008/09 93.14% 95.18% 94.20% 96.02% 94.64% 94.64%2009/10 91.59% 95.18% 94.18% 96.04% 95.81% 94.56%2010/11 92.07% 95.57% 93.67% 95.70% 95.57% 94.52%2011/12 92.44% 95.68% 94.33% 94.00% 95.28% 94.35%Effect of Best Practice (Additional Donations Saved)
1,920 NA 2,792 1,644 578 6,935
Combined Processing and Collection Losses
The difference combines session related losses and processing/testing related losses.
Fig. 16 Number of banked, or validated, red cell units per 100 whole blood donations
Platelet Wastage - % Expiry
This indicator measures the number of platelet doses expiring within the Blood Services as a percentage of validated platelet doses produced. Overall losses due to expiry reduced from 12.57% in 2010/11 to 8.88% in 2011/12, the lowest level ever reported.
Apheresis Platelet Expiry
Fig. 17 % expiry platelet expiry for comparable blood services
Apheresis wastage is a particular focus as the cost of this product is significantly higher than for pooled platelets. The overall level of wastage reduced for the first time in 4 years and markedly so. The large variation between countries shows that there is still significant potential to unlock savings.
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Pooled NIBTS NHSBT SNBTS WBS IBTS Average2005/06 12.60% 7.70% 16.20% 9.30% 17.80% 12.72%2006/07 12.46% 8.19% 15.33% 6.07% 16.69% 11.75%2007/08 14.60% 8.23% 14.70% 7.60% 11.30% 11.29%2008/09 18.24% 10.60% 13.50% 8.75% 13.83% 12.98%2009/10 15.96% 11.13% 15.04% 13.97% 15.40% 14.30%2010/11 17.21% 11.73% 21.64% 13.59% 22.18% 17.27%2011/12 6.31% 10.94% 14.37% 4.68% 16.42% 10.54%
Total NIBTS NHSBT SNBTS WBS IBTS Average2005/06 13.30% 8.00% 12.40% 8.80% 14.60% 11.42%2006/07 10.15% 8.62% 11.31% 6.05% 13.57% 9.94%2007/08 8.70% 8.17% 11.80% 5.80% 10.16% 8.93%2008/09 12.78% 9.70% 11.70% 6.58% 12.64% 10.68%2009/10 13.51% 9.31% 12.47% 9.45% 16.68% 12.28%2010/11 10.12% 8.79% 18.10% 9.52% 16.33% 12.57%2011/12 5.77% 6.91% 14.54% 4.55% 12.63% 8.88%
0.00%2.00%4.00%6.00%8.00%
10.00%12.00%14.00%16.00%18.00%20.00%
NIBTS NHSBT SNBTS WBS IBTS Average
Platelet Expiry % 2005/062006/072007/082008/092009/102010/112011/12
Pooled Platelet Expiry
Fig. 18 % Pooled platelet expiry
Pooled platelet expiry has reduced to its lowest level in the last 8 years. Pooled platelet expiry has benefited from many of the positive influences described under apheresis expiry. The predictability and reliability of apheresis supply is a key factor in being able to minimise pooled platelet production. The Welsh Blood Service has the lowest overall expiry rate (4.55%) Total Platelet Expiry
Fig. 19 Total platelet expiry
Fig. 20 % Platelet expiry
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In addition to UK service comparative data the Welsh Blood Service contributes to the European Blood Alliance (EBA) benchmarking group. Established in 2006 the EBA executive group have taken a four phase approach, namely:
• Assess variation in EBA member operational practices and performance • Identify the key factors that underpin good practice • Support EBA members with the implementation of those factors • Monitor and publish EBA Member examples of operational development, and as a
consequence, performance improvement across a range of metrics.
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Forecast Demand for services
Whole blood
Fig. 21 Forecast red blood cell demand
In recent times there has been a year on year reduction in the size of the whole blood donor panel. Although this has been roughly parallel to a reduction in demand for red cells, in line with other UK services, it is anticipated that there will be an increase in demand for whole blood to meet the needs of an ageing population.
A priority for the service is to stem the loss of long term donors from the established panels and recruit new donors that will become lifetime volunteers. It will achieve this by putting in place a modernised service that meets the needs of changing demographics and lifestyles, and by employing recruitment strategies that will improve donor loyalty.
The management of blood collection and provision of blood products to North Wales’ hospitals is currently administered and managed by NHSBT. However, in line with the Welsh Government vision of how the NHS will look in five years, the Minister for Health and Social Services announced on the 13th June 2012 the need to establish an all-Wales Blood Service. As such, North Wales’ collection and provision will transfer to the Welsh Blood Service by 2016.
The number of units collected from Welsh clinics does not meet the demand for whole blood in the region to customer hospitals. The shortfall is supplied from NHSBT stocks collected from outside Wales.
The shortfall in collection will need to be met by the Welsh Blood Service following the transfer and establishment of an all-Wales Blood Service by 2016. The WBS has identified opportunities to increase collection to address the shortfall:
• New sessions identified in areas not currently serviced by NHSBT;
0
20000
40000
60000
80000
100000
120000
2013/14 (WBS) 2014/15 (WBS) 2015/16 (All Wales Blood
Service)
2016/17 (All Wales Blood
Service)
Red Blood Forecast Demand
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• Increased session times or substitute panels; and, • Where current sessions are below capacity, and local donor relations knowledge
suggests that increase in capacity is achievable. The potential for additional collection activity will require investment to support the development of new donor panels that will require time to establish themselves. New donor recruitment will require a targeted campaign of activity between now and 2015 to ensure that the additional donors required have been recruited and are attending in preparation for the transition to the WBS by 2016.
The Welsh Blood Service is therefore assuming steady state +/-1% over the forthcoming 3 years in terms of demand for whole blood including North Wales’ provision.
Platelets
Fig. 22 Forecast platelets demand
The outlook for platelets is one of increasing demand. Platelets can be prepared from a number of whole blood donations (4) and then pooled, or directly from individual donors using a process known as apheresis. Apheresis is a procedure for collecting blood components. The device separates a certain blood component from blood, and the remainder returns into the blood donor’s circulatory system. This automated process makes it possible to collect between 1 and 3 adult therapeutic doses of platelets from a donor in a single setting. Because only very few red blood cells are taken during apheresis, donors can give platelets more often than they can give whole blood.
In 2011/12 the overall demand for platelets increased significantly by just over 8% in Wales with a total of 9,535 platelets issued to customer hospitals across South, mid and West Wales, of which 24.8% were pooled and 75.2% derived from apheresis collection. This stabilised in 2012/13 and is currently on track to increase by 2.7% during 2013/14
0 2000 4000 6000 8000
10000 12000 14000
2013/14 (WBS) 2014/15 (WBS) 2015/16 (All Wales Blood
Service)
2016/17 (All Wales Blood
Service)
Platelets Forecast Demand
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compared to the previous year. Demand in North Wales for the same period (currently serviced by NHSBT) amounted to a total of 2,029, of which 17.3% were pooled, 82.6% derived from apheresis collection and nearly 10% requiring Human Leukocyte Antigens (HLA) matching.
We anticipate that our current donor base is capable of meeting overall platelet demand in the near term, but will need to invest in a long term recruitment and retention strategy to meet the projected 5% growth in demand by 2016. This strategy will also need to factor the additional collection requirements arising to support North Wales’ service provision and ensure capacity to meet a potential increase in HLA match requirements.
In the future, platelet production will be a key area of focus for the Welsh Blood Service. The Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO) have recommended that the current requirement that UK Blood Services should produce 80% of platelets by apheresis be removed; and that Platelet Additive Solution (PAS) should be used for the suspension of platelets. In addition, the British Committee for Standards in Haematology (BCSH) guidelines on the use of single donor platelets for children born since 1/1/96 are also under review with the potential that this may be removed. However, it should be noted that clinical reaction to an increased utilisation of pooled platelets, in particular for children and those born post 1996 is as yet unknown, as such demand forecasting is difficult to predict at this time. As a result, the WBS is undertaking a review of its platelet production and is considering the future balance between apheresis and pooled platelets. The WBS will need to ensure that any future balance between platelet methods guarantees that we are able to meet the clinical requirements for HLA and HPA matched platelets. Operational implications for the WBS will also need to be carefully considered given the existing apheresis harness contract runs until 2015, IT infrastructure requirements, multiple change programmes underway and the cost effectiveness, implications of delivering a new service model. Consequently, a major programme of work is underway by the WBS to develop an Apheresis Strategy for the Service. This will be designed to ensure the WBS is best positioned to addresses all of the above factors, develop further our understanding of apheresis requirements for an all Wales Service, whilst ensuring continuous improvement in performance is achieved to support donor and patient outcomes.
Stem cell donation and transplant immunology
Demand for stem cell donation and transplant immunology services is also expected to increase due to a number of factors:
• Projected increase in chronic kidney disease where transplantation is the treatment of choice.
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• Continual advances in medicine and technology enabling transplant of increasingly complex cases where previously this wasn’t possible.
• Welsh Government legislation for presumed consent will become effective in Wales by December 2015.
• UK strategy, Taking Organ Donation to 2020 that calls for NHS, public and professional bodies to work in partnership to ensure everyone who requires a transplant is able to receive one.
• Increased worldwide demand for unrelated stem cell transplants.
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Our Priorities for the Future: by 2017 our blood and transplant service will....
Equitable and timely access to services
• Improve retention of existing donors • Increase the recruitment of new blood and BMV donors with a focus on
younger donors • Improve standard of premises in which blood donation takes place • Implement new service model to support the provision of an all-Wales
Blood Service
Supporting our staff to excel
• Support staff to receive all required statutory and mandatory training • Ensure all staff have a PADR • Support attendance at work • Improve staff work/life balance • Develop a flexible workforce which can respond to changing clinical needs • Develop capacity, capability and leadership to deliver strategic change • Develop talent management and succession planning within the service • Continue to work in partnership with staff and their representatives • Continue to embed a learning culture within the service • Develop a flexible workforce which can respond to changing clinical needs • Develop staff to support continuous improvement and quality management
Providing evidence based care and research which is clinically effective
• Deliver clinical outcomes which are comparable with the best elsewhere • Develop a Research and Development Strategy for the service • Develop partnerships to create a targeted research and development
programme • Develop hospital partnerships to improve patient care • Review laboratory service arrangements to consider real time PCR project • Explore research opportunities and funding
Spending every pound well
• Ensure the provision of a new all-Wales Blood Service represents value for money for NHS Wales
• Improve the supply chain • Further reduce waste across the full range of services • Improve the use of our estates • Increase income generation • Continue to participate in strategic joint procurement opportunities with UK
and European Blood Services • Explore further opportunities to improve any inappropriate use of blood • Develop lean culture and ways of working to ensure effective use of
resources
Safe and reliable services
• Meet demands for all blood components • Meet all diagnostic Service requests in accordance with agreed ‘turnaround
times’ • Improve performance against regulatory requirements and work towards a
‘zero majors’ policy • Reduce the number of Serious Adverse Blood Reactions and Events (SABRE) • Implement all mandated changes to testing and emerging clinical priorities • Retain our wholesaling license • Welsh Bone Marrow Donor Registry (WBMDR) to achieve accreditation status
with the FACT Joint Accreditation Committee-ISCT (Europe) • Achieve CPA ISO 15189 accreditation for diagnostic laboratories and UK NEQAS
for H & I • Continue to meet all Health and Safety and Environment Agency legislative
requirements
First class service and donor experience
• Modernise our collection sessions and the way we interact and manage our donors
• Continue to improve the donation experience • Review and develop a volunteer programme • Continue to improve satisfaction ratings from our donors • Continue to improve satisfaction ratings from our customer hospitals • Respond to all concerns in a timely and effective way • Strengthen our Community Partnership Forum with donors • Identify and implement advances in technology • Support Pathology Modernisation initiatives
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Our performance and quality ambitions by 2017
1 Active donor = have donated within a 2 year period
Dimension
Ambition
Equitable and timely access to services
- 3% increase in the number of 1‘active’ donors on the whole blood panel 50% increase in the number of ‘active’ donors on the apheresis panel in line with clinical need and the establishment of an all Wales Blood Service
- Hold a minimum of 1 Donor Awards Evening event in each geographical area per year - 30% increase in the number of new donors attracted (whole blood) - 60% increase in the number of new donors attracted aged 17-30 (whole blood) - 8000 new Bone Marrow Volunteer (BMV) samples - 30% of new Bone Marrow Volunteer (BMV) samples aged 18-30 - Review current baseline standards of premises in which blood donation takes place - All existing venues will be measured against the new baseline standard - Full implementation of an all-Wales Blood Service
Safe and reliable services
- 100% of blood component requests met to satisfy clinical need - ≥98% of commercial product requests met - Develop platelet production strategy in response to SaBTO recommendation on the removal of the 80%
target - 100% facilitation / import of HSC products for patients in Cardiff and Value UHB - ≥90% deceased donor typing / cross matching reported within 6 hours - ≥90% Anti-D & -cQuantitation results provided to customer hospitals within 5 working days - ≥90% routine antenatal patient results provided to customer hospitals within 3 working days - ≥80% samples referred for red cell reference serology work up provided to customer hospitals within 2
working days - Work towards 0 ‘critical’ and 0 ‘major’ regulatory non-compliances across full range of services - Reduce number of reportable SABRE events from (8) to (5) - Maintain 100% to close SABRE reports to MHRA within 30 days - Accreditation retention: MHRA / HTA / CPA (UKAS)/ EFI/WMDA - WBMDR to achieve accreditation status with the FACT Joint Accreditation Committee-ISCT Europe
(JACIE) - Achieve ISO 15189 (UKAS) accreditation for diagnostic laboratories and UK NEQAS for
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Histocompatability and Immunogenetics - Retain wholesaling license - Keep abreast of mandated changes to testing and emerging clinical priorities, for example: o Prion testing for vCJD o Introduction of a new microbiology contract o Review BACT alert testing contract o Implementation of Euroblood bag o Maintain compliance with Health & Safety Environment Agency Legislation
Providing evidence based care and research which is clinically effective
- Develop a Research and Development Strategy for the service - Develop hospital partnerships to improve patient care e.g. undertake feasibility study to expand apheresis therapeutic services - Review laboratory service arrangements to consider real time PCR project - Explore research opportunities e.g. clinical effectiveness of non-invasive haemoglobin test
First class donor experience
- Roll out donor Self Assessment Health History (SAHH) - Roll out online donor appointment system - Roll out online self donor record management - Review and develop a volunteer programme - ≥70% of blood donors scoring ≥9/10 for satisfaction with overall service - ≥70% of customer hospitals scoring ≥9/10 for satisfaction with overall service - ≥90 % of concerns answered within 30 days - Strengthen our community partnership forum with donors - Continue to improve the donation experience with a feasibility study to assess semi-
reclining donation chairs - Undertake a feasibility assessment to determine benefits of next generation sequencing
technology for HLA typing - Explore research and clinical effectiveness of non-invasive haemoglobin test
Supporting our staff to excel
- ≥95% of statutory training delivered - ≥95% of mandatory training delivered - 100% of staff to receive PADR - sickness absence rate of 3.5% or less
Spending every pound well
- Ensure the provision of an all-Wales Blood Service represents value for money for NHS Wales - <7% time expired platelets - <0.5% volume of waste (red cells) - <5% total losses prior to issue - Optimise estates footprint to support 16% reduction in carbon emissions for Velindre NHS Trust
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Blood and Transplant Services Plan for 2013/2014 – 2016/2017
Quality and Performance Ambitions over the next 3 years
Strategic Theme
Objective Performance ambitions
Equitable and timely access to services Baseline
2012/2013 2013/2014 2014/2015 2015/2016 2016/2017
Equitable and timely access to services
Improve retention of existing donors: - 3% increase in the number of ‘active’
donors on the whole blood panel - 50% increase in the number of ‘active’
donors on the apheresis panel - Hold a minimum of 1 Donor Awards
Evening event per year in each geographical area served
100,305 653 100%
Maintain Maintain 100%
+1.0% +10% 100%
+1.0% +10% 100%
+1.0% +30% 100%
Improve recruitment of new donors and BMV samples, especially young donors:
- 30% increase in the number of new donors attracted (whole blood)
- 60% increase in the number of new donors attracted aged 17-30 (whole blood)
- 8,000 new Bone Marrow Volunteer (BMV) samples
- 30% of new Bone Marrow Volunteer (BMV) samples aged 18-30
8,864 4,659 1842 66%
9,750 5,362 2,000 30%
10,725 6,113 2,000 30%
11,000 7,078 2,000 30%
11,523 7,454 2,000 40%
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Review minimum standard of premises in which blood donation takes place within local communities whilst maintaining the balance of donor need.
Baseline standard in line with Good Manufacturing Practice requirements
Review current baseline standards of premises
50% of venues will be measured against the new baseline standards per year
50% of venues will be measured against the new baseline standards per year
50% of venues will be measured against the new baseline standards per year
Safe and reliable services
Safe & reliable services
Meet all blood component demand in line with clinical need:
- 100% of blood component requests met to satisfy clinical need
- ≥98% of commercial product requests met - Develop platelet production strategy in
response to SaBTO recommendation to remove 80% apheresis target and that additive solution should be used for the suspension of platelets
100% 98% 70%
100% 98% Review existing Apheresis Strategy and conduct scoping exercise
100% 98% Develop new Apheresis Strategy 70%
100% 98% Take forward new Apheresis Strategy within the Service 70%
100% 98% Maintain and review as required Apheresis Strategy 65%
Meet all transplant service requests: - ≥90% deceased donor typing / cross
matching reported within 6 hours - 100% delivery of Haemotopoietic Stem Cell
(HSC) internal targets - 100% facilitation / import of HSC products
for patients in Cardiff and Vale UHB internal targets
100% 98% 100%
90% 100% 100%
90% 100% 100%
90% 100% 100%
90% 100% 100%
90
Meet all diagnostic service requests: - ≥90% Anti-D & -cQuantitation results
provided to customer hospitals within 5 working days
- ≥90% routine antenatal patient results provided to customer hospitals within 3 working days
- ≥80% samples referred for red cell reference serology work up provided to customer hospitals within 2 working days
90% 90% 80%
90% 90% 80%
90% 90% 80%
90% 90% 80%
90% 90% 80%
Improve performance against regulatory requirements:
- 0 ‘critical’ regulatory non-compliances across full range of services
- 0 ‘major’ regulatory non-compliances across full range of services
- Reduce the number of reportable SABRE events
- Maintain 100% to close SABRE reports to MHRA within 30 days
Accreditation Retention: - MHRA - HTA - CPA - EFI - WMDA
0 2 8 100% Retain Retain Retain Retain Retain
0 2 7 100% Retain Retain Retain Retain Retain
0 1 6 100% Retain Retain Retain Retain Retain
0 1 5 100% Retain Retain Retain Retain Retain
0 1 5 100% Retain Retain Retain Retain Retain
Extend accreditation to include: - FACT Joint Accreditation Committee-ISCT
Europe (JACIE) for WBMDR - ISO 15189 accreditation for:
UK NEQAS H&I Diagnostic laboratories
Not sought Not sought Not sought
Gap analysis Not sought Not sought
Apply Gap analysis Gap analysis
Achieve Achieve Progress
Retain Retain Achieve
Retain wholesaling license Retain Retain Retain Retain Retain
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First class donor experience
First class donor experience
Modernise our collection sessions and the way we interact and manage our donors:
- Roll out donor Self Assessment Health History (SAHH)
- Roll out online donor appointment system - Roll out online self donor record
management
0% 0% 0%
0% 0% 0%
100% 0% 0%
100% 100% 100%
100% 100% 100%
Review and develop a volunteer programme
N/A Develop Volunteer Strategy
Finalise Volunteer Strategy
Develop supporting business case
Launch new volunteer programme
Continue to improve satisfaction ratings from our donors:
- ≥70% of blood donors scoring ≥9/10 for satisfaction with overall service
eSurvey not live
68%
69%
70%
71%
Continue to improve satisfaction ratings from customer hospitals:
- ≥70% of customer hospitals scoring ≥9/10 for satisfaction with overall service
Not assessed
68%
69%
70%
71%
Respond to all concerns in a timely and effective way:
- ≥90 % of complaints answered within 30 days
51%
70%
80%
90%
90%
Strengthen our Community Partnership Forum with donors:
- Hold a minimum of 4 per year
Not established
Launched
4 per year
Extend to include a North Wales forum
Continue to improve the donation experience: - Conduct feasibility study to assess semi-
reclining donation chairs
N/A Commence review of existing donation chairs
Feasibility study to determine viability of semi-reclining
Trial and development of business case
Take forward phased roll out
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bleed couches
Keep abreast of advancements in technology: - Undertake a feasibility assessment to
determine benefits of next generation sequencing technology for HLA typing
N/A N/A Feasibility study of next generation sequencing for HLA typing
Secure necessary funding Business case development
Take forward next generation sequencing typing for HLA within the service
Supporting our staff to excel
Supporting our staff to excel
Support staff to receive all required statutory and mandatory training:
- ≥95% statutory training - ≥95% mandatory training
78% 78%
85% 85%
90% 90%
95% 95%
95% 95%
Ensure all staff have a PADR
60% 80% 90% 100% 100%
Reduce sickness absence levels to improve staff attendance:
- sickness absence rate of 3.5% or less
4.7%
4.7%
4.2%
3.9%
3.5%
Manage staff work / life balance: - Reduce the percentage of staff on sickness
absence due to stress related illness
1.21% 1.21% 1% 0.9% 0.9%
Develop a more flexible workforce to meet changing service needs
Phased roll out of redesigned blood collection roles
Complete roll out of redesigned blood collection roles
Increase take up of fully multi-skilled blood collection roles
Increase take up of fully multi-skilled blood collection roles
Develop capacity, capability and leadership to deliver strategic change
N/A Scope change management / leadership requirements to support delivery of
Pilot and initiate change management / leadership development programme to
Further roll out of change management / leadership development programme and IQT Training initiative
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How will we achieve it
major strategic change within the service
support major strategic change within the service Roll out IQT Training
Develop talent management and succession planning within the service:
N/A N/A Initiate Pilot Talent Management initiative within the Service
Roll out talent management strategy within the service
Review impact of talent management strategy within the service
Spending every pound well
Reduce volume of waste across the full range of services:
- <7% time expired platelets - <0.5% volume of waste (red cells) - <5% total losses prior to issue
4.3% 0.1% 6.9%
<7% <0.5% <6%
<7% <0.5% <5%
<7% <0.5% <5%
<7% <0.5% <5%
Improve optimisation of Estates footprint: - Work to support 16% reduction in carbon
emissions target for Velindre NHS Trust
Business as usual (BAU) carbon emissions
Support 10% reduction in carbon emissions target for Velindre NHS Trust as a whole
Support 15% reduction in carbon emissions target for Velindre NHS Trust as a whole
Support 16% reduction in carbon emissions target for Velindre NHS Trust as a whole
Support 16% reduction in carbon emissions target for Velindre NHS Trust as a whole
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Strategic Theme
Objective Key Action
Equitable and timely access to services 2013/2014 2014/2015 2015/2016 2016/2017 Equitable and timely access to services
Implement new service design model to support realisation of an all-Wales Blood Service and supporting infrastructure
all-Wales Blood Service Programme Board -established with ToR agreed
Develop comprehensive service design model Develop robust project plan agreed with all key stakeholders Develop overarching communication plan to ensure programme of effective stakeholder engagement that supports delivery of an all-Wales Blood Service
Confirm service design model including staff structures and the necessary supporting infrastructure Support development of comprehensive business case identifying transitional and ongoing costs Confirm and support consultation arrangements regarding staff TUPE Deliver overarching communication plan to key stakeholders
Full -implementation of service design model and agreed Trust support to identified transitional and ongoing costs to providing an all-Wales Blood Service in line with key strategic priorities
Improve retention of existing donors:
- 3% increase in the number of ‘active’ donors on the whole blood panel
- 50% increase in the number of ‘active’ donors on the apheresis panel
• Re-engage with staff and donors on opening times and utilisation of the appointment system to tailor our offering to provide donors with more opportunities to donate in line with
• Further develop application of smart phone technology and social media platforms in donor communications
• Ensure effective arrangements are in place to hold sufficient Donor
• Extend provision of Donor Awards Evening events to North Wales in line with the establishment of an all-Wales Blood Service
• Continuous monitoring of eSurvey donor feedback to address as appropriate
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- Hold a minimum of 1 Donor Awards Evening event in each geographical area per year
donor preferences • Ensure effective
arrangements are in place to hold sufficient Donor Awards Evenings
• Continuous monitoring of eSurvey donor feedback to address as appropriate
Awards Evenings • Continuous
monitoring of eSurvey donor feedback to address as appropriate
Improve recruitment of new and BMV donors (especially young donors):
- 30% increase in the number of new donors attracted (whole blood)
- 60% percent of new donors attracted aged 17-30 (whole blood)
- 8,000 new Bone Marrow Volunteer (BMV) samples by 2016
- 30% of new Bone Marrow Volunteer (BMV) registrations aged 18-30
• Implement digital telephony within Donor Relationship Management (DRM) to support donor management, recruitment and retention strategies
• Establish Bone Marrow Volunteer (BMV) Recruitment Steering Group
• Develop BMV Recruitment Strategy to: (1) Provide a road map for the strategic co-ordination of future recruitment activities; (2) Engage and raise our profile with donors
• Explore opportunities to help better understand the motivation and needs of young blood donors to help secure our future donor base
• Strengthen our education and ambassador programme to build links and relationships with students so they become engaged volunteers and champions for the service.
• Explore opportunities from Phase 2 – ePROGESA: (1) online donor
portal; (2) app technology
and electronic point of care solutions to capture blood collection information at the bedside;
(3) eDonor Relationship Module (eDRM) to improve campaign and marketing drives for the future service
• Explore further opportunities from Phase 2 – ePROGESA
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(3) Identify clear marketing plans; (4) Explore the use of social media and ICT to engage donors and registry members.
Improve minimum standard of premises in which blood donation takes place:
• Review current baseline standards of premises
• 50% of venues will be measured against the new baseline standard per year
• 50% of venues will be measured against the new baseline standard per year
• 50% of venues will be measured against the new baseline standard per year
Full implementation of an all-Wales Blood Service:
• Develop comprehensive service design model
• Develop robust project plan agreed with all key stakeholders
• Develop overarching communication plan to ensure programme of effective stakeholder engagement that supports delivery of an all-Wales Blood Service
• Develop detailed specification and project plan for the migration of donor database
• Confirm service design model including staff structures and the necessary supporting infrastructure
• Support development of comprehensive business case identifying transitional and ongoing costs
• Confirm and support consultation arrangements regarding staff TUPE
• Deliver overarching communication plan to key stakeholders
• Work with commercial
• Full implementation of service design model and agreed Trust support to identified transitional and ongoing costs to providing an all-Wales Blood Service in line with key strategic priorities
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• Support NHSBT with the planned relocation of the Caernarvon team base
• Manage and agree capital assets and equipment list during transfer of service
suppliers and NHSBT for robust, validated and seamless migration of North Wales donor database
Safe and reliable services Safe & reliable services
Meet all blood component demand in line with clinical need:
- 100% of blood product requests met to satisfy clinical need
- ≥98% of commercial product requests met
- Develop platelet production strategy in response to SaBTO recommendation to remove 80% apheresis target and that additive solution should be used for the suspension of platelets
• Strengthen planning arrangements to help develop a more targeted collection programme that accounts for variations in donor attendance throughout clinic sessions and by clinic type in line with donor preferences
• Develop a new conversation with donors and staff regarding clinic opening times to ensure that we can anticipate their needs and translate into appropriate
• Implement new blood agitators on the mobile donation units (bloodmobiles) to support a more efficient blood collection model
• Roll out two tier medical health screening process
• Understand emerging development of HLA matched platelets preference by clinicians
• Develop economic model for the PAS business case on the % platelet method proposed
• Review apheresis
• Implement Phase 2 ePROGESA (e-DRM module) to develop donor informatics capability to segment donor panels and offer sophisticated donor profiling to improve donor recruitment and retention
• Embed Phase 2 ePROGESA (e-DRM module) to develop donor informatics capability
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service plans. • Work with staff to
support realisation of the optimum skill mix.
• Increase the number of collection days serviced by the mobile blood donation centres
• Establish project group to conduct apheresis scoping exercise to review apheresis % required and assess the potential introduction of PAS
donor panel requirements to meet clinical requirements for HLA and HPA matched platelets
Meet all transplant service requests:
- ≥90% deceased donor typing / cross matching reported within 6 hours
- 100% delivery of Haemotopoietic Stem Cell (HSC) products to stakeholders in full
- 100% facilitation / import of HSC products for patients in Cardiff and Vale UHB
• Extend BMV donor high resolution HLA typing at registration to reduce time taken to provide stem cells for transplantation to improve patient outcomes
• Implement UK Stem Cell oversight committee recommendations regarding alignment of donor registries
• Monitor and review service performance to ensure it continues to meet requirements
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• Welsh Bone Marrow Donor Registry (WBMDR) to join the National Marrow Donor Programme (NMDP) as a Donor Centre improving the visibility of ‘welsh’ donors to American transplant centres
Meet all diagnostic service requests:
- ≥90% Anti-D & -cQuantitation results provided to customer hospitals within 5 working days
- ≥90% routine antenatal patient results provided to customer hospitals within 3 working days
- ≥80% samples referred for red cell reference serology work up provided to customer hospitals within 2 working days
Continue to monitor and review service performance to meet hospital requirements
Improve performance against regulatory requirements:
- 0 ‘critical’ regulatory non-compliances across full range of services
- 0 ‘major’ regulatory non-compliances across full
• Prepare for MHRA inspection December 2013
• Implement detailed audit programme
• Continue to develop and deliver Good
• Consider opportunities regarding deployment of resources into key departments across the service
• Prepare for 2015/16 MHRA inspection
• Extend self inspection audit programme to targeted areas
• Extend self inspection audit programme to targeted areas
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range of services - Reduce the number of
reportable SABRE events - Maintain 100% to close
SABRE reports to MHRA within 30 days
Manufacturing Practice (GMP) training provision
• Investigate and monitor serious adverse events (internal / external), advise preventative actions and lessons learnt
• Extend provision of Root Cause Analysis training
• Review ongoing training
Accreditation Retention: - MHRA, HTA, CPA and EFI
Extend accreditation to include: - FACT Joint Accreditation
Committee-ISCT Europe (JACIE) for WBMDR
- CPA ISO accreditation for diagnostic and External Quality Assessment laboratory
• Support and prepare service for all accredited inspection programmes
• Gap analysis on standards
• Dedicated quality resources to be embedded into key department
• Develop action plan to address outcomes of gap analysis
• Training & self inspection audits • Review inspection findings and address with
action plan • Ongoing monitoring and self inspection
Retain wholesaling license
• Continue to offer value for money and meet all hospital requests
• Continue to offer value for money and meet all hospital requests
• Continue to offer value for money and meet all hospital requests
• Continue to offer value for money and meet all hospital requests
Keep abreast of mandated changes to testing and emerging clinical priorities for example:
- Club 96 impact - Pathogen inactivation
• Monitor and review mandated changes
• Implement new replacement blood testing systems via WG funding
• Consider all mandated changes for an all-Wales Blood Service
• Consider all mandated changes for an all-Wales Blood Service
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- Prion testing for vCJD - Introduction of new
microbiology contract
- Review BACT alert testing contract
- Implementation of new replacement blood testing systems
• Award microbiology contract and implement new changes
• Monitor and review
with NHSBT • Develop business
case for WG
• Monitor and review contract
• Monitor and review contracts
• Implement new equipment
• Monitor and review contract and include in All Wales
• Monitor and review contract and include in All Wales
• Monitor and review
contract and include in All Wales
• Monitor and review contract
• Monitor and review contract
• Monitor and review
contract
Providing evidence based care and research which is clinically effective Providing evidence based care and research which is clinically effective
Develop a Research and Development Strategy for the service
N/A • Develop R&D strategy for the WBS
• Explore NLIAH funding iron deficiency anaemia and patient ID into theatre project
• Explore opportunities with implementation of an all-Wales Blood Service
• Explore opportunities with implementation of an all-Wales Blood Service
Develop hospital partnerships to improve patient care
• N/A • Medical Director to engage with hospital partners
• Undertake feasibility study to expand apheresis therapeutic services
• Enhance relationships with North Wales customer hospitals
Review laboratory service arrangements to consider real time PCR project
• Review service structure and strategy in light of resignation of
• Consider submission of a business case to WHSSC to seek redistribution of LHB
• If required pending business case approval take forward real time
• Monitor and review
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service lead
funding for this patient service enhancement
PCR project development as patient focussed service
Explore research opportunities: - Explore research and
clinical effectiveness of non-invasive haemoglobin test
• Undertake feasibility study of non-invasive haemoglobin tests
• Develop user requirement specification
• Develop supporting business case with a view to taking forward key
recommendations
• Implement non-invasive haemoglobin test across the collection teams
• Monitor and review
First class donor experience First class donor experience
Modernise our collection sessions and the way we interact and manage our donors:
- Roll out donor Self Assessment Health History (SAHH)
- Roll out online donor appointment system
- Roll out online self donor record management
• Scope donor engagement requirements
• Donor engagement and market demonstration research
• Implement Phase 1 ePROGESA
• Maintain and manage and implement at an all-Wales level
• Phase 2 ePROGESA
Review and develop a volunteer programme
• Commence development of Volunteer Strategy
• Finalise Volunteer Strategy
• Develop supporting plan
• Launch new volunteer programme in South and West Wales
• Launch new volunteer programme North Wales
Continue to improve satisfaction ratings from donors:
• Review and analyse results of eSurvey
• Identify and implement key
• Review donor satisfaction eSurvey
• Review donor satisfaction eSurvey
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- ≥70% of blood donors scoring ≥9/10 for satisfaction with overall service
improvements resulting from eSurvey analysis
• Improve estates and facilities for blood donation
• Determine optimum service provision regarding appointment times
and benefits from improvements in 2014/2015
• Develop new set of improvement actions and implement
and benefits from improvements in 2015/2016
• Develop new set of improvement actions and implement
•
Continue to improve satisfaction ratings from customer hospitals:
- ≥70% of customer hospitals scoring ≥9/10 for satisfaction with overall service
Review and analyse results of customer hospitals survey
Continue to strive for improved satisfaction by engaging with customer hospitals
Respond to all concerns in a timely and effective way:
- ≥90 % of concerns answered within 30 days
• Implement new standard operating procedure
• Continuous monitoring and review of concerns themes and timelines of responses
Strengthen our Community Partnership Forum with donors:
- Hold a minimum of 4 per year
• Establish groups in the following four areas: (1) West Wales; (2) mid Wales; (3) South Wales and (4) East Wales. Each group will meet up at least once per year to discuss different aspects of: - Service delivery - Recruitment &
• Hold a minimum of four forums across each geographical area serviced
• Extend Community Partnership Forum to North Wales in line with the establishment of an all-Wales Blood Service
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Retention - Partnership
working
Continue to improve the donation experience: - Conduct a feasibility study to
assess semi-reclining donation chairs
• Point of Care research to establish need
• Feasibility study to determine viability of alternate semi-reclining bleed couches
• Trial and development of business case
• Secure funding for All Wales Blood Service changes
Identify and implement advancements in technology
• Determine benefits of next generation sequencing technology for HLA typing
• Develop business case to increase funding for high resolution typing
• Engage commissioners on benefits of funding for high resolution typing with an aim of securing funding
• Implementation
Supporting our staff to excel Supporting our staff to excel
Support staff to receive all required statutory and mandatory training:
- ≥95% statutory training - ≥95% mandatory
training
• Develop robust training schedule
• Appointment of Trust-wide statutory and mandatory trainer
• Core skills matrix: e-learning to be promoted and rolled out from 2013 onwards
• MSS/ESS rollout for OLM in 2013/14 enabling employees
• Proactive monitoring
• Review of training resource
• Proactive monitoring
• Proactive monitoring
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to self-book onto courses
Ensure all staff have a PADR • Appraiser training • Monthly monitoring
with departments • Preparation of
progress statistics • Reports and
feedback on progress to SMT
• Updated PDR paperwork
• Monthly monitoring with departments • Preparation of progress statistics • Reports and feedback on progress to SMT • Continue to deliver training / refresher training
Reduce sickness absence levels to improve staff attendance:
- sickness absence rate of 3.5% or less
• Return to work interviews • Use of Occupational Health assessments • Sickness audits • Stress risk assessments • Use of sickness policy • Promotion of Health and Wellbeing initiatives
Manage staff work / life balance • Consider applications in line with the Work-life Balance Policy • Provision of support services e.g. advice and counselling through Employee Assistance Programme
(EAP) • Provision of childcare vouchers, holiday child subsidy scheme
Develop a more flexible workforce to meet changing service needs
• Complete roll out of redesigned blood collection roles
• Identify further opportunities for improving scope / skill mix for staff • Work with staff to support realisation of the optimum skill mix
Develop capacity, capability and leadership to deliver strategic change
• Work with Public Health Wales, Academi Wales and Higher Education Institutions.
• Scope leadership and change management
• Take forward partnership working arrangements to deliver targeted leadership and change management development
• Embed leadership and change management initiatives within the service
• Continue roll out of IQT Training initiative
• Review impact of leadership and change management development programme within the service and assess further
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development programme requirements including Lean
programme • Roll out IQT Training
initiative
requirements • Continue roll out of
IQT Training initiative
Develop talent management and
succession planning within the service:
• Initiate review of Pilot outcomes of VCC talent management initiative
• Explore with Workforce Education Development Service (WEDS) funding for scientific training post in line with modernising scientific careers
• Complete review of Pilot outcomes and develop plans to take forward talent management strategy within the service
• Develop succession plans within the WBS
• Roll out talent management strategy within the service
• Review impact of talent management strategy within the service
Embed a learning culture within the service:
• Take part in World Quality Day 2013 to promote awareness of the quality agenda and that every member of staff has a responsibility to participate to help raise standards
• Continue publication of staff newsletter Quality Matters to raise the profile of quality issues and promote
• Plan and work not only at building individual capability, but also team, and collaborative and co-operative capabilities to promote a culture of learning
• QA Department to hold annual event at WBS to promote learning • Targeted GMP training programme that focuses on key lessons / issues for
the Service • Continue publication of staff newsletter Quality Matters to raise the
profile of quality issues and promote learning within the organisation • Promote CPD attendance and sharing of learning via papers / lectures to
staff within the Service
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learning within the organisation
Spending every pound well Spending every pound well
Ensure the provision of a new all-Wales Blood Service represents value for money for NHS Wales:
• Ensure all aspects of service costs scoped out in service design model. As a minimum transitional capital and revenue costs need to be understood
• Produce internal business justification case to secure funding from WHSSC
• Implement all-Wales Blood Service
• Implement all-Wales Blood Service
Explore opportunities to improve the supply chain
• Conduct scoping exercise to assess viability and ROI for introduction of ambient overnight hold within the processing laboratory
• Pending recommendations of scoping exercise, develop supporting business case to take forward spend to save initiative
• Ensure supporting infrastructure requirements within Collections can be achieved to facilitate ambient overnight hold within the service
• Explore a number of initiatives via the BBTT and work to develop existing arrangements within the supply chain pathway to help maximise the use of donated blood and platelets and ensure continuous improvement in blood supply management
Reduce volume of waste across the full range of services:
Maintain good inventory practice e.g. First in First Out (FIFO) principle in line with fluctuating demand
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- <7% time expired platelets - <0.5% volume of waste (red
cells) - <5% total losses prior to issue
based on clinical need by blood group e.g. CMV status
Improve optimisation of Estates footprint:
- Support 16% reduction in carbon emissions target for Velindre NHS Trust
• Work towards principles of ISO environmental building standards once professional support identified
• Decommission Carmarthen Unit 20
• PC shutdown at night once updates have been carried out.
• Interface the split units to the BMS to prevent the two systems fighting each other. The BMS would control the air handling units (AHU) and the split air conditioning units off of the space temperature2.
• Boiler replacement: replace 2 of the 5 boilers with two lead condensing boiler so as to improve the combustion efficiency from 80% to 90% for most of the heat load
• Lighting controls:
• Bocam Park closure • Potential expansion
of WBS estate in line with the needs of an all-Wales Blood Service
• Expansion of WBS estate in line with the needs of an all-Wales Blood Service
2 The AHU’s would supply air at a lower temperature and the splits would be used to provide top-up heating and cooling. Low heat gain areas without splits would have a moisturised volume control damper fitted.
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daylight control can be fitted to most of the corridor and entrance foyer lighting. These areas are well day lit because of the courtyards.
• Review WBS estates footprint in readiness for the establishment of an all-Wales Blood Service
Increase income generation • Establish a Business Planning Sub Group to explore commercial opportunities for the service
• Join National Marrow Donor Panel (NMDP) to extend potential to generate income to service for donor marrow
• Secure additional renal transplantation service income from future renal transplantation projections
• Explore opportunities within university networks that specialise in R&D and or laboratory training regarding commercial products available from the service
• Explore income opportunities in line with all-Wales Pathology modernisation programme requirements relating to the transportation of results and tests
• Review and offer WASPS scheme to North Wales community
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identified in business case developed jointly with Cardiff & Vale Health Board and renal network via WHSSC joint committee
between Health Boards and Trusts
Continue to participate in strategic joint procurement opportunities with UK and European Blood Services
• Ensure participation and / or oversight with all UK & European identified business opportunities available
Explore further opportunities to improve any inappropriate use of blood
• Review of service moving forward
• Develop nurse prescribing programme
• Review education, usage and audit work
• Engage stakeholders and implement recommendations of service review
• Review plans for further development upon introduction of all-Wales Blood Service
Improve efficiency of existing WTAIL IT resources
• Explore existing IT system for on-line EQA results entry
• If required develop business case
• Scope implementation requirements
• Take forward implementation of on-line EQA results entry
• Increased utilisation of IT generated customer reports
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Section 6: Developing a culture of high quality and continuous improvement
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Supporting Staff to Excel The Trust has a committed and highly talented workforce which makes a difference to patients and donors on a daily basis. In order to sustain this we need to ensure that we fully understand the challenges that face us over the coming years and respond to them effectively to ensure we create the environment, opportunities and support for our staff to continue to grow and achieve their potential.
A few things on our mind.........
Recruiting to key Workforce Posts
The success of Velindre NHS Trust depends on the staff who work for us. We continuously strive to recruit the right people, with the right knowledge, skills and experience, at the right time, and support them to achieve their potential and delivery of the quality care we expect.
Whilst the recruitment of staff has not historically been difficult, there are a number of challenges within the external environment which we need to be mindful of.
i. Nursing Workforce
The Royal College of Nursing has warned of unprecedented uncertainty about the future nursing workforce, due to the numbers reaching retirement age (Wales: 29% over the age of 50 and 12% over the age of 55 ) and the agreed shift to a graduate entry profession, which has the potential to discourage new entrants into a career in nursing. These issues pose a real challenge to the future supply of nurses and the ability of the workforce to support the delivery of extended healthcare support workers roles and addressing and moving away from the traditional skill mix model.
Whilst the Trust has traditionally been able to recruit to its nursing vacancies, it cannot become complacent as 16% of the Trust’s workforce is nurses. We must therefore consider how we can use the nursing and healthcare support worker workforce differently in the future, to address potential qualified nursing shortages and maintain safe, productive and effective services.
When developing our workforce plans we have considered the age demographic of our current nursing workforce and made projections of future numbers based on our knowledge and expertise. We have, and will continue to seek, opportunities to be proactive in developing existing roles and creating new roles which offer greater job satisfaction and flexible career paths for the nursing workforce. This will enable professionals to cross boundaries and to work in broader roles, such as research, policy development and management, which allow people to contribute more fully to the enhancement of care and service delivery and modernisation, within a constrained financial environment.
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ii. Allied Health Professional Workforce (AHPs)
The future supply of AHPs is a cause for concern within Wales due to the age profile of this staff group, with 22% of the workforce over the age of 50 and 10% are over the age of 55. Consequently, if nothing changes, there is a significant risk that the there will be a shortage of senior and specialist AHP staff within NHS Wales within the next 5 to 10 years.
This position may be further affected by reductions in education commissioning and the inability of NHS organisations to offer supervised clinical placements, which are a key component of the current training programme. This will result in a reduction in new entrants at a time when many experienced staff will be retiring.
The Centre for Workforce Intelligence (CfWI) is currently undertaking a review of those AHP professions which have been identified as having the most significant future workforce issues. The professions currently being reviewed, which could have an impact on the Trust are diagnostic radiographers and therapeutic radiographers. At Velidre, 10% of the Trust’s total workforce are AHPs, with a significant proportion of these being radiographers. The demands for both of these roles within the Trust and the NHS are increasing.
Demand for diagnostic radiographers is also being driven up due to Welsh Government policy initiatives such as the National Stroke Strategy and the development and extension of screening programmes. Improved access to radiotherapy treatment is also increasing the demand for therapeutic radiographers. The pressures are accentuated by the high attrition rate on these training courses. Thus, there is a significant risk that in the future demand for radiographers will far outstrip supply and the Velindre may experience recruitment difficulties within these specific staff groups.
iii. Healthcare Scientist Workforce (HS)
The future supply of HS is a cause for concern due to the age profile of this staff group in Wales with 32% over the age of 50 and 17% over the age of 55. Consequently, almost 50% of the existing healthcare sciences workforce could retire within the next 5 -10 years.
In recent years the number of students taking science based qualifications and graduating with science based degrees has declined. Due to the decline in graduate numbers, the NHS currently has to actively compete with private sector industries to attract graduates and experienced staff to fill vacancies. Unless the NHS can offer attractive employment packages or excellent career pathway opportunities to potential applicants, it may not be able to attract the high calibre healthcare scientist it requires to maintain the delivery of high quality services.
Given the rapid pace of technological and organisational change within the NHS, this could pre-maturely increase attrition rates, especially for those staff nearing retirement age. This would result in the most experienced members of this workforce leaving the service, with a real
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possibility of the Trust not being able to fill the vacancies, in what is increasingly becoming recognised as a shortage profession.
At Velindre, HS make up 7.5% of the Trust’s overall workforce and given their age profile, the technological challenges, and the shortage of newly qualified graduates, we are likely to experience recruitment and retention difficulties in the future.
iv. Medical Workforce
The medical workforce (consultants) makes up 7% of the entire Trust workforce numbers. It however accounts for approximately 18% of the staff budget expenditure. Over the last decade the size of this staff group in Wales has increased significantly, as have the associated costs. The introduction of the Consultant Contract in Wales was intended to assist NHS organisations in service modernisation. There have been some positive benefits from this, although it has not perhaps achieved the full range of expected benefits initially identified.
Over the past decade the NHS in Wales, and Velindre, have been able to recruit more medical staff. However, it is unlikely that the rate of growth will continue over the next decade given the forecast resource position. Velindre will therefore need to continue to find better ways to meet the clinical needs of patients using innovative clinical and technological practice.
v. Succession Planning
The Trust recognises that succession planning is a key tool for securing the future success of the organisation to ensure that there are no critical shortages in key roles and posts in the future. The Trust does not currently have a robust succession planning process, although an internal talent management tool has been developed and is currently being piloted.
The key challenge for the Trust is to proactively identify, develop and nurture talent at all levels within the organisation, to ensure that it has a supply of healthcare workers, healthcare professionals and clinical and non clinical managers and leaders to fill those posts which are critical to the successful delivery of our services.
It must also ensure that any such process balances the aspirations of individual employees and can meet the future requirements of the Trust, which are likely to change and evolve relatively quickly in the current political and financial environment. Our succession planning process must also recognise that there will be posts which cannot or should not be filled from the internal pool of talent because there is a need to recruit an external candidate with fresh insight and a different set of skills / competencies.
The Trust moving forward must therefore ensure that succession planning is not only part of the Workforce and Organisational Development Strategy but is an integral part of workforce planning process.
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vi. Staff Engagement
The Trust is committed to being a great employer and delivering quality, care and excellence. The NHS Wales Staff Survey 2013 has provided us with a wealth of information from our staff at an important time in the development of the NHS in Wales.
We achieved a 52% response rate, which in survey terms was categorised as “high” and an overall engagement index of 3.69 (on a scale of 0 – 5) with index scores for each area:-
• Intrinsic psychological engagement (3.75); • Ability to contribute towards improvements at work (3.42); and • Staff advocacy and recommendation (3.9).
Whilst these scores can be viewed positively, the Trust recognises that there is always more work to do. All leaders, managers and staff within the organisation are being supported and encouraged to become actively engaged in the decisions made within the organisation at a strategic and operational level. This is essential as engaged staff are likely to be productive and committed and to “go the extra mile” for patients and donors.
vii. Supporting attendance at work Over the past two years the Trust has experienced an increase in both short and long term sickness absence. This is consistent with the picture across the NHS and wider public services in Wales. We have identified work related stress as the most prevalent reason for both short term and long term sickness absence within the Trust. Whilst of concern, it mirrors the wider public sector where stress is the most common reason.
We are very committed to supporting staff to attend work as there are direct links with the quality of care provided to patients and donors, and it supports positive well-being of staff. We are working towards a 1% reduction in sickness absence over the next two years using a variety of approaches.
We have submitted a detailed Supporting Attendance action plan to the Welsh Government and are currently implementing it.
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Putting strong foundations in place for our staff 2013 - 2017
Developing strong workforce enablers to achieve Delivering Excellence
We have identified a series of workforce enablers will support the development of a motivated and high performing workforce within the Trust.
• Strong leadership / Role Modelling: we will support staff in developing a strong culture of
high performance through effective leadership, management. This will be founded upon our values and behaviours and seeks to provide the required learning opportunities and experience to all staff on their journey.
• Competency Based Recruitment Processes: we will recruit staff based on their knowledge, skills, competende and potential for development.
• Supporting health and well-being: we are committed to providing support and opportunities for our staff to maintain their health, well-being and safety. We aspire to develop culture and supporting programme that enables us to be viewed as an exemplary employer.
• Comprehensive Education and Development Programme: we will ensure that our development programmes are appropriate, challenging and accessible to our staff and offer the opportunity to apply the learning in a practical way.
• Succession Planning: we will develop a strong partnership with our staff to support and
actively manage their progression within the organization. This will allow staff to experience new opportunities and enable the organisation to manage the future in a planned way.
• Managing staff performance: we will use an effective performance appraisal system to continuously improve team and individual performance. It will be aligned to our values, competences and reward systems and will assist staff in achieving their potential.
• Staff Engagement: we recognise that a fully engaged workforce is critical to our success
and is vital if staff are to fulfill their potential and patients and donors are to receive the highest quality services. We wish to develop a culture and reputation that makes us an the employer of choice nationally and internationally.
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Workforce Plans 2014 – 2017 We have been developing our workforce plans in accordance with our plans. The plans are indicative at this stage and subject to ongoing discussions internally, with commissioners and Welsh Government.
Velindre Cancer Centre
Pay scale Baseline 2013/14
2014/15 2015/16 2016/17
FTE Band 1 30.80 Band 2 73.76
FTE Band 1 30.80 Band 2 73.76
FTE Band 1 30.80 Band 2 73.76
FTE Band 1 30.80 Band 2 73.76
Band 3 57.43 Band 4 63.54
Band 3 57.43 Band 4 63.12
Band 3 57.43 Band 4 63.12
Band 3 57.43 Band 4 63.12
Band 5 130.54 Band 5 130.94 Band 5 130.94 Band 5 130.94 Band 6 103.65 Band 6 103.65 Band 6 103.65 Band 6 103.65 Band 7 93.94 Band 7 97.53 Band 7 97.53 Band 7 97.53 Band 8 60.63 Band 8 60.33 Band 8 60.33 Band 8 60.33 Band 9 2.00 Band 9 2.00 Band 9 2.00 Band 9 2.00 Jnr Dr 28.20 Registrar 7.20 Consultant 47.78
Jnr Dr 30.20 Registrar 3.20 Consultant 43.28
Jnr Dr 30.20 Registrar 3.20 Consultant 43.28
Jnr Dr 30.20 Registrar 3.20 Consultant 43.28
Total 699.47 Total 696.24 Total 696.24 Total 696.24
Overall numbers in Velindre Cancer Centre likely to increase in the future as a result of the increasing incidence of cancer, the complexity of treatment and the introduction of new services which have commissioner support and funding. These include Stereotactic body radiotherapy, surgical radiotherapy and image guided radiotherapy. There are also a range of additional and important service developments which are in the early stages of development such as organ motion control, advanced vivo dosimetry and increased access rates. The full workforce implications of these are not yet fully determined or agreed with commissioners.
The addional area of focus is the continued transformation of the workforce in relation to scope of practice, skill mix and patterns of working which provides better quality care in a more efficient and productive way. A significant amount has already been achieved in this regard but further opportunities will be continuously sought to make our workforce fit for the future in a sustainable way.
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Welsh Blood Service
Pay scale 2012/13 2013/14 2014/15 2015/16 2016/17 FTE Band 1 0.32 Band 2 61.72
FTE Band 1 0.00 Band 2 59.88
FTE Band 1 0.00 Band 2 59.35
FTE Band 1 0.00 Band 2 59.35
FTE Band 1 0.00 Band 2 59.35
Band 3 101.45 Band 4 45.02
Band 3 99.20 Band 4 43.75
Band 3 114.73 Band 4 42.87
Band 3 110.73 Band 4 42.87
Band 3 104.73 Band 4 43.87
Band 5 30.96 Band 5 35.63 Band 5 37.63 Band 5 37.63 Band 5 37.63 Band 6 56.76 Band 6 53.76 Band 6 53.76 Band 6 53.76 Band 6 53.76 Band 7 44.92 Band 7 44.96 Band 7 44.46 Band 7 44.46 Band 7 44.46 Band 8 21.43 Band 8 24.43 Band 8 23.43 Band 8 22.93 Band 8 22.93 Band 9 2.00 Band 9 2.00 Band 9 2.00 Band 9 2.00 Band 9 2.00 Consultant 3.20 Consultant 3.70 Consultant 3.70 Consultant 3.70 Consultant 3.70 Total 367.26 Total 366.81 Total 381.93 Total 363.47 Total 363.47
The above table excludes details regarding staff uplift from 2016 to provide an all Wales Blood Service. It is anticipated that the establishment of an all Wales Blood Service will result in the TUPE transfer of additional staff across a variety of bandings. Furthermore, preliminary work undertaken by the Service Design workstream has identified the potential requirement for a stock holding unit in north Wales, which would require 24/7, cover 365 days per year. As such, additional staff to man this facility and dedicated drivers to transport blood from Llantrisant in the south, to the north Wales stock holding unit and onwards to the surrounding hospitals would be required as a minimum.
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Our approach to Organisational Development
Enabling the Strategic Plans through Organisational Development
We recently published an Organisational Development Strategy which identifies that successful organisations rely upon the continuous development of people and a supportive organisational culture. The key elements of the strategy are set out in Fig. 23.
OD Strategic Vision Supported by
Employee Relations & Engagement
Workforce & OD professionals providing a flexible and responsive service to all members of staff and management which enables exemplary employee relations in all areas of the organisation. All staff are able to make the connections between the Trust’s objectives and the valuable contribution that their role and that of their colleagues makes, which results in them experiencing increased job satisfaction and increasing their commitment to delivering “quality, care and excellence”.
• Workforce policies & procedures
• Working Differently Working Together
• Staff Engagement Strategy
Health & Wellbeing
To maintain and improve the health and wellbeing of our entire workforce, which increases the Trust’s ability to deliver safe and effective services, to our patients and service users
• Working Differently Working Together
• Health & Wellbeing Strategy
Management & Leadership
Managers throughout the organisation being confident and competent in fulfilling their management role, and all members of staff feeling empowered to fulfil their personal leadership role regardless of role or seniority
• Working Differently Working Together
• Training Prospectus • Training Plan
PADR Every member of staff having a high quality individual Performance Appraisal & Development Review at least annually
• Working Differently Working Together
• PADR Policy • PADR Handbooks • Training Plan
Service Improvement
All individuals, teams & departments engaging with ongoing service improvement cycles which results in understanding service needs and seeking to establish a workforce which provides high quality and excellence through effective deployment of appropriate knowledge, experience and skills
• Workforce Planning • 1000Lives+ IQT • Skill Mix Reviews
Talent Management
Ensuring that the organisation explores, recognises and nurtures the potential and talent of every member of staff
• Revised PADR Form (inc Talent Tool)
• Talent Management Process
Team Working
Teams throughout the organisation seeking to reflect on performance on a regular basis, and align team activities to service needs alongside pursuit of exemplary team working practices
• Working Differently Working Together
• Training Prospectus • Training Plan
Training, Education & Development
Every member of staff ensuring to meet the mandatory and statutory training needs required of their role and to further engage in continuous personal and professional development as influenced by service needs and individual aspirations
• Training Prospectus • Training Plan
Fig. 23 Key elements of successful organisational development
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Following the publication of the strategy, a number of developments have occurred which will require further and ongoing work from an organisational development persecptive:-
• The development of a vision, and model and facilities for cancer services. • Creation of an all-Wales Blood Service. • The all-Wales WfIS project is creating a renewed momentum in relation to workforce
information and e-Learning, which creates tangible opportunities and benefits for Velindre NHS Trust.
• The Velindre NHS Trust Staff Survey results have been analysed locally and understanding of staff opinion and establishment of resultant action continues to develop.
To support the achievement of the Trusts’ ambition, an organisational development programme has put in place which is set out in Table 2. This will be continuously reviewed and revised in light of changing needs.
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Table 2 Organisational Development Programme 2014/2015 – 2016/2017
Action →
↓ OD Strategic Vision
2014/15 2015/2016 2016/2017
Employee Relations & Engagement
1. Establishment of a Trust-wide ‘Staff Engagement’ group
2. Adoption of the WDWT ‘Staff Engagement Toolkit’
3. Staff Survey results analysis & report generation
4. Publication of related managerial guidance & support on Trust intranet site
5. Review of WfOD structure & service provision
6. Embedding of principles via discrete staff engagement activity
7. Measurement of staff engagement index via Trust-wide ‘Pulse Survey’
8. Implementation of any revised WfOD structure
9. Continued embedding of principle via discrete staff engagement activity
10. Measurement of staff engagement index via Trust-wide ‘Pulse Survey’
11. Efficacy review of any revised WfOD structure implementation
Health & Wellbeing
12. Approval of revised Trust Health & Wellbeing Action Plan
13. Re-launch of the Trust’s Sickness Absence Management Group
14. Publication of a Trust-wide Sickness Absence Management Plan
15. Submission of bid for funding to support recruitment of a ‘Sickness advisior’
16. Retention of the ‘Health @ Work’ Gold Award
17. Continued action against Trust’s Health & Wellbeing Action Plan
18. Achievement of ‘Health @ Work’ Platinum Award
19. Continued action against Trust’s Health & Wellbeing Action Plan
20. Maintenance of ‘Health @ Work’ Platinum Award
Management & Leadership
21. Maintain provision of in-house management & leadership
23. Extend provision of in-house management & leadership
25. Retain ILM Centre accreditation
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development programmes 22. Develop Trust-wide understanding, &
adoption, of Clinical Leadership principles
development programmes to include an ILM Level 2 Team Leader Award
24. Embed Trust-wide implementation of distributed Clinical Leadership
26. Maintain Trust-wide implementation of distributed Clinical Leadership
PADR
27. Pilot revised PADR process in each Division of the Trust
28. Evaluate pilot & amend process as necessary
29. Use Staff Survey results to establish baseline of PADR activity
30. Launch revised PADR process throughout the Trust
31. Establish robust process of data collection to support measurement of PADR activity
32. Use PADR activity data to support deployment of training & support to increase PADR activity where necessary
33. Launch a PADR Quality Assurance process throughout the Trust
34. Evaluate PADR Quality Assurance process
35. Use PADR Quality Assurance data to support discussions in relation to action 36. below
36. Maintain PADR activity data collection & analysis
37. Maintain provision of training & support where necessary
Service Improvement
38. Launch IQT training programme within Corporate, VCC and hosted organisations
39. Meet 1000Lives+ target of 25% headcount trained in service improvement methodologies
40. Maintain ongoing Service Improvement projects e.g. VIP and D2D activity within the VCC and WBS
41. Launch IQT training programme within WBS
42. Maintain IQT training programmes within Corporate, VCC and hosted organisations
43. Meet 1000Lives+ target of 25% headcount trained in service improvement methodologies
44. Embed IQT training principles in daily practice for all staff groups
45. Consider establishing a Corporate Service Modernisation/Improvement team of specialist staff
46. Maintain IQT training programmes throughout the Trust
47. Meet 1000Lives+ target of 25% headcount trained in service improvement methodologies
48. Continue to embed IQT training principles in daily practice for all staff groups
49. Seek to measure service improvement ethos within the Trust
Talent Management
50. Establish a ‘Talent Tool’ for Velindre NHS Trust
54. Launch Talent Tool & Pipeline guidance throughout the Trust
56. Maintain use of Talent Tool & Pipeline
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51. Pilot the Talent Tool within the revised PADR process
52. Evaluate pilot & amend process as necessary
53. Establish ‘Talent Pipeline’ guidance to support use of the Talent Tool
55. Measure efficacy throughout the Trust via the PADR Quality Assurance process
throughout the organisation
57. Continue to provide training & support where necessary
Team Working
58. Increase the number of Aston trained facilitators within the Trust x 2
59. Increase awareness of Aston Team Working principles within the WfOD community via an in-house training workshop
60. Continue to provide Aston Team-based Working workshops throughout the organisation where appropriate
61. Increase provision of Aston Team-based Working workshops via increased referral from WfOD and improved marketing
62. Establish a process for capturing Aston-related activity within the Trust
63. Evaluate the benefits of Aston Team-based Working workshop activity
64. Continue to increase, or maintain, provision of Aston Team-based Working workshops via increased referral from WfOD and improved marketing
Training, Education &
Development
65. Establish scope of IT infrastructure requirement to enable access to e-Learning for all staff
66. Appoint Mandatory & Statutory Trainer post to improve range of delivery options
67. Integrate ‘e-Learning Lead’ responsibility into an existing WfOD role
68. Increase completion of Mandatory & Statutory training via e-Learning by ≥20%
69. Maintain ongoing evaluation of training, education & development opportunities to ensure in-house
73. Review impact of Mandatory & Statutory trainer role on training compliance
74. Achieve ≥95% Mandatory & Statutory compliance across the organisation
75. Increase completion of Mandatory & Statutory training via e-Learning by ≥15%
76. Maintain ongoing evaluation of training, education & development opportunities to ensure in-house provision is meeting service needs
77. Establish online Study Leave Form which allows data capture of
81. Increase completion of Mandatory & Statutory training via e-Learning by ≥10%
82. Maintain ongoing evaluation of training, education & development opportunities to ensure in-house provision is meeting service needs
83. Maintain high levels of in-house training evaluation
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provision is meeting service needs 70. Analyse in-house training evaluation 71. Improve communication with learners
via Intranet/Internet by refreshing/re-designing content
72. Recruit a fixed-term post to re-model Medical Education administration
external learning attendance 78. Analyse external learning
attendance to ascertain themes, seek to exploit economies of scale or bring provision in-house
79. Launch revised online in-house training evaluation process & increase completion by ≥25%
80. Evaluate impact of fixed-term Medical Education post & make case for permanent appointment if appropriate
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Our approach to Quality Improvement
We are committed to the continuous improvement of the quality of our services and view quality improvement as core business as it will assist us in moving from short-term performance improvements to sustained organisation-wide patient and donor care improvements.
The terms ‘quality’ and ‘quality improvement ‘mean different things to different people in different circumstances and within healthcare, there is no universally accepted definition of ‘quality’. However, a number of common domains are universally acknowledged. These state that healthcare must be:
• Safe • Effective • Patient-centred • Timely • Efficient • Equitable
The definitions seen in the literature often regard ‘quality’ as the degree of excellence in healthcare and recognise that it is multi-dimensional. Similarly, there is no single definition of ‘quality improvement’. What is commonly seen is a description of a systematic approach that uses specific techniques to improve quality. One important ingredient in successful and sustained improvement is the way in which the change is introduced and implemented. The key elements are the combination of ‘a change’ (improvement) and a ‘method’ (an approach with appropriate tools), while paying attention to the context in order to achieve better outcomes. Just as there is no single definition of ‘quality improvement’ there is no single approach. What is needed is a combination of approaches, context specific, to ensure sustained improvements.
As illustrated above, ‘quality improvement’ draws on a wide variety of methodologies, approaches and tools. Many of these share some simple underlying principles, including a focus on:
• Understanding the problem, with a particular emphasis on what the data tell you; • Understanding the processes and systems within the organisation, particularly the
patient/donor pathway, and whether these can be simplified; • Analysing the demand, capacity and flow of the service; • Choosing the tools to bring about change, including leadership and clinical
engagement, skills development and staff and patient/donor participation; and, • Evaluating and measuring the impact of a change.
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Regardless of the approach used, how the change is implemented (including factors such as leadership) clinical involvement and resources, is vital for success.
We are currently in the process of reviewing our approach to quality improvement across the Trust. Whilst this is undertaken, we will continue to deliver against our established quality improvement programme which is set out in Table 3.
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Table 3 Quality Improvement Programme 2014/15 – 2016/2017
Year Velindre Cancer Centre Welsh Blood Service
Trust-wide
2014-15
Continue VCC Improvement Programme of service improvement work including:
• review pathways for radical radiotherapy for specific patient groups (including lung and neurology patients) with a view to reducing waiting times
• seek to spread lessons from the urology outpatient VIP work to other cancer sites to improve patient experience and waiting times
• review of chemotherapy/ SACT services to ensure wherever possible patients are treated locally to home
Continue to actively participate on national 1000 Lives programmes; including care of critically ill, infection prevention etc. Evaluate results of All Wales cancer survey results and development, as appropriate – as action plan to address any issues.
Develop a Customer Service Culture amongst frontline staff to improve the donation experience. Scope engagement of both staff and donors on the introduction and roll out of new technology in the donation pathway. Pursue collaborative working with a wide range of individuals and organisations, in particular Higher Education Institutions, to develop a lean culture and ways of working to maximise best use of resources within the Service and strive for continual best practice. Explore how we incorporate continuous improvement and capture IQT into major programmes of work. Develop our participation in the national 1000 Lives / 1000 Lives Plus programme with a specific focus on how new technology impacts on the Service.
Increase by 25% from baseline year of 2013/14 the % staff trained in IQ at bronze and silver levels. Pursue collaborative partnership with Cardiff University Business School for access to academic improvement science and mathematical modelling expertise.
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Commence work with Health Boards on improving pathways for patients, whose needs cross VCC and HBs. Review and analyse data collection of palliative care (i.e. preferred place of care etc) and then develop implementation plan to improve performance to meet patients’ requests. Work with Health Boards to develop Acute Oncology Services (AOS) in all Local Health Boards supported by Velindres’ Acute Oncology Service hub.
Scope the WBS business intelligence requirements to ensure our operations are underpinned by highly effective and efficient management data to support and ensure continuous Service improvement.
2015-16
Continue to actively participate on appropriate areas of work from the national 1000 Lives programme Review VIP work to date and develop priorities for 2015/16 Continue work with Health Boards around clinical pathways for oncology patients with complex requirements e.g. deteriorating patients Continue development with Health Boards of AOS
Review work to date and develop further priorities. Continue the development of lean initiatives to support continual step changes in performance ensuring quality improvement remains at the forefront of everything we do. Co-ordinate and secure the necessary resources to establish effective Business Information Systems to continually improve the way we work and support our ambition to be the best in class
Identify potential programmes of research in improvement science and develop opportunities for researchers. Consider opportunities afforded through Business Case development for new Cancer Centre for local faculty development.
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blood collection service. Identify potential programmes of research across the organisation that will support donor and patient outcomes and continual Service improvement. Continue to actively participate on appropriate areas of work from the national 1000 Lives / 1000 Lives Plus programme.
2016-17
Continue VIP work programme to meet identified quality and performance improvement areas Actively contribute to national 1000 Lives programmes relevant to VCC
In line with the establishment of an all Wales Blood Service take forward initiatives and programmes of work to ensure appropriate arrangements are in place to promote IQT, Business Intelligence and continuous improvement on an all Wales basis.
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Section 7: Enabling Transformation: improving the infrastructure
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Information, communication and technology plan 2014 – 2017
Velindre Cancer Centre
The ICT programme for the Velindre Cancer Centre has been developed to support the significant change programme necessary to underpin the information requirements of the clinical service and those of the patient. Whilst treatment for cancer is increasingly successful, it is also becoming much more complex, both in terms of treatments being offered and patient pathways which may traverse primary, secondary, tertiary, community and social care. The emerging Cancer Centre ICT requirements must be balanced with the ongoing operational service, ensuring that we can continue to support the patient’s cancer journey but also addressing the evolving needs of the patients and healthcare professionals across organisations as new pathways and treatment options become available.
The key components of the IM&T plans include:
• Local ICT Change Programme
These projects will be implemented within the Cancer Centre to the benefit of clinicians and patients. Examples include the ability for clinicians to access their emails and work calendars on their own mobile devices, and technical upgrades to the rooms where cancer multi-disciplinary team meetings are held to improve their access to relevant information when discussing patient treatment.
• National ICT Change Programme
The availability of information at the point of care is key to managing the increasing complexity of cancer care delivery, and an integrated view of the health record is critical. The Cancer Centre has an electronic patient record (Canisc) which is also a national oncology patient record, and the system is being developed to support the information requirements for the Cancer Services in Wales, and is endorsed by Welsh Government.
The National ICT Change Programme objectives are based on the Wales Integrated Services Strategy and the Cancer Delivery Plan. They include the implementation of national products within the Cancer Centre, such as the Welsh Clinical Portal, the national picture archiving system, the new laboratory information management system, and the ability through the Welsh Clinical Communications Gateway to transfer documents electronically between primary secondary and tertiary care.
This programme of work will provide significant benefits for patient safety, with health care professionals having more information available at the point of care, thereby supporting decision-making and reducing any chance of inappropriate treatment or medication errors. The change programme also delivers more patient-focussed care with information from a variety of systems and sources being brought together.
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• Patient Centric Improvements
The change programme has taken into account feedback from the Patient Liaison Group, and includes some significant improvements for anyone visiting the Cancer Centre. Examples include the ability to access the internet using their own devices, and by the end of 2015/2016 the introduction of a patient entertainment system. The patient experience will also be improved through the introduction of an electronic holistic needs assessment, and a self check-in system in outpatients.
• Operational maintenance/project delivery programme
The Cancer Centre must respond to an evolving set of operational support requirements, and a detailed infrastructure programme plan has been developed for such projects as the standardised desktop, server replacements, infrastructure enhancements etc. However, the same resource is also responsible for implementing the ICT Change Programme, and the organisation recognises that the operational needs of the service may impact on the ability of the team to deliver the ICT change programme.
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Strategic Priority Area ICT: Key Actions Velindre Cancer Centre
2013/2014 2014/2015 2015/2016 2016/17
Equitable and timely services
Provide staff with accurate information at the point of care.
• Availability of pathology results from across Wales within the electronic patient record, Canisc, (EPR) from the new national laboratory system.
• Use of mobile carts/handhelds on wards and Day Units to allow clinicians access to patient information
• Mobile Device Management
Safe and reliable services
Implementing new technology to enable documentation to become a formal record within the EPR.
• Integration of the EPR (Canisc) with the WCCG, allowing eReferrals and eDischarges between primary and secondary care
• Implementation of an integrated EPR (Canisc)with the Welsh Clinical Portal
Providing evidence based care and research which is clinically effective
Rolling programme of data quality improvement, & availability of data to support the health informatics agenda.
Data Quality project
Supporting our staff to excel
Ensure that staff have electronic access to important clinical information from other organisations during treatment discussions.
• Cancer multi—disciplinary meeting room upgrades
• Implementation of a new electronic multi-disciplinary team module within the EPR
Improve the resilience and performance of ICT to facilitate patient care
• Infrastructure Review
• Infrastructure Action Plan
• Standardised Desktops • PC and Laptop replacement programme • Infrastructure Refresh Programme
Table 4 Velindre Cancer Centre Information, Communications and Technology Programme
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Strategic Priority Area ICT: Key Actions Velindre Cancer Centre
2013/2014 2014/2015 2015/2016 2016/17
First class patient experience
Improve the overall patient experience.
• Patient Internet Access
• Patient Self-Check in
• Beyond Breast Cancer • Patient Entertainment System Spending every pound well
Digitisation project to allow patient services to be run entirely electronically and reduce the dependence on paper records.
• Paperlite Project
Table 4 Velindre Cancer Centre Information, Communications and Technology Programme
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Velindre Cancer Centre ICT Programme
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Welsh Blood Service
The IM&T programme for the Welsh Blood Service reflects the need to maintain regulatory compliance while supporting the significant change programmes currently being implemented across the Service. In order to achieve this there is a prioritised balance between the operational project delivery programme, which acts as an enabler for operational departments to gain efficiency of service provision, and the delivery of new systems and services, which are aligned with international transfusion practices and ensure the Service has supporting systems that are fit for purpose for the future.
The key components of the IM&T plan are:
• An operational project delivery programme (including continuation of the infrastructure improvement programme)
• Implementation of a Blood Establishment Computer System (BECS)
• Implementation of the All Wales Laboratory Information Management System (LIMS)
• Software solutions to support the emergence of an All Wales Blood Service
Operational Project Delivery programme
Alongside a significant IM&T modernisation programme, the WBS is required to respond to a constantly evolving set of operational requirements. The WBS currently has a detailed software development work plan with activity currently planned until the end of 2014.
The majority of the software development is focused on development of the WTAIL systems, however it is known that there are complex laboratory instrument procurements planned for 2014, that may require software development to existing blood management systems.
Such operational requirements significantly impact on the service’s ability to deliver the IM&T modernisation programme, as resource, whether it is IM&T, Validation, Quality or Operational, is prioritised to the operational projects.
In addition to this, the WBS infrastructure is continually evolving and a detailed infrastructure plan exists to manage work programmes such as server replacements, PC roll out plans, encryption and other infrastructure enhancements such as IP telephony
As a result of these current operational work plans existing software and technical skill sets will need to be maintained to ensure competency and appropriate levels of support are in place for the service into the future. Furthermore it is increasingly apparent that ePROGESA is requiring the development of middleware solutions to support long term operational requirements, and this further strengthens the need to retain these specialist skills.
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All of the work performed against the operational project delivery plans is subject to strict regulatory control, with every activity reviewed and impact considered against Good Manufacturing Practice (GMP). A significant challenge for the operational project delivery plans is that mandated requirements don’t often materialise with long lead in times. The plan has to be responsive to key operational issues and sometimes there is only a very limited period of time before the requirement/benefit needs to be realised.
For example, working is ongoing on projects such as standardisation of labelling for blood components and tissues, it is likely that things will be mandated in 2014/2015 however, there is no clear scope of the change or indeed the timeline to be met.
As a result of this limited planning time, resources constantly have to be reviewed and re-prioritised to manage the successful delivery of the operational project delivery plan. This can on occasions result in delivery times being amended.
Blood Establishment Computer System (BECS)
In 2010, the WBS began a procurement exercise to purchase a new Blood Establishment Computer System (BECS). The BECS will ensure that blood can be safely collected, processed, tested, labelled and issued to hospitals across Wales. The new BECS will deliver a number of benefits including:
• Enhanced functionality to support the recruitment and retention of donors; • Business intelligence reports to support operational decision making; • The provision of more information on session to support the donation process; • Ability to collect donor and donation information on session; • Ability to respond quickly to regulatory changes/operational requirements.
Following the procurement process, MAK-System was identified as the successful supplier, to deliver their ePROGESA system.
One of ePROGESA primary benefits is to integrate all parts of the service. As a result there is a constant requirement for numerous operational, technical and quality resources to be made available in order to support its implementation. ePROGESA is a highly configurable system which requires detailed analysis and opportunities for future process redesign. However with a high degree of configurability the system is susceptible to regular change. This can be viewed as a negative and sometimes leads to difficulties in agreeing a final system state.
By the end of 2013 the WBS plans to have determined its final system state. From here the service will validate the system during the first half of 2014, before moving the system into operational services during the second half of 2014. Once operational, the WBS will then focus on the many enhancements ePROGESA has available to its user base, such as its online donor portal, app technology and electronic point of care solutions to capture blood collection information at the bedside. It will also explore the use of its eDonor Relationship Module (eDRM) to improve campaign and marketing drives for the future service.
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All Wales Laboratory Information Management System (LIMS)
The National Pathology Programme was established to direct the modernisation of pathology services across Wales. Part of the programme’s focus is on improvements to IM&T, delivered through an All Wales Laboratory Information Management System (LIMS). The Programme recognised some shortfalls in current organisational laboratory systems and identified a number of benefits through an All-Wales LIMS including:
• Enables a complete patient pathology record; • Ability to provide tests from ‘regional’ laboratories; • Reduction in costs for system support and future developments; • Supports future Pathology modernisation work; and, • Supports the establishment of Health Boards / re-organisations across Wales.
NHS Wales Informatics Service is leading the LIMS programme. In June 2010, a contract was signed on behalf of NHS Wales with InterSystems to purchase and implement the TrakCare Laboratory System across Wales. The WBS will be implementing LIMS in two stages:
• Antenatal & Antibody testing (Blood Transfusion Modules) • Welsh Transplantation and Immunogenetics Laboratory (WTAIL Modules)
The programme has required a large resource commitment from WBS and a number of all-Wales work streams have been established to support the work. Both Blood Transfusion and WTAIL modules will require significant regulatory control and to this end timelines for both are still being planned. At present Blood Transfusion is planned to be rolled out across Wales towards the end of 2014 and into 2015.
The WTAIL modules will require some development and engagement with third party suppliers in order to deliver the required functionality. Therefore the go-live for WTAIL is anticipated towards the end of 2015 and into early 2016. This aspect of LIMS will also require significant internal IM&T resource to support the migration from existing WTAIL systems.
All Wales Blood Service
In line with the Welsh Government (WG) vision of how the NHS will look in five years, the Minister for Health and Social Services announced on the 13 June 2012 the need to establish an All Wales Blood Service.
This statement included a clear intention to move towards establishing such provision by 2016, with significant progress evident by 2014. Subsequently, on 20 September 2012, Welsh Government wrote to the Chief Executive of the Velindre NHS Trust with Terms of Reference for the project board as agreed by the Minister.
A significant IM&T project has been initiated to support this programme of work. This work primarily involves the migration of a defined data set from NHS Blood and Transplant (NHSBT)
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computer systems to the WBS blood management systems, but also requires a review of infrastructure requirements.
As with all blood transfusion related projects, strict governance, control and change management is required. The work is being performed in co-operation with WBS, Velindre NHS Trust, NHSBT, Betsi Cadwaladr University Health Board (BCUHB) and Welsh Government representatives.
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Table 5 Welsh Blood Service Information Communications and Technology Programme
Strategic Priority Area Key Actions Welsh Blood Service 2013/2014 2014/2015 2015/2016 2016/2017 Equitable and timely services Safe and reliable services Supporting our staff to excel Spending every pound well Providing evidence based care and research which is clinically effective Supporting our staff to excel
Operational Project Delivery Programme
• Software solutions to
support introduction of new microbiology analysers
• Software to support
the use of Euroblood Pack
• Software solutions to
support the implementation of new Autoscopes
• Software
enhancements to ensure an alignment of the WBS with international donor registries
• Software to support
the outsourcing of HLA Typing
• Software solutions to
support automated grouping analysers
• Future operational
projects to ensure regulatory compliance
Equitable and timely services Safe and reliable services Supporting our staff to excel
Implementation of a Blood Establishment Computer System (BECS)
• Enhanced
functionality to support the recruitment and retention of donors
• Online donor
appointments • Online donor
record management
• Integration with
North Wales teams
• Hospital Web
Ordering • Bedside PDAs
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Strategic Priority Area Key Actions Welsh Blood Service 2013/2014 2014/2015 2015/2016 2016/2017 Providing evidence based care and research which is clinically effective
• The provision of
more information on session to support the donation process
• Ability to collect
donor and donation information on session
• Ability to respond
quickly to regulatory changes/operational requirements
• Business intelligence
reports to support operational decision making
• Online Donor
Health Questionnaire
Equitable and timely services Safe and reliable services Supporting our staff to excel
Implementation of an All Wales Laboratory Information Management System (LIMS)
• Standardisation of
Blood Transfusion practices
• Enables a complete
patient pathology record
• Integration of
WTAIL LIMS with national systems (eg LIMS, WCP)
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Strategic Priority Area Key Actions Welsh Blood Service 2013/2014 2014/2015 2015/2016 2016/2017 First class patient experience
• Ability to provide tests from ‘regional’ laboratories
• Reduction in costs for
system support and future developments
• Electronic transfer of
test results and reports
• Improved visibility of
blood stocks across Wales
Equitable and timely services Safe and reliable services Supporting our staff to excel Spending every pound well
All Wales Blood Service
• Migration of
donor records from NHS Blood & Transplant (NHSBT)
• Implementation of
supporting infrastructure
• A single blood
collection process for Wales
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Strategic Priority Area Key Actions Welsh Blood Service 2013/2014 2014/2015 2015/2016 2016/2017 Safe and reliable services Supporting our staff to excel Spending every pound well
Infrastructure Improvement Programme
• IP telephony
• Server, PC &
Laptop replacement
• Standardised
Desktops
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Welsh Blood Service High Level ICT Programme
Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2013 2014 2015 2016
Change ProgrammesKey:
Business As UsualStaff Development
2017
ePROGESA Implementation
ePROGESA Enhacements
Existing Systems Maintenance & Support
All Wales LIMS WTAIL
All Wales LIMS Blood Transfusion
All Wales Blood Servcice Migration & Infrastructure
Training / Best Practice / Innovation
Operational Project Delivery Programme (Software & Infrastructure)
Infrastructure Replacement Programme
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Capital Plans and Resource Requirements 2014 – 2017
Velindre NHS Trust is capital intensive and requires continuous capital investment to maintain service delivery. Cancer care is fast-moving and there will continue to be a requirement to invest in new equipment to keep pace with advances in patient treatments, particularly in radiotherapy. The Welsh Blood Service also requires capital investment to maintain its excellent quality and highly regulated services. The capital requirements of the Trust operate at three distinct levels;
(i) strategic; (ii) service development; and, (iii) operational.
The main priorities in each of these areas are summarised below.
Strategic Capital Requirements • The development of a new cancer campus: the initial capital requirements are related to
the purchase of land and development of business cases (Strategic outline programme, strategic outline case and full business case);
• Transfer of the provision of blood and transplantation services in North Wales from the English Blood and Transfusion Service to the Welsh Blood Service: the initial capital requirements are related to the acquisition of estates and facilities in North Wales to operate the service;
• A range of national patient information systems and enabling technologies: the main focus will be on the development and implementation of electronic patient records and the all-Wales LIMS (WTAIL)(Blood Transfusion) systems.
Service Development Capital Requirements • The development of a range of new services including SBRT and enhanced radiotherapy
planning facilities for IMRT and HDR: capital requirements will be sought through business cases to commissioners and Welsh Government;
• Provision of additional and more capable LINACS, MRI scanners and related infrastructure to meet increased demand: the complexity of treatment is changing and we need to be more capable to provide new treatments and technology such as SBRT and IGRT.
Operational Capital Requirements • Statutory compliance, backlog maintenance and accommodation: the Cancer Centre is
sixty years old and has significant issues related to statutory compliance, backlog maintenance and providing an environment that is suitable for patients and staff. There are a number of specific issues which need to be resolved very quickly including
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the replacement of the water distribution system and bracytherapy theatres, and significant improvements to the patient environment to improve the patients experience and service effectiveness;
• Equipment Replacement Programme: replacement of very expensive items of equipment is required such as CT simulators, CT scanner, gamma camera and linear accelerator for the Velindre Cancer Centre and blood testing systems for the Welsh Blood Service.
The Trust recognises that our capital requirements for the next three years are more than double the Trust’s current allocation. However, they are a true representation of need across the Trust. We have undertaken an initial prioritisation exercise which has identified a set of level one priorities. We have been successful in securing additional capital resources in previous years and will be pursuing this route during 2014/2015 in order to address the other salient issues. However, we recognise that this cannot be relied upon and we have plans in place to manage the position if we are unable to access capital funds over our stated allocation of circa £1million.
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Capital Programme 2013/2014
£000's
Welsh Government Business Cases - Approved: VCC - Replacement Linac In Bunker 4 4,260
VCC - Replacement MRI Scanner 1,531 VCC - Enhanced Radiotherapy Planning Facilities for IMRT & HDR Brachytherapy 506 VCC - New Cancer Centre SOP/SOC Feasibilty Study 110 VCC - Pharmacy E Reader & Software 9 VCC & WBS - Capital Works 1,289 VCC - Transfer of Land/Buildings (Post Grad) 5,750 WBS - Replacement of Blood Grouping Analysers 410 Sub-Total 13,865
Discretionary Capital Schemes - Approved: VCC - Estates Schemes 361
VCC - IT Infrastructure 44 WBS - Replacement Equipment 220 WBS - Estates Schemes 60 WBS - IT Infrastructure 318 Sub-Total 1,003
TOTAL 14,868
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Capital Programme 2014/2015 £000's
Welsh Government Business Cases - Approved: VCC - Replacement Linac In Bunker 4 150
Sub-Total 150
Welsh Government Business Cases - Submissions Expected: VCC - Site Development/Cancer Centre 1,350
VCC - Accommodation Project 2,500 VCC - Replacement of Water Distribution System Phase 1 400 VCC - Theatre Refurbishment/DevelopmentDevelopment 530 VCC - Replacement Linac within Bunker 2 4,000 WBS - Replacement of Blood Grouping Analysers 600 WBS - BECS/eProgesa Phase 2 500 Carbon Reduction Commitment Schemes 245 Sub-Total 10,125
Discretionary Capital Schemes: VCC - Replacement Equipment 640
VCC - Estates Schemes 693 VCC - IT Infrastructure 480 WBS - Replacement Equipment 346 WBS - Estates Schemes 381 WBS - IT Infrastructure 350 Corporate Headquarters - IT Infrastructure 10 Sub-Total 2,900
Discretionary Capital Schemes: VCC - Donated Asset (First Floor Ward) 421
VCC - Donated Asset (Fluorescence Microscope) 60 Sub-Total 481
TOTAL 13,656
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Capital Programme 2015/2016
£000's
Welsh Government Business Cases - Submissions Expected:
VCC - Site Development FBC Work 2,365 VCC - Accommodation Project 1,000 VCC - Replacement of Water Distribution System Phase 2 600 VCC - Replacement Linac within Bunker 2 1,500 VCC - Replacement of CT Scanner 1,100 VCC - Replacement of CT Simulator (1) 1,000 VCC - Radiotherapy Verification System 500 WBS - All Wales Blood Service Programme 300 WBS - BECS/eProgesa Phase 2 250 Trust - Electronic Document Records Management System 500 Sub-Total 9,115
Discretionary Capital Schemes: VCC - Replacement Equipment 585
VCC - Estates Schemes 270 VCC - IT Infrastructure 583 WBS - Replacement Equipment 559 WBS - Estates Schemes 520 WBS - IT Infrastructure 140 Corporate Headquarters - IT Infrastructure 10 Sub-Total 2,667
TOTAL 11,782
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Capital Programme 2016/2017
£000's
Welsh Government Business Cases - Submissions Expected:
VCC - Site Development 50,000 VCC - Replacement Linac 5,000 VCC - Replacement of Gamma Camera 1,000 VCC - Replacement of CT Simulator (2) 1,000 VCC - Microselectron 500 WBS - Apheresis Equipment 750 WBS - All Wales Blood Service Programme 3,000 WBS - BECS/eProgesa Phase 2 250 Sub-Total 61,500
Discretionary Capital Schemes: VCC - Replacement Equipment 350
VCC - Estates Schemes 282 VCC - IT Infrastructure 530 WBS - Replacement Equipment 560 WBS - Estates Schemes 150 WBS - IT Infrastructure 100 Corporate Headquarters - IT Infrastructure 15 Sub-Total 1,987
TOTAL 63,487
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Section 8: Spending our resources effectively
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Financial Strategy 2014 – 2017
Our financial strategy has been developed on the following assumptions:
• We will continue to receive “flat cash” from the Health Boards. • There will no uplift to the funding currently provided other than for NICE and High Cost
Drugs that are funded on an actual basis. • Public sector pay increases will be limited to 1% per year applies. The assumptions have led to the following financial projections: • A 1% wage award has been built into the strategy at a cost of £0.414millions in year
one, £0.403millions in year 2, and rising to £0.405 millions in year three. • Staff entitlement to receive incremental progression through the payscales has also
been included at a cost of £0.342 millions in year one, £0.420 millions in year 2, and £0.346 millions in year 3.
Incremental costs have been calculated in detail based on each staff member’s current point on the payscale and their ability to move up annually to a next increment. The year two increase is due to a cohort of staff regraded as part of Welsh Blood Service modernisation programme who will be entitled to one further increment in year two before reaching the top of the new payscale.
Local divisional cost pressures have been included, in line with the approach adopted in previous financial years to ensure that all issues of financial risk are identified and managed. The divisional plans include approved business case funding. Expenditure increases have been included in both the staff and non staff budgets with the approved funding increases shown against the income due from the relevant Health Boards.
Funding has been included for Intensity Modulated Radiation Therapy (IMRT) at Velindre Cancer centre for 2.55 WTE and associated non staff costs at £73k in 2014/15. The most significant of these developments relates to the Velindre Cancer Centre and the Stereotactic Body Radiation Therapy (SBRT) development which will require an additional 12.18 whole time equivalent staff which are funded together with the associated non-staff costs to a value of £854k in 2014/15.
There Trust is required to achieve savings requirement of 5.57% in year one, 3.86% in year two and 3.99% in year 3 to achieve a balanced position.
Plans are in place for the delivery of the savings with year one (2014/2015) being well detailed and the following two years still considered to be in development.
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Financial Plan 2014/2015 – 2016/2017
2014/15 2015/16 2016/17
1. High Level Summary NHS/WHSSC/WG Income 2013/14 Other Income Total Revenue Comparator - see note below 2 Underlying deficits and cost pressures b/f 3 New WG allocations 4 New Cost Pressures Cost Growth Pay Inflation Pensions Costs Non pay Inflation Travel Allowance Changes Statutory Compliance and National Policy Continuing Health Care Funded Nursing Care Prescribing Total Inflationary costs Demand / Service Growth NICE and New High Cost Drugs Continuing Heath Care Funded Nursing Care Prescribing Specialist Services Demographic / Demand on Acute Services Demand / Growth LocalService/Cost Pressures Velindre Cancer Centre Welsh Blood Service Corporate .... .... .... .... ..... Local Cost Base Change Savings Plans/Cost Avoidance Pay & Employee Benefit Expenses Non Pay Primary Care Contractor Medicine Management Continuing Care and Funded Nursing Care Commissioned Services Income Total Savings Plans Forecast Outturn
£m
£m
£m
50.9 36.0
50.9 36.0
50.9 36.0
86.8 86.9 86.9 0.0 0.0 0.0
1.2
0.8
0.2 0.0 0.1
0.9
0.8 0.0 0.2 0.0 0.1
1.1
0.8 0.0 0.2 0.0 0.1
1.1 1.1 1.0
0.0 0.0 0.0
0.3 0.8 0.0
0.4 -0.1 0.0
0.4 -0.1 0.0
1.1 0.4 0.4
-3.0 -0.3
-1.5 -0.9
-1.6 -0.8
-3.4 -2.3 -2.4
0.00 0.00 0.00
Comparator based on H&CHS expenditure - note 3.3 of 2011/12 accounts adjusted as follow · less Depreciation and Impairments (note 3.3 of the accounts) · less Hosted Services · plus Prescribing (note 3.1 of the accounts) · plus Continuing Health Care (note 3.2 of the accounts) · plus Funded Nursing Care (note 3.2 of the accounts)
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BASE YEAR - TRUST BOARD AGREED FINANCIAL STRATEG
PLAN 2013/14
£000 £000 £000 £000 £000 Income Powys LHB Core Funding ABMU LHB Core Funding AB LHB Core Funding C&V LHB Core Funding CT LHB Core Funding HD LHB Core Funding WHSSC Core funding (WBS) WHSSC Core funding (VCC) Welsh Government Trust revenue Delegated Expenditure Control Limits
Div Savings Income Staff Non Staff Required DECL
VCC (24,828) 28,215 22,599 (1,921) 24,065 WBS (10,717) 12,307 17,584 (945) 18,229 Corp (430) 3,479 1,027 (301) 3,775 Depreciation
Y
£000
(416) (1,928) (8,768) (5,518) (3,571)
(293) (21,005) (7,822)
(603) (49,924)
46,069
3,855
0
PLAN 2014/15
£000 £000 £000 £000 £000 Income Powys LHB Core Funding ABMU LHB Core Funding AB LHB Core Funding C&V LHB Core Funding CT LHB Core Funding HD LHB Core Funding WHSSC Core funding (WBS) WHSSC Core funding (VCC) Welsh Government Trust revenue Delegated Expenditure Control Limits
Div Savings Income Staff Non Staff Required DECL
VCC (24,828) 27,702 24,267 (2,149) 24,992 WBS (10,717) 12,029 17,767 (1,112) 17,967 Corp (430) 3,217 1,366 (116) 4,037 Depreciation
£000
(418) (1,935) (8,796) (5,539) (3,585)
(294) (21,005) (8,676)
(603) (50,851)
46,996
3,855
0
VELINDRE NHS TRUST
FINANCIAL PLAN 14/15 to 16/17
YEAR 1
Adjustments in Plan to 14 / 15
13/14 Savings IMRT &
Staff Cost
Non Staff Cost
New Savings
D2D release
made SBRT Presures Presures requiremen Plan
(2) (7)
(28) (21) (14)
(1)
(854)
(1,921) 927 481 1,668 (2,149) (945) 929 183 (1,112) (262) (301) 39 77 (116)
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PLAN 2014/15
£000 £000 £000 £000 £000 Income Powys LHB Core Funding ABMU LHB Core Funding AB LHB Core Funding C&V LHB Core Funding CT LHB Core Funding HD LHB Core Funding WHSSC Core funding (WBS) WHSSC Core funding (VCC) Welsh Government Trust revenue Delegated Expenditure Control Limits
Div Savings Income Staff Non Staff Required DECL
VCC (24,828) 27,702 24,267 (2,149) 24,992 WBS (10,717) 12,029 17,767 (1,112) 17,967 Corp (430) 3,217 1,366 (116) 4,037 Depreciation
£000
(418) (1,935) (8,796) (5,539) (3,585)
(294) (21,005) (8,676)
(603) (50,851)
46,996
3,855
0
PLAN 2015/16
£000 £000 £000 £000 £000 Income Powys LHB Core Funding ABMU LHB Core Funding AB LHB Core Funding C&V LHB Core Funding CT LHB Core Funding HD LHB Core Funding WHSSC Core funding (WBS) WHSSC Core funding (VCC) Welsh Government Trust revenue Delegated Expenditure Control Limits
Div Savings Income Staff Non Staff Required DECL
VCC (24,828) 26,034 25,189 (1,403) 24,992 WBS (10,717) 11,221 18,336 (873) 17,967 Corp (430) 3,255 1,281 (69) 4,037 Depreciation
£000
(418) (1,935) (8,796) (5,539) (3,585)
(294) (21,005) (8,676)
(603) (50,851)
46,996
3,855
0
VELINDRE NHS TRUST
FINANCIAL PLAN 14/15 to 16/17
Year 1 Year 2
Adjustments in Plan to 15 / 16
14/15 Savings made
Staff Cost
Presures
Non Staff Cost
Presures
New Savings
requiremen
(2,149) 481 922 (2,115) (1,112) 304 569 (1,206)
(116) 38 31 (141)
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PLAN 2015/16
£000 £000 £000 £000 £000 Income Powys LHB Core Funding ABMU LHB Core Funding AB LHB Core Funding C&V LHB Core Funding CT LHB Core Funding HD LHB Core Funding WHSSC Core funding (WBS) WHSSC Core funding (VCC) Welsh Government Trust revenue Delegated Expenditure Control Limits
Div Savings Income Staff Non Staff Required DECL
VCC (24,828) 26,034 25,189 (1,403) 24,992 WBS (10,717) 11,221 18,336 (873) 17,967 Corp (430) 3,255 1,281 (69) 4,037 Depreciation
£000
(418) (1,935) (8,796) (5,539) (3,585)
(294) (21,005) (8,676)
(603) (50,851)
46,996
3,855
0
PLAN 2016/17
£000 £000 £000 £000 £000 Income Powys LHB Core Funding ABMU LHB Core Funding AB LHB Core Funding C&V LHB Core Funding CT LHB Core Funding HD LHB Core Funding WHSSC Core funding (WBS) WHSSC Core funding (VCC) Welsh Government Trust revenue Delegated Expenditure Control Limits
Div Savings Income Staff Non Staff Required DECL
VCC (24,828) 25,112 26,241 (1,533) 24,992 WBS (10,717) 10,581 18,926 (823) 17,967 Corp (430) 3,364 1,169 (66) 4,037 Depreciation
£000
(418) (1,935) (8,796) (5,539) (3,585)
(294) (21,005) (8,676)
(603) (50,851)
46,996
3,855
0
VELINDRE NHS TRUST
FINANCIAL PLAN 14/15 to 16/17
Year 2 Year 3
Adjustments in Plan to 16 / 17
15/16 Savings made
Staff Cost
Presures
Non Staff Cost
Presures
New Savings
requiremen
(2,115) 481 1,052 (2,047) (1,206) 233 590 (1,065)
(141) 37 29 (120)
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2014/1
VCC WBS CORP £000 £000 £000
230 99 13 251 137 26 164 101 46
5
Total £000
342 414 311
1,067
1,617
693
3,377
(3,377)
0
0.56% 0.68% 0.51%
645 337 85
1,504 82 31 0 693 0
1.76%
2.66% 1.14%
2,149 1,112 116 5.57% (2,149) (1,112) (116)
0 0 0 0.00%
2015/1
VCC WBS CORP £000 £000 £000
230 179 11 251 125 27 141 71 31
6
Total £000
420 403 243
1,066
801 478
2,345
(2,345)
0
0.69% 0.66% 0.40%
622 375 69
781 20 0 0 478 0
1.76%
1.32% 0.79%
1,403 873 69 3.86% (1,403) (873) (69)
-3.86%
0 0 0 0.00%
2016/
VCC WBS CORP £000 £000 £000
230 107 9 251 126 28 141 71 29
7
Total £000
346 405 241
992
911 519
2,422
(2,422)
0
0.57% 0.67% 0.40%
622 304 66
911 0 0 0 519 0
1.63%
1.50% 0.86%
1,533 823 66 3.99% (1,533) (823) (66)
-3.99%
0 0 0 0.00%
VELINDRE NHS TRUST
POTENTIAL COST PRESSURES
National Pressures
Staff increments Staff wage award @ 1% Non Pay inflation
Sub Totals
Local Pressures Service Modernisation Pressures
Total Cost Pressures
Less identified savings identified
Further savings required to balance plan
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Recurrent Grn Amb Red
381 100 500 100 140
20 15 10 8 150
100 20 40 10
60 40
10 70
15 1,306 483 0
1,789
Non-recurrent Grn Amb Red
100 100
60 20
20
60
240 120 0 360
Recurrent Grn Amb Red
30
100 200 133
100
433 130 0 563
Non-recurrent Grn Amb Red
200
20 100
15 50 165
235 315 0 550
Recurrent Grn Amb Red
36
0 36 0 36
Non-recurrent Grn Amb Red
80
80 0 0 80
Velindre Cancer Centre Plan TOTAL
VCC-wide 1 Pay pressures absorbed by Depts savings 481 2 Vacancy turnover 500 3 Managed vacancy savings 300 4 Recognise activity income 140 5 Senior management staffing opportunity 60 6 Electronic referral project (WCCG) 20 7 Travel costs (10% reduction) 15 8 SLA review (incl anaesthetics) 10 9 Sickness management (spend to save) 8
SACT 10 Dispense & deliver service 150 11 Increase private income (drugs margin) 100 12 SACT review of delivery clinics 20 13 Temporary funding opportunity 20 Outpatient & Imaging 14 SLA negotiation (Nuc Med) 40 15 MRI capacity sales 10 Radiotherapy 16 Increase private income for advanced RT 100 17 New service income stream (1) 20 18 New service income stream (2) 10 Medical & Palliative Medicine 19 Staffing opportunity (Med) 70 20 Staffing opportunity (Pall Med) 60 Facilities Management 21 Improve rental stream from property 15
TOTAL SAVINGS IDENTIFIED 2,149
Welsh Blood Service
Plan TOTAL
WBS 1 Staff Inflation to be managed at department level 230 2 HPC Income Stream increases 120 3 increased services provided to Screening 100 4 Microbiology testing procurement initiative 200 5 Budget setting departmental savings found 198 6 Service Improvement Programme 265
TOTAL SAVINGS IDENTIFIED 1,113
Corporate
Plan TOTAL
WBS 1 Staff Vacancies 80 2 Miscellaneous Non Pay Cost improvements 36
TOTAL SAVINGS IDENTIFIED 116
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Section 9: Managing the delivery of our plan
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Commissioning Arrangements
The Local Health Boards are responsible for commissioning cancer and blood services from the Trust to meet the needs of their population. This process is currently managed by the Welsh Health Specialised Services Committee (WHSSC) on behalf of the LHBs, with strategic advice provided by the Cancer Networks. There is a common view across Wales that the commissioning process could be strengthened and the Trust will seek to work with LHBs to improve the current arrangements to ensure that the people of Wales continue to receive services of high quality.
Integrated Performance, Risk and Assurance Framework We utilise an Integrated Risk Management Assurance Framework to manage the delivery of services and strategic plans. This ensures that there is a “golden thread” that links all organisational plans and priorities, risk, delivery and measurement into an overall system of assurance. This is illustrated in Fig. 24.
Fig.24 Integrated Performance, Risk and Assurance Framework
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The components of the Assurance System are described below.
Plans and priorities Our strategic aims and priorities are set out within our 5 year framework ‘Delivering Quality, Care and Excellence’ and translated into translated into specific objectives and actions within this plan. Risk We assess the risk of achievement against each of our strategic aims, priorities and objectives as part of the planning process. This is undertaken in a systematic way in accordance with the Trusts’ risk management framework. All identified risks are set out on the corporate risk register at the beginning and are regularly reviewed and updated. All new risks identified during the year are assigned against the relevant objective. Delivery The focus of delivery is the Annual Delivery Plan which sets out the actions we will take to deliver the identified priorities and objectives and how we will mitigate identified risks. Measure We use a range of quantitative and qualitative information to allow us to monitor our progress in delivering the objectives and the quality and safety of our services.
Performance Management /Quality Improvement System
We use a robust quality improvement / performance management system to support our staff in achieving the improvements required. The system is based upon four main elements:
• A clear set of aims, objectives, plans and supporting actions to improve quality; • A range of performance measures; • A regular process of monitoring and review; and, • A process of escalation/action if we are not on track to achieve our aims.
The performance management system operates at 4 levels as set out in Fig. 25.
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Fig.25 Performance Management Quality Improvement System
The management of performance and improvement of quality is supported by the Trust committee structure with the Planning and Performance Committee and Quality and Safety Committee having the lead responsibility for scrutinising the quality and performance of service on behalf of the Trust Board.
Governance Arrangements
Good governance essentially means that the organisation has the appropriate arrangements in place to make the best decisions as fast as possible. This requires the Trust to have good systems, processes and well-trained people in place to achieve the highest levels of service. The Board is accountable for Governance and Internal Control for those services directly managed and those managed via hosting arrangements. As Accountable Officer, the Chief Executive has responsibility for maintaining appropriate governance structures and procedures
Man
agem
ent o
f Ris
k at
all
leve
ls
Trust Board monitor service quality, performance and risk (bi-monthly)
Level 1
Trust Committees monitor and service quality, performance and risk (bi-monthly)
Executives monitor and manage service quality, performance and risk
Level 2
Senior managers Executives monitor and manage service quality, performance and risk (weekly/monthly)
Level 3
Department/line managers monitor and manage service quality, performance and risk (daily/weekly)
Level 4
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as well as a sound system of internal control that supports the achievement of the organisation’s policies, aims and objectives, whilst safeguarding the public funds and this organisation’s assets for which he is personally responsible. These are carried out in accordance with the responsibilities assigned by the Accounting Officer of NHS Wales.
The Board discharges its responsibilities through its Committees (listed below) and scheme of delegation which is set out in our Standing Orders. The Board established two new committees during 2012/2013, namely the Workforce and Organisational Development Committee, and the Planning and Performance Committee, the Terms of Reference for which were both approved at the Trust Board meeting in May 2012.
There are 8 Committees, reporting directly to the Board which are supported by sub-committees/groups in the discharge of functions;
• Quality and Safety Committee • Audit Committee • Charitable Funds Committee • Research and Development Committee • Information Governance and IMT Committee • Remuneration Committee • Workforce and Organisational Development Committee • Planning and Performance Committee
The Trusts’ Assurance Framework is illustrated in Fig. 26.
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Investment
Performance
Learning
Committee Genetic
Modification Sub Committee
Research Risk
Review Sub
Committee
Non Executive
(Independent
Executive
CE
Executive Management Board
• Planning • Delivery • Performance • Reporting
Committee
CFC W&OD Audit R&D IM&T P&P Q&S Rem
• Organisational Objectives
• Strategy • Scrutiny • Priorities • Standards • Governance
• SWAFF • Objectives • Delivery Plans • Delivery & • Performance
Management. • OD • Audit • Risk
Management & • Risk Register.
Qua
lity
Mea
sure
men
t Fra
mew
ork
• Assurance • Advice • Strategic Oversight • ‘Champion’ Role • Board Member
Agreement
BOARD
VCC SMT
WBS SMT
Fig. 26 Trust Assurance Framework
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Measuring our Success
We have developed a wide range of measures which we will use to monitor the quality of our services and to evaluate the progress we are making in achieving our ambitions. The high level measures are set out below.
Table 6 Cancer Services
QUALITY DOMAIN MEASURE Access/Timeliness % patients commencing radical radiotherapy within 28 days % patients commencing palliative radiotherapy within 14 days % patients commencing emergency radiotherapy within 2 days % of patients commencing non-emergency chemotherapy within
21 days % of patients commencing emergency chemotherapy within 5 days % in-patients commencing therapies within 2 working days of
referral (SALT, complementary, dietetics, physiotherapy, occupational therapy)
% of in-patients commencing therapies within 1 working days of referral for metastatic cord compression (MSCC)
% of out-patients commencing therapies within 14 weeks SALT, complementary, dietetics, physiotherapy)
% of patients seen by a physiotherapist within 5 working days when needed for radiotherapy planning
QUALITY DOMAIN MEASURE Clinical Effectiveness Unexpected deaths % of patients who die in 30 days of a chemotherapy cycle (overall) Compliance with CAUTI Insertion Care Bundle Compliance with CAUTI Maintenance Care Bundle Compliance with CVC Care Bundle Compliance with Skin Care Bundle Patients on palliative care pathway receiving care in preferred
place Patients on palliative care pathway dying in preferred place of
death QUALITY DOMAIN MEASURE Safety Number of Never Events Healthcare Associated Infections (HCAI) - C diff (All Ages) Healthcare Associated Infections (HCAI) - MRSA (Bacteraemia) Healthcare Associated Infections (HCAI) - MSSA (Bacteraemia) Velindre Acquired Pressure Ulcers Average Hand Hygiene Compliance - Non In-Patient Areas Average Hand Hygiene Compliance - In-Patient Areas % Patients Eligible who Receive Thromboprophylaxis NICE Compliance
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QUALITY DOMAIN MEASURE Patient Experience Patient survey data on:
- patients waiting over defined periods - patients perception of ‘everything available for their care’ - patients perception of ‘involvement in decisions’ - patients ‘understanding of explanations’
% patients satisfied with the experience % staff who would be happy for their families to be treated at
Velindre % of Complaints % of Complaints dealt with within 20 days
Table 7 Blood and Transplant Services
QUALITY DOMAIN MEASURE Access Donor bank capacity meeting need New Donors per Quarter (Whole Blood) New Donors per Quarter (Apheresis) Number of New Bone Marrow Volunteer Registrations QUALITY DOMAIN MEASURE Clinical Effectiveness % Whole Blood Supply Meeting Demand % Platelets Supply Meeting Demand % Red cells issues less than 14 days old %Volume of Waste (Red Cells) %Time Expired Platelets Against Platelets Available % Part Bags Collected Average age of blood product issued
Delivery of HSC Products to Stakeholders % routine ante-natal patient results provided to hospitals within 3
working days % of deceased donor typing/cross-matching reported within 6
hours QUALITY DOMAIN MEASURE Safety % Unsuccessful Venepuncture Donor acceptance errors by collection teams per million Documentation errors on clinics per million Serious Adverse Events (SAE) / Serious Adverse Reactions (SAR)
reported to MHRA Number of datix incidents Number of SABRE events Retention of accreditation QUALITY DOMAIN MEASURE Donor Experience % Donor Satisfaction Scoring 9 or Above (Out of 10) % of Concerns Handled within Required Timescales
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Section 10: Risks to delivery
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Risk Register Risk Title Risk
Summary Risk Potential
Impact RA Date (opened)
Risk Assessment Last
Reviewed
Mitigation Actions
Further Action Due Date (Action)
Action Status Risk Level (Target)
Exec Lead for Risk
Assuring Com for
Risk
Loss of Personal Identifiable Data
Unsecure use of mobile media devices could result in personal identifiable information being lost, stolen or unauthorised access gained.
Prosecution and Reputational Damage
8-Aug-2010
23/05/2013 10/01/14 Due for review 10/06/14
1. All staff receive Information Governance Training every 2 years which highlights risks associated with removable media. 2. All laptops are encrypted. 3. IG audits undertaken and monitored by the IG&IMT Committee 4. IG action plan in place 5. All incidents reported to divisional/IM&T committees
1. Encryption technology to be implemented which meets Industry Standard (FIPS140-2) across the Trust on end point devices e.g. memory sticks. This is being progressed on an all-Wales basis. 2. Review relevant IT policies in accordance with the prioritised policy risk assessment.
Ongoing 1.Plan in place to implement end point encryption in the VCC and corporate, with roll out to WBS. 2. Velindre IT policies have been approved by the Trust Board apart from the Email Policy which is being developed Nationally. 3.It was agreed that the current risk level of 12 remains appropriate but will be reviewed upon completion of the roll-out of endpoint encryption is completed in Welsh Blood
Yellow 8
Executive Director of Finance
Due to be received at IG & IMT Com: 18.02.14 TB: 06.02.14 and EMB - 20.02.14 Q&S-06.03.14
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Service. Following discussion, it was agreed that the target risk level should be increased as the Impact would always be Major in the event of loss of PII: Target Risk: Impact 4 Likelihood 1 Rating: 8
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Limited Trust IM&T Capacity
A limited IM&T capacity within the Trust's which is compounded by a recent retirement
The potential impact is that service delivery is not flexible and responsive enough to meet service requirements
1-Apr-2011
10/01/14 Due for review 10/06/14
1. SLA's formalising relationships and services in place 2. Regular meeting schedule with Director of Informatics service to ensure lines of communication are open 3. Standing item on IG & IM&T Management Group 4. SLA arrangements in place 5. 3 new posts identified 6. Infrastructure plans in place – prioritised at Divisional management Meetings 7. New Action: Skill sets for IM&T resource across Trust to be evaluated to ensure appropriate/efficient use.
1. Information analysis resource needs to be identified and in place 2. Completion of recruitment for 3 posts
Ongoing 1- SLAs in place and regular monitoring and development meetings in place. 2. One post appointed and staff member now in post and one post filled on secondment basis. 3.The Group and Committee agreed that the Current score should remain at 12, however acknowledged that the original risk should have had a higher score, there was agreement that this risk must continue to be monitored as the Trust may experience an increasing likelihood of capacity affecting delivery/qualit
Yellow 6
Executive Director of Finance
Due to be received at IG & IMT Com: 18.02.14 TB: 06.02.14 and EMB - 20.02.14 Q&S-06.03.14
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y. The target risk level should be increased as the Impact may be reduced due to recent recruitments to key roles, however the likelihood of capacity impacting this risk is increasing. Target Risk: Impact 3 Likelihood 2 Rating: 6
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Estate Capacity (VCC Accommodation)
(a) Lack of Physical space to accommodate the current requirements at the Velindre Cancer Centre (b) Quality of the environment may impact on patient and staff experience
(a) Patient experience may be affected e.g. delays in outpatient clinics due to insufficient accommodation and the quality of the accommodation (e.g. areas of inpatient accommodation) may impact on overall patient experience. (b) Insufficient office/support accommodation may impact on recruitment and retention of staff.
1-Jan-2005
Due for review Feb 2014
Staffing levels and the care provided is of a high standard to mitigate some of the environmental shortfalls for example VCC won RCN 'Enhancing Patient Dignity' Award.
(a) (i) Continually review capacity availability to ensure best use and maximisation. (ii) Increase the percentage of services undertaken in outreach clinics (iii) Plans being developed for post graduate centre to become operational. (iv) A project has been established to review/determine best use of current accommodation, given recently freed space and acquisition of PGC. (b) A business case is under development and positive discussions with Welsh Government regarding potential capital funding. Submitted outline capital requirements for phase 1. Close to completion of land acquisition of identified site.
Ongoing 1. Project is established to review accommodation. 2. Review of outreach is underway; with some improvement in amount of services delivered in outreach. 3. Requirements for PGC completed and actions underway. 4. Process underway for review of space by external consultants. This will include additional available space e.g. PGO; as well as review co-locations and adjacencies etc 5. Accommodation Working Group established and chaired by Director of Planning. Lee Wakemans engaged.
Yellow 6
Director VCC
Planning & Performance Committee 14.11.13 Received at:- EMB - 21/11/13 Q&S-18/11/13
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5. ASU ward being re-comissioned and will be available from the end of December 2013. 6. Tender sent out for design and works to make Post-Graduate Centre functional from May 2014 - with business case for additional funding submitted and decision expected in December 7. Final plan for accommodation expected in January 2014 and a business case will then be developed for a 3-4 year programme and be sent to WG for consideration. 8) Identified improvements to First Floor Ward out to tender.
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(b) Lack of physical space to meet future expansion requirements at VCC
1-Jan-2005
26/02/2013 Due for review Feb 2014
(b) A business case is under development and positive discussions with Welsh Government regarding potential capital funding.
March 2014
(b) A business case is under development. Discussions are underway with Welsh Government about the appropriate presentation and potential funding routes. (c). Feasibility study was completed in October 2013 (d). £110k support secured from WG to support business case development (e) Programme Board experts engaged to assist in business case development (F). Strategic Outline Programme will be submitted on December 19th to WG. (g)Submitted outline capital requirements for phase 1. Additional land purchased January 2014
Yellow 6
Director VCC
Planning & Performance Committee 22.01.14
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Compliance with RT waiting time targets.
Limited radiotherapy capacity and other pathway bottlenecks may impact on throughput and therefore the optimum quality of patient treatment intent as measured against UK standards
Longer waiting times having a potential impact on patient survival and anxiety. Insufficient capacity may limit the implementation of new radiotherapy techniques and participation in radiotherapy trials.
1-Jun-2011
Dec 2013 Due for review June 2014
1. Ongoing review of radiotherapy capacity and demand. 2. Staff provide extra capacity at peak times when possible. Agency staff utilised when appropriate. 3. Radiotherapy capacity requirements are built into estate development plans which are of concern due to delays. Plans and alternative models are being explored. 4. On-going monitoring via VCC SMT and the Trust Board
A plan for RT for next 5 years is being developed to identify future requirements to meet demand and deliver new RT technology. Implementation of the Site development plans. Interim plans for an increase in radiotherapy capacity are being developed in parallel to ensure continuity of service during the site development project
March 2014
1.Development of a radiotherapy strategic plan is underway. 2. Waiting times initiatives continue within the radiotherapy department with a view to improving waiting times and minimise the patients affected. Clinical need and the impact of any delay are taken into account. 3. The number of patients affected is variable and recorded in the monthly breach reports. The position is monitored weekly. 4. The longer term site development plans will include requirements to address linac capacity.
Yellow 6
Chief Executive
Planning & Performance Committee 22.01.14 TB 06.02.14 and EMB 20.02.14 Q&S-06.03.14
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Estates Compliance
Areas of the Velindre estate are in breach of statutory standards. examples: Asbestos - non compliance with CAWR 2012. Waste Carbon Management - ISO14001. Estates Appraisal. Building Maintenance inspections. Fixed circuit testing not meeting statutory interval requirement. Specific external areas of the Velindre estate posing a hazard to staff visitors and patients.
Prosecution and Reputational Damage
1-Apr-2011
Dec 2013 Due for review June 2014
1. Capital programme in place - estates identified within the programme 2. Programme of estates inspections in place 3. Regular review of the estate risk profile 4. Funding issues are being discussed and considered at a bi monthly meeting chaired by the CEO and are expected to feature highly in matters to be discussed at the Planning and Performance Committee.
4.Action plan presented to EMB (Jan13) but requires further work before it can be approved. Asbestos - Establish a trust wide working group including hosted bodies. (complete) -Develop an action plan (complete) -Develop an asbestos policy (complete) -Develop an asbestos management plan by the end of August 2013. (complete) -Identified a nominated person and training booked 2nd August 2013 (complete) ISO 14001 -identify all key actions required to retain accreditation at VCC (complete) -Review the resources requirement by July 5th 2013 (complete)
1-Mar-2014
4.Asbestos policy was approved on 5th Dec 2013 and Asbestos Management Plan being implemented. Clear roles and responsibilities identified across Trust and hosted bodies and training provided (Tier 1 training ) Specification for asbestos site re-inspection being written and going out to tender (March 2014) Carbon strategy developed and a number of reduction schemes identified awaiting funding from WG (awaiting decision) 5. The following schemes are being delivered and due for completion in March 2014:-
Yellow 6
Director of Planning & Performance
Planning & Performance Committee 22.01.14 Due to be received at:- TB 06.02.14 and EMB 20.02.14
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1)refurbishment of staff and visitor toilets. 2)outpatient department refurbishment of consulting rooms. 3) removal of asbestos on Zone 13. 4) ventilation slats and guttering improvements. 5) replacement of hot and cold water infrastructure. 6) replacement of electrical switchgear voltage.
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Capital Funding Availability of capital resources to the Trust
On-going service provision
1-Apr-2011
23/5/2013 Due for review 17-12-2013
1. Trust to develop risk assessed capital schemes over the medium term 2. Develop BJC's and business cases in preparation for availability of funding 3. Engage with WG at Capital review meetings and other forums to maximise Trust access to capital 4. Prioritised programme agreed at Sept 2011 Board
1. Relevant action underway
Ongoing 1. A programme of Business Justifiable Case (BJC's) is now in place to ensure that the Trust is able to ensure that the Trust is able to align Trust replacement programme with Welsh Government funding. 2. Chair, CEO, and FD utilising all avenues to emphasise importance of capital to the Trust 3.Strategic paper submitted to Welsh Government
Green 3
Executive Director of Finance
Planning & Performance Committee 22.01.14 Due to be received at:- TB 06.02.14 and EMB 20.02.14
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WBS Service Modernisation - BECS Implementation
Implementation of a new Blood Establishment Computer System (BECS) . The BECS will be known to the Service as ePROGESA. During roll-out, training to new functionality and roles will be given to existing staff.
1. Major programmes will need to be implemented by the end of 2013, namely Euroblood Pack and Microbiology Replacement Procurement. 2. Dependency on third party supplier to meet timelines. 3. Training of collection staff in old and new process as D2D continues to be rolled out. 4. Support from internal departments, to achieve implementation Delay to implementation of BECS Resource Availability Supplier Delays Delays in project dependencies
07/05/2013
4 December 2013
1. SMT prioritisation of work programmes to ensure an October implementation. 2. Regular supplier engagement meetings. 3. Some collection sessions may be required to operate a manual process in order to minimise the impact of change on some of the collection teams. 4. Liaising with SMT representatives to identify appropriate resource
Review of plan required in light of slippage against defect resolution, prioritisation of activities due to operational requirements, consideration for deployment of ePROGESA for the collection teams. A new plan will be agreed in partnership with SMT, Operational Managers, the Supplier and Trust Exec's Workshop for implementation 9th Jan 14 - timeline to be drafted by March 14
31-Jan-14
Review of plan
Yellow 6
WBS Director
Due to be received at:-Q&S Com 06.03.14 TB 06.02.14 and EMB 20.02.14
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Blood Testing Systems
Legislative Requirement to test three mandatory markers.
1. Breakdown and lack of support on existing Olympus systems 2. Performance of mandatory tests will not be possible. 3. Breach of GMP 4. Capacity failure to meet the requirements of expanding Service into North Wales.
10/04/2012
20 November 2013
* Funded from Trust Discretionary Capital Allocation. * Two systems need to be available to meet needs of the service.
Business Case to WG to support funding the replacement purchase of two Blood Testing Systems Trust Capital Planning Group for funding via Trust Discretionary Capital Allocation
31-Dec-13
BJC being prepared
Green 1
WBS Director
Q&S Com 06.03.14 TB 06.02.14 and EMB 20.02.14
Fully Automated/Integrated Blood Grouping System
ABO & RhD group, red cell antibody screening and phenotyping, Direct antiglobulin tests and high titre anti-A/B tests
1. Breakdown and lack of support on existing Tecan system beyond Oct 2014 2. Performance of mandatory tests will not be possible. 3. Breach of GMP
13/06/2013
20 November 2013
Funded from Trust Discretionary Capital Allocation. System not supported by supplier beyond 2014.
Replace with fully automated/integrated blood grouping system. Purchase via discretionary capital a new automated/integrated grouping system (approx £80k) Possible additional significant impact on revenue for consumables & reagents (approx £80k)
31/12/2013
BJC being prepared
Green 1
WBS Director
Q&S Com 06.03.14 TB 06.02.14 and EMB 20.02.14
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Physical environment of VCC operating Theatre
Physical environment in VCC operating theatres does not currently meet infection control standards in relation to some of its facilities
Increased risk of infection to patients
01/10/2012
01/10/2013
Reviewed decontamination of equipment policies/procedures to reduce risks of cross infection. Reviewed infection control measures within theatre environment to reduce risks of infection. WRP audit of clinicl practice scored 93% 2013. Reviewed use of sink to ensure only clinical use. Ensure all theatre staff receive infection control training
1. External review of theatre suite commissioned to identify any further action in short-term to manage risks. 2. Plans developed with architects to make alterations to the environment to address issues with physical environment identified in control of information audits - additional capital funding needed for this. 3. Ongoing infection prevention audits by control of infection team.
1. January 2014 2. Subject to funding sources 3. Ongoing progress of audits
1. External review scheduled for December 2013 2. Draft plans developed to meet redesignation as 'daycase' suite and approved by Theatre User Group. Discussed at EMB September 2013. Last audit August 2013, next planned 2014. 3) National lead for Transferring Theatres engaged to support local review. Initial scoping visit completed December 2013 and observational visit of theatre procedures being organised to inform future options.
Green 3
Andrea Hague, Director of Velindre Cancer Centre
Planning & Performance Committee 22.01.14 TB 06.02.14 and EMB 20.02.14 Q&S-06.03.14
