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SDC - Healthcare Planning Design brief guidance

2003

STATUS IN WALES

INFORMATION

SDC –Healthcare Planning:

Design brief guidance

01

Introduction – The purpose of this documentThe NHS is currently embarking on the mostextensive re-development of its facilities in itshistory. The Private Finance Initiative isdelivering a record number of newer hospitalbuilds and this procurement route sitsalongside other initiatives such as LIFT andProcure 21 which are also delivering newfacilities into the NHS.

What is recognised is that a pre-requisitefor ensuring that any new building schemereflects accurately the NHS clientrequirements is the production of a robustdesign brief. It is the design brief whichacts as the core content of the clinical andnon-clinical output specifications and inturn forms a major element of the Invitationto Negotiate (ITN) documentation.

The role of the healthcare planningprocess is to produce the design briefand this document gives guidance on theprocess and example outputs which needto be produced.

It is not intended for this guidance to beprescriptive but more to support thoseembarking on the planning of new schemes.Neither is it intended to be all encompassing;there is significant material available tosupport the planning process and PFIprocess, in particular see:

• The Private Finance Unit:www.doh.gov.uk/PFI

• NHS Estates:www.nhsestates.gov.uk

• The Modernisation Agency:www.modernnhs.nhs.uk

Evidence also suggests that the earlier theplanning process starts the more detailedthe brief and the smoother the procurementprocess. The design brief needs to becomprehensive to enable private sectorbidders to correctly interpret requirementsand develop robust and innovative designsolutions.

http://www.doh.gov.uk/PFI

http://www.nhsestates.gov.uk

http://www.modernnhs.nhs.uk

02

Context – The role of Healthcare planning

Healthcare planning is an essentialpart of the work leading up to theOutline Business Case / Public SectorComparator stage of the PFI process.

Healthcare planning, within the overall PFIprocess, allows Trusts to reflect on currentways of working and provides a frameworkto refine / alter / improve service delivery.A robust healthcare planning process allowsthe opportunity for Trusts to embrace newways of working and provides a vehicleby which space and environmentalrequirements can be reconfigured tooptimise efficiency. In particular the processsupports the production of an informeddesign brief that balances the relationshipsbetween the care process, development anduse of medical technology and the design ofthe physical environment.

Healthcare planning allows Trusts todevelop new models of care and thento translate them into detailed servicespecifications, suggesting the way in whichthe services and departments could beconfigured for optimal performance andefficiency. In summary the process is abouttranslating opportunities presented in newmodels of health care delivery and newtechnology into the requirements forphysical space and design.

Detailed overleaf is a diagram that showshow the health care planning fits into theoverall development of a capital scheme.Increasingly it is recognised that goodquality healthcare planning at the earlieststages of the overall process invariablyleads to a better quality scheme.

03

Context – How does healthcare planning fit into the overall process

Project Phase Operational PhaseStrategic Phase

OBC Stage PFI Selection Stage Build StageCommissioning& Operational

use

Healthcare Planning

Service &Estate

Strategy

StrategicOutlineCase

OutlineBusiness

Case

OJECAdvert

Memorandumof

Information

FullBusiness

Case /Preferred

Bidder

FinancialClose

Implementationof contractPITN FITN

Post ProjectEvaluation

04

Healthcare Planning – The process

This document sets out principles in helpingTrusts to develop a robust design brief andin particular how this can be influenced bythe healthcare planning element of theoverall process. Thereare three key concepts / stages in thehealthcare planning process that will becovered within this document, they are:

• Developing the Model of Care;

• Developing the Operational Principles/Functional Content;

• Developing the Operational Policies/Schedules of Accommodation.

The document also seeks to show howcertain tools can be used to enhance andinform the development of the model of carein particular this will cover:

• Utilisation Modelling,

• Patient Flow Mapping.

This document seeks in a simple way todefine what each of the healthcare planningconcepts are, how they are developed andthe people who need to be involved.

A series of worked examples are given in theappendices to help the user to understandfurther the concepts and outputs ofhealthcare planning.

05

Healthcare Planning – The process

The document is structured to follow the healthcare planning process,leading to the production of outputs that cumulatively represent the designbrief and in turn inform output specifications and Invitation to Negotiatedocumentation.

The overall process and structure of the document is set schematically below.The diagram below shows the 3 key, sequential stages of thehealthcare planning process

Stage 2 Stage 3Stage 1

FunctionalContent

Schedules ofAccommodation

UtilisationModels

OperationalPrinciples

OperationalPolicies

PatientFlows

Modelof Care

06

Developing the model of care – A definition

The model of care is the overarchingphilosophy identifying how the healtheconomy, and organisations within it, willdeliver care in the future. This should reflectthe health care philosophy and particularcircumstances of the whole health economy /organisation. Models should assess theopportunities for future provision withparticular emphasis on modernising:

• The care process;

• Use of technology;

• Use of design.

Examples of a whole system model of careare set out over the following schedules.Diagram 1 represents the provision ofservices across primary and secondarycare. The output of the work underpins thebalance of care provision between the acutehospital and care outside of hospital withina primary/community setting.

Stage 1 Stage 2 Stage 3

07


This diagram represents the role and functions of organisations andfacilities across the care spectrum.

Diagram 1

Primary/Community

RapidResponse

teams

NHSDirect

SpecialistGP’s

Walk inCentre

GP directreferral

AmbulanceService

Hospital

A&E

Emergencyadmissions

andassessment

ITU/HDU

Surgicalmedical

specialty beds

DiagnosticGP Outof Hoursservice

Intermediate careservices e.g. step

up beds RehabService

08


In the context of the whole system individual service models can be developed. The examplebelow shows a proposed model for therapies across all settings.

Diagram 2

HUB for rehabilitation service

• One stop multi-disciplinary assessmentand treatment (whole systems) includingGait Lab, Gym and Pool

• Hub or Spoke for Orthotic Services• Centre store for rehabilitation aids and

Orthotics

• Spoke local citizens

Hub for allied professionals

• Management and admin base

• Main staff base

Education centre

• For staff, students and patients

Primary Care Centre

• Multiple locations for local deliveryeg. schools, libraries, local sports centre,homes, day centres

• “Healthy Living Centre”• Local repair services

eg. Surgical, footwear, hearing aids

Non-Health Settings

• Surgical facility including SurgicalPodiatry

• Orthopaedic Triage• Videofluoroscopy• Hub or Spoke for Orthotics Services

• Spoke for local citizens

• Base for relevant AHP’s

PCC or D&T Centre

• Multiple locations for local deliveryof AHP services eg. Health Centres,GP Practices, PCC

• Intermediate Services

NHS Health Settings

• Complex/Acute/Critical• Hub or Spoke Orthotic Services• Base for relevant AHPs

D&T Centre In-Patients

Acute Hospital

Locations and bases dependent on outputsfrom relevant SDGs

OutreachTeam

Other Multi-Disciplinary Teams

Neuro RehabTeam

RapidResponse

Team

SpecialNeedsTeam

PaediatricFeedingTeam

9


The acute setting model is understood in the context of the whole systemthinking illustrated in diagram 1. The diagram below sets out the keybuilding blocks for the configuration of the acute hospital.

Diagram 2

Emergency Beds eg• Trauma• Complex emergency surgery

Emergency Beds eg.• Trauma• Complex emergency

Emergency Theatre Elective Theatres

Elective beds eg.• Cancer surgery• Joint replacement

Diagnostics

Emergency Care Centre• A & E• Observation wards• Admissions wards

Diagnostic & Treatment Centre• OPD• Day/23 hour surgery• Medical day care

HDUITU

IntermediateCare/Rehab

Emergency Elective

Critical Care

0

10

Developing the model of care – The process

The first stage in developing the new modelof care, is to form an appropriate projectframework to include a project team as wellas service design / task groups withmembership taken from healthcareprofessionals within the local healthcarecommunity. The project structure and rolesand responsibilities need to be clearlyarticulated prior to project commencement.

The purpose of Service Design / TaskGroups is to bring a multidisciplinary groupof healthcare professionals together, in orderto discuss and consult on how to best deliverservices to patients in the context of theoverall strategic direction.

The service design / task groups wouldtypically include:

• Medical staff;• Nursing staff;• Therapists / PAMs;• Directors / Management;• GPs / Primary care representatives;• Support service representatives

e.g. Pharmacy, Laboratories etc.• Other agencies e.g. social services and

ambulance trust.

It is important that appropriate individuals areselected for this work, as a high levelstrategic approach is required, care shouldbe taken that the groups do not focus on thelevel of detail that is required at the laterstages of the process.

The project structure should reflect thenature of the scheme, covering keyprocesses usually across the whole healtheconomy. For example:


11


Diagnostic &therapies

Chronic diseasemanagement

Emergency/non-elective

Elective admission

Elderly &intermediatecare

Primary, community,ambulatory &pre-admission

Criticalcare Discharge

12


In order to ensure clarity of purpose, priorto the initial meeting of each of the groups,briefing material should be developed, whichoutlines the purpose and remit and expectedoutputs of the group. This material shouldprovide a detailed summary of the overallscheme and ensure the group discussionstake place within the correct context.

Detailed below is a checklist for assemblinga briefing pack for service design / taskgroups, this is based upon a new buildacute hospital scheme and therefore mayneed to be adapted for smaller schemes.An example of a full briefing pack is includedas Appendix A.

13


Introduction:

Description of the aims of the scheme, both in terms of building stock and the wider benefits topublic health / social issues.

An outline of the scheme in the context of other national schemes.

The progress of the scheme, in terms of Strategic Outline Case (SOC), working towards OutlineBusiness Case etc. A brief summary of the SOC should be included for further clarity.

A guide to the timescales involved in the current phase of the scheme and the schemes overalltimescale targets.

Background

A summary of what will be delivered e.g. total number of beds within the development, newdiagnostic services and suggested new ways of working such as Diagnostic & TreatmentCentres (DTCs) and developments in Primary Care etc.

Structure of the Service Design / Task Groups

A list of all the groups should be provided, with contact names and details for each of them.

Each Briefing Pack should include a definition of what the group’s aims / terms of reference are,e.g. “The planning of the provision of critical care including CCU, HDU, ITU, Theatres &Recovery and the development of an understanding of the linkages to emergency / non-electivecare in particular”.

A project structure diagram could also be provided at this point, which would demonstrate wherethe group work fits into the overall scheme.

Group Aims and Outputs

A clear definition of the remit and required outputs should be included.

The principles upon which the more detailed planning can take place;

The production of the model of care.

Work plan

The work plan should set out the areas to be covered in each meeting, with a clear indication ofthe outputs required.

14


The final output of the service design / task groups will be the model of carepaper; this should address a number of key issues. Many of the issues tobe addressed in this paper are often complex and it is advisable to expresswhat is often conceptual thinking in diagrammatic form.

15

Model of care – Content

Detailed below is the suggested coverageof the model of care development process(a fully worked up example of a Model ofCare paper is included as Appendix B):

1. Whole System Principles

• The main points from the SOC should beincorporated, including the overallobjectives of the scheme.

• Examples of what the overall healtheconomy should provide in light of thenew model of care e.g. people centredservices, services that addressinequalities etc.

2. Whole System Model of Care

• It should reflect the work of each of theService Design / Task Groups and howthe services fit into the overall model ofcare.

• The whole system model of care shouldreflect the national context in which theservices in question are affected e.g.National Bed Inquiry, Waiting Bookingand Choice recommendations andNational Service Frameworks.

• The first stage of this work should be in asimple diagram to identify the keycomponents that are to be discussed.

Each service should then be set out andaggregated into its component parts andthen organised according to importantclinical and functional linkages, an exampleis set out overleaf.


16


An example profile of key components for a major new acute hospitalscheme is set out below:

Teaching and Research Space

POST ACUTE CARE

DentalOutpatientsDay InvestigationsDay Surgery

Cardiac

Catheterisation

Operating

Theatres

Emergency

Admissions Ward

Observation

Ward

Primary Care

Facility

Accident &

Emergency

Investigations/ScopingPathologyRadiology

Coronary

Care Unit

Cardiac Intensive

Care Unit

High Dependency

Unit

Intensive

Care Unit

Special Care andBaby Neonatal Unit

Paediatric ICU

Cardiac

• Cardiology• Cardiac Surgery

Surgery

• General Surgery• Urology• ENT• Burns• Plastics• Opthalmology

Orthopaedics

• Orthopaedic Surgery

Neurosciences

• Neurology• Neurosurgery

RehabilitationServices

• Physiotherapy• Occupational Therapy• Speech Therapy

Obstetrics &Gynacology

• Obstetics• Gynaecology

Acute Mental Illness

• Adult Psychiatry• Child & Adolescent

Psychiatry

Medicine

• General Medicine• Infectious Diseases• Gastroenterology• Respiratory• Dermatology• Renal• Clinical Haematology

Paediatrics

• Paediatric Medicine• Paeadiatric Surgery

Emergencies

Treatment

Critical Care

Diagnostics

Specific

Aggregations

Teaching &Research

Ambulatory

Care

Rehabilitation

17


3. Model of Care (Process/Service Specific)

• There is a need to focus down from thewhole system model of care into each ofits component processes and examinethem in more detail. This is likely to be thedetail from each service design / taskgroup. For example, emergency care asset out in the diagram overleaf:

This section should also include any relevantinformation on new ways of serviceconfiguration such as DTCs, EmergencyAdmissions Units, and Primary CareCentres etc.

IntermediateCareeg. RapidResponse

A&E

Other Health Serviceeg. Pharmacy

Diagnostics

Blue Light/Self Referral

EmergencyCare Unit(72 Hour Stay)

Hospital

General Practice

Direct Booked OPConsultation by GP

Rehabilitation

Ambulance Service

Direct GP referral following consultationwith Hospital Specialist (SpR or Higher)

18


4. Impact of Model of Care

• A description of the impact that the modelof care will have on the capacity of thehealth economy in terms of how manybeds, consulting rooms etc should beprovided.

• It should also outline the suggestedconfiguration of the rooms / beds e.g.number of consulting rooms to beprovided in the community, number ofbeds in the Emergency Admissions Unitetc.

• The impact in terms of the healthworkforce should also be detailed. Thissection should include information onproposals for GPs with a SpecialistInterest, development of the NursePractitioner roles etc. Staff and skill mixshould also be considered in this section.

• The IM&T requirements needed tounderpin the model of care should beincluded. This should include systemssuch as the Electronic Health Record(EHR), Picture Archiving &Communication Systems (PACS), andTelemedicine etc.

5. Way Forward

• The final element of this document shouldcover the next steps in the process. Itshould include details of which staffgroups are required to sign off the modelof care, both as a whole and as servicespecific models. Ongoing work for theService Design / Task Groups should alsobe detailed and could include continueddevelopment / refinement of carepathways.

19

Model of care – Issues to consider

In formulating the new model of care, eachgroup will be required to consider anycurrent influences and developments in thehealth care field amongst which could be:

• Future service models and levels ofcare, such as changes in clinical practice,facility organisation, national guidance(National Beds Inquiry, NSFs etc),configuration of beds etc.

• Physical setting, includingaccommodation of patients, internal flow,travel distances and environmentalconsiderations.

• Quality Issues, including patientconvenience and privacy & dignity issues.

• Emerging technologies, such aselectronic health records (EHR),appointment scheduling (bookedadmissions) and computer links toprimary care.

• Workforce planning, including theimpact of new methods of working on staffroles & responsibilities, working patterns,skill mixes and training / developmentissues.

• University teaching and research,such as consideration as to how theconfiguration of some services will haveimplications for the provision ofeducational / research activities.


20

Model of care – Tools and techniques

In developing the model of care there are anumber of “tools” that can be used to informthe process. These include:

• Patient flow diagrams;

• Utilisation models.

Patient / service flow diagrams

There are two main advantages of thisapproach:

• Patient flow diagrams play a vital part inmapping the future flows of patients inlight of the new model of care.

• They can then be used to identifypotential areas ofduplication/conflict/inefficiency/bottlenecks.


21


Diagrams should be produced at “service” level. Example of an emergencyservice diagram is set out below.

Service Level

Assessment

Assessment

Diagnostics

GP Referrals Self Referral

FUTURE EMERGENCY PATIENT FLOWS

A&E

OPD

Tertiary

Children’s assessment

Main theatres

Emer

elec

A&E

Direct

Acute Beds

Hospital non-acute beds

Self Referral

Major/resus

Total attendances Children

Minor

Level 2

Level 1

Total attendances

Minor

General assessment ObservationEmergency OPD

Discharge

Assessment and critical care

Primary Care(on or off site)

Rad

Path

Other

Pharmacy

22


Utilisation Models as a tool

Like patient flow diagrams, utilisation modelscan be used to inform the model of care.Once the model of care is agreed the use ofutilisation models will help to establish thesize of the scheme in terms of capacityrequirements such as beds and theatres etc.This in turn informs the functional contentand schedules of accommodation.

High-level models may utilise population ordemographic data and the demand that thepopulation has for the local healthcareservices. The model of care as defined inthe service design / task groups is thenapplied in order to determine the functionalrequirements by each specialty.

The whole purpose of utilisation models is totest planning assumptions and to establishthe impact of changes in assumptions oncapacity requirements. For example, Modelscan allow Trusts to see what the impactwould be in terms of beds, theatres and outpatient rooms etc, if a 3 session day wasadopted, or the bed occupancy assumptionswere altered.

Examples of some of the following utilisationmodels are included in Appendix C.

Theatre models

• The model is based on the number ofcases passing through the theatres byspecialty.

• This figure is then broken down further byelective inpatient, emergency and electiveday cases and a standard time taken perprocedure is allocated by specialty (e.g.an elective in patient case for generalsurgery may take on average 1.3 hoursand an elective in patient case forcardiothoracic surgery may take onaverage 2.33 hours);

• Assumptions are then added to thisinformation. The assumptions used arebased on national guidance / practice (3.5hour sessions twice daily, 5 days perweek, 48 weeks per year with an 80%utilisation rate).

• The outcome of the calculations carriedout by the model details the requirementsfor in-patient, day case and emergencytheatre sessions based on current activityand the assumptions outlined above.

• By altering the assumptions e.g.lengthening the working day toaccommodate modernised practices, therequirement for theatre sessions changesaccordingly.

23


Bed models

• This model is based on the sameelements as the Theatre Model, in that itis based on specialty activity (this can beobtained via a PAS download of patientactivity data from the Trust).

• The model allows users to plan thenumber of medical and surgical bedsrequired in an Emergency AdmissionsUnit by selecting which specialties the unitshould serve. By selecting the specialtiesthat the user wants to provide from theunit, the activity data for those specialtiesis converted into FCE’s, then intoOccupied Bed Days and finally intonumbers of beds by specialty selected.

• This model is based on assumptions thatcan be altered. The assumptions includeoccupancy rates, length of stay detailsand how to treat day cases. In terms oflength of stay (percentage staying halfday and percentage whole day).

Diagnostic models;

The example of a model as included in theappendix details how a Radiologydepartment could be planned using variousassumptions.

• The total activity for the RadiologyDepartment is broken down by specificmodality (CT, MRI, Ultrasound etc) and isthen projected forward. Tests are alsosplit by patient group (inpatient/outpatient/emergency) to give a percentage of workfor that group of patients.

• Assumptions are then applied to thefigures (9 hours of operation per day, 5days per week, 80% utilisation, averagetime per procedure etc) for current activityand then also for the future.

• Activity is then broken down by patientgroup (in patient, out patient etc) in orderto give a more accurate view of the usageof the service by different patient groups.

• In doing this, the Trust is able to identifywhich tests are used by emergency /elective patients, how this will translateinto future requirements and also providesthe ability to test the impact in thedepartment of different methods / timesof working.

24

Developing the Operational Principles – The process

Once the model of care has been agreed thenext key stage of producing the design briefis to develop operational principles andsupporting functional content.

Operational principals are a statement thatidentifies for each element of the scheme themain ways in which that element willfunction, it’s purpose is to test the impact ofthe overall model of care on each element ofthe scheme. The organisation can testthrough the operational principles its modelof care before they proceed with the detailedhealthcare planning of schedules ofaccommodation and operational policies.

Operational Principles and FunctionalContent should be developed for eachservice affected by the proposeddevelopment (examples provided inAppendix D) they will provide the basis ofinformation from which the OperationalPolicies and Schedules of Accommodationwill be developed. The operational principlesshould incorporate the following headingsand answer the following questions;


25

Developing the Operational Principles – The process

Heading Questions

Scope of Service What care will the service provide e.g. emergency, elective,outpatients, investigations, and diagnosis?

Workload / Activityindicators

What is the normal through-put for the department this may be interms of FCEs, diagnostic procedure, pathology tests or otherindicator?

This will be developed from activity modelling work

Key accommodationrequirements

What is the estimated accommodation requirement for the service?

(This information should be informing the functional content.)

Configuration Where will the service be located?

Will it be collocated or split between various locations?

What will the relationships with other departments be? Where willthey be located in relation to the department in question?

Will some services remain where they are?

Key Relationships What are the key relationships of the service?

Should it be located close to A&E, outpatients, acute wards etc?

Should it have dedicated facilities for some elements of it’s service

Work Patterns How many sessions will the service run each day?

How many days per week will it function?

Is there any need for direct primary care services out of hours

This work is linked to workload / activity indicators and couldincorporate analysis completed using activity models

Patient flows This should provide a detail of a how the patients will move throughthe system from initial presentation to discharge

26

Developing the Functional Content – The process

In parallel with the development of operational principals should be the development of thefunctional content. At its most basic level this is a list of the key departments within the schemeand their room requirements. At this stage this should be based upon NHS Estate Health BuildingNotes (HBN’s) ensuring that the sizes and rooms reflect the consumerism agenda. A fullfunctional content example is set out at Appendix D.

An example for an A&E is provided below:

The main A&E Department will require the following rooms and cubicles with associated receptionand waiting areas:

Areas 1 & 2• 11 x individual rooms (10 for general use and 1 for psychiatric patients)• 6 x resuscitation beds, in a side by side formation, with curtains dividing each bay

Area 3• 12 x cubicles, with curtains dividing each area• 4 x fast track individual rooms - The observation ward will require 4 beds

The Paediatric Assessment Unit will require 6 beds and 2 paediatric HDU beds (see OperationalPolicy for the Children’s Ward)

The sub departments of the A&E department will be co-located with each other and in closeproximity to the following:• Observation beds• Emergency admissions beds• Central diagnostics, particularly radiology


27

Developing the Operational Policy – The process

Following the development of the Model ofCare and the production of the OperationalPrinciples / Functional Content, the nextlevel of detail required is the production,refinement and sign off of the OperationalPolicies.

The Operational Policies should bedeveloped for specific departments wherethese are to be newly built, re-furbished orleft in situ. Operational policies are requiredto convey how each department functions aspart of the overall hospital and how theindividual facilities elements of thedepartment (i.e. schedules ofaccommodation / facility requirements) relateto each other, so that the department isplanned in a functional way.

Each department should evaluate the draftOperational Policies for their own areas. Theservice design/task groups should have theopportunity to review each of the policies, inorder to ensure that a wide internalconsultation has taken place.

The Operational Policies should includesections incorporating the following headingsand information (a full worked example isprovided in Appendix E):

As many examples of schedules exist thereis no need to develop from first principles butrather to use an example andamend/develop as appropriate.

It is at this point that attention / referenceshould be made to the ongoing developmentof the “non-clinical” brief. Outputspecifications need to be produced for theFM services of the project, which shouldinclude details such as how catering will beprovided to patients / staff, how often wastewill be collected from clinical areas etc.


28

Developing the Operational Policy – The process

These specifications will not produce the facilities brief, however they do need to be crossreferenced with the clinical operational policies to ensure that they match e.g. are regenerationkitchens required, how many disposal holds should there be per floor etc. The following listdetails areas for consideration under the “non-clinical” brief:

• Access• Security & Safety• Fire• Communications• Car Parking• Estate Management• Voluntary Services• Religious Facilities• Materials Handling• Catering• Domestics• Transport

• Staff Accommodation• Linen & Uniforms• Admission & Discharge• Health Records & PAS• Sterile Services• Portering• Post Room• Social Work• General Management• Education & Training• Medical Engineering• Control of Infection

29

Developing the Schedules of Accommodation – The process

The schedules of accommodation, includedwithin the operational policies, detail for thedesign team the required number of roomsand floor areas of each ward, department,operating theatre etc.

The number of beds, theatres etc that will berequired in the new build will be dictated bythe new model of care. The utilisationmodels are a useful tool that allow differentscenarios to be scoped using alternativeassumptions such as higher or lower bedoccupancy rates and the impact of 3 sessiondays / 7 day working.

The purpose of the schedule ofaccommodation is to provide a detailed,robust description of the facilities required toprovide services in the new build. Thisinformation is then fully costed and isincorporated into the Outline Business Case.The Public Sector Comparator will use thisinformation to detail how the Trust foreseesits services being provided in the future andallows the private sector to produce similarplans.

An example of a Schedule ofAccommodation for an A&E Department isprovided on the following pages.


30


Activity Space Area m² Numberrequired

Total area m² Activity Space Area m² Numberrequired

Total area m²

Main Entrance Lobby 20.00 1 20.00 Paeds Resus Room – 2 bays –Category 1

40.00 1 40.00

Reception Desk 35.00 1 35.00 Psychiatric Interview Room 12.00 1 12.00

Main Waiting Area 52.50 1 52.50 MRC Trauma Research Lab 20.00 1 20.00

Children’s Wait/Play Area/Nappy Change 18.00 1 18.00 Sitting Room 13.00 1 13.00

Feeding Room 5.50 1 5.50 Visiting Room/viewing room 10.00 1 10.00

Patients & escorts WC (Male and Female) 4.00 6 24.00 Recovery Bay 15.00 1 15.00

Assisted WC 8.00 1 8.00 Trolley/Wheelchair Bay 12.00 1 12.00

Sub Waiting Area 25.50 2 51.00 Mobile X-ray bay 2.00 1 2.00

Triage Room adjacent to front entrance 5.00 3 15.00 Records Store 15.00 1 15.00

Triage Waiting Area 25.50 1 25.50 Staff & Supplies Base 37.00 1 37.00

Examination/Treatment Cubicle – Category 2 8.50 11 93.50 Relatives / Interview Room 10.00 1 10.00

Examination/Treatment Cubicle – Category 3 8.50 16 136.00 Directors Office 11.00 1 11.00

Treatment room – drug and alcohol recovery 12.50 1 12.50 Nursing Officer Office 11.00 1 11.00

Treatment room - paediatrics 12.50 1 12.50 Secretary Office 10.00 1 10.00

Treatment room - ENT & Ophthalmic 12.50 1 12.50 Office for CPN 11.00 1 11.00

Treatment room – dental 12.50 1 12.50 Office for Age Concern 11.00 1 11.00

Dirty Utility/Sluice/Disposal Room 12.00 2 24.00 Office for Rapid Response 11.00 1 11.00

Specimen WC 4.00 1 4.00 Admin Offices 15.00 1 15.00

Minor Theatres Area 17.00 1 17.00 Sisters Office 11.00 1 11.00

Clean utility/Preparation Room 14.00 1 14.00 SpR Office 11.00 1 11.00

Patient Decontamination Room 12.00 1 12.00 Staff Grade Office 11.00 1 11.00

Resuscitation Room – 6 bays - Category 1 115.00 1 115.00 Consultant Offices 11.00 5 55.00

31


Activity Space Area m² Numberrequired

Total area m² Activity Space Area m² Numberrequired

Total area m²

Lead Nurse Office 11.00 1 11.00 Staff WC 2.00 2 4.00

Secretarial Office 11.00 2 22.00 Medical Staff Overnight Stay 15.00 2 30.00

Managers Office 11.00 1 11.00 En-suite Shower and WC 6.00 2 12.00

Senior Bed Manager Office 11.00 1 11.00 Staff Lockers 2.00 2 4.00

General Bed Management Offices (2 people) 10.00 2 20.00 Seminar Room 36.00 1 36.00

General Bed Management Officer (4 people) 20.00 1 20.00 Decontamination Equipment Store 8.00 1 8.00

Waiting Area 25.50 1 25.50 Main Equipment & Supplies Store 30.00 1 30.00

Reception 15.00 1 15.00 Sterile Supplies Store 12.00 1 12.00

Consulting Rooms with 2 Exam Rooms Attached 30.00 2 60.00 Major Incident Store 8.00 1 8.00

Staff Office 11.00 1 11.00 Medical Gas Cylinder Store 8.50 1 8.50

Treatment Room 12.50 1 12.50 Crutches and Splint Store 12.00 1 12.00

Clean Utility 14.00 1 14.00 Cleaners Room 7.00 1 7.00

Dirty Utility 12.00 1 12.00 Disposal Hold 6.00 1 6.00

Patients WC (Disabled Access) 8.00 1 8.00 Switchroom 4.00 1 4.00

Pantry 9.00 1 9.00 Pharmacy Store 6.00 1 6.00

Staff WC / Facilities 16.00 1 16.00 Stationery Store 3.00 1 3.00

Emergency Ambulance Staff Duty Room 12.00 1 12.00 Linen Store 3.00 1 3.00

Major Incident Co-ordination Room 12.00 1 12.00 Equipment Store 3.00 1 3.00

Porters’ Base 12.00 1 12.00

Staff Rest Room 15.00 1 15.00 Sub-Total 1613.50

Staff Pantry 9.00 1 9.00 Circulation at 35% 564.50

Staff Shower 2.50 2 5.00 GRAND TOTAL 2178.00

32

Producing the Design Brief – The structure

Having covered all the key stages and produced the required outputs this material can beassembled into the design brief. This should follow the process outlined in this document and themajor components of the design brief are set out schematically below:

The design brief once assembled feeds into the Invitation to Negotiate (ITN) documentation andrepresents the clinical output specifications.

Strategic Content andStrategic Directions

Model of Care

Functional Content Schedules ofAccommodation

Operational Principles Operational Policies

Utilisation Models

Patient Flows

Introduction

The following paper incorporates theappendices that are referred to in themain text of the “Healthcare PlanningProtocol” and hence should be read inconjunction with that protocol.

The aim of the appendices is to providethe reader with fully worked up versionsof the following elements that are describedin the protocol. The appendices are laid outas follows:

A. Briefing Packs

B. Model of Care

C. Utilisation Models– Theatres– Beds– Diagnostics / Radiology

D. Operational Principles &Functional Contents

E. Operational Policies & Scheduleof Accommodation

Anywhere NHS Trust

Service Design Group forEmergency and Non Elective

BRIEFING PACK

Anywhere NHS Trust


BRIEFING PACK

Table of Contents

Section Page

1. Introduction ........................................................................................................ 01

2. SOC Background .............................................................................................. 02

3. Service Design Group Structure ....................................................................... 03

4. Service Design Group Aims And Outputs ........................................................ 06

5. Service Design Group Workplan....................................................................... 07

6. Issues To Consider ........................................................................................... 08

01

1. Introduction

1.1 The project aims to create modern, highquality, value for money, and cost effectivehealth services for the people of xxx. Theinvestment will help to improve health andwell-being, reduce the incidence of ill health,associated suffering and premature death. Itwill help to close the health gap and tacklekey causes of social exclusion.

1.2 The investment is one of a number ofschemes approved by the Secretary ofState for Health following the publication ofthe NHS national plan and its ambitioustargets for service and hospitalinfrastructure.

1.3 Work is progressing to take this initial workforward to develop an Outline BusinessCase (OBC). The OBC is an importantdocument as it will establish a baseline interms of affordability and scheme contentagainst which the redevelopment will betaken through the PFI process.

1.4 In order to meet the programmerequirements, it will be necessary tocomplete the OBC by XXXX. This willnecessitate clinicians, health professionalsand senior managers throughout the healtheconomy in developing the detail of howfuture health services across the areashould be organised and what configurationof facilities they should be provided from.

1.5 It is proposed that this detailed planningwork will be undertaken within a ‘careroute’ framework established by eightService Design Groups based upon themodel of care established in the StrategicOutline Case (SOC) document.

1.6 The SOC proposed that future healthcaredelivery should be based upon providingthe right care by the right people, atthe right time and the right place. Itproposes a whole health economydevelopment with key developmentfeatures including:

• New specialist acute hospital facilities;• New diagnostic and treatment centre;• New primary care centres;• Intermediate care services;• Delivering care at home.

1.7 The following document has beenproduced to assist the Service DesignGroup in determining frameworkprinciples and it is structured as follows:

• SOC background and model of care;• Service Design Group structure;• Service Design Group aims and

outputs;• Service Design Group workplan;• Issues to consider.

02

2. SOC Background

2.1 The Partners have together created a visionwhich puts the NHS plan into practicethrough a radical transformation in the localhealth and social care infrastructure. Thiswill promote responsive andpersonalised 24 hours, 7 days a weekintegrated health and social care for localpeople, delivered to a consistently highstandard.

2.2 New models of care will improve thepatients’ experience. Patients will havegreater access to local health services, careprocesses will be planned around meetingtheir needs in the most efficient, effectiveand integrated way whether it is anemergency or planned episode of care.

What the Investment will deliver

2.3 The SOC delivers a significantimprovement in health services for thepeople of xxx and supports the ongoingdevelopment of specialist care and clinicalteaching facilities.

• XXX extra beds - additional beds in thesystem to deliver growth in activity in linewith the National Bed Inquiry.

• New Specialist Acute Hospitalfacilities with new wards and theatres,allowing improved access andsupporting new service developments,covering Neurosciences, Renal andChildren’s services.

• New primary care centres offeringlocal diagnostic and treatment facilitiesin localities of high deprivation andhealth inequality.

• New specialist Diagnostic &Treatment Centre at xxx Hospital withintegrated imaging, pathology,theatres, therapy and outpatientconsultation services.

• New Intermediate care servicesoffering inpatient and community basedservices aimed at step down andrehabilitation following acute care.Rapid response services and primarycare managed beds aimed at meetingpatients needs in the community and athome for longer.

• A community-wide Electronic HealthRecord, a level 6 hospital IM&Tenvironment, with full integrationbetween primary and secondary healthsectors in the area.

03

3. Service Design Group Structure

3.1 It was agreed that future project planningshould be structured on a whole economymodel of care based on the followingservices types:

• Primary, community, ambulatory andpre- admission – planning of primaryand community services and facilities,particularly exploring the potential forprimary care centres.

• Emergency/non elective – planning ofservices and facilities around emergencycare. The partners will be able to dealeffectively with emergency hospitaladmissions by designing appropriatecare routes across primary andsecondary care and arranging serviceand facilities appropriately.

• Elective admissions – taking theconcept of diagnostic and treatmentcentres to determine how and where tobest provide outpatients, day casesurgery and planned investigations,including the provision of integrated“high-tech” diagnostic facilities.

• Chronic disease management –planning of services and facilities aroundthose chronic diseases recognising therange and incidence of service provision.

• Elderly and intermediate care –planning of services and facilities for agroup of patients who requirerehabilitative care; or those who cannotbe discharged for social reasons; orcould be maintained in the communitywith the appropriate design andprovision of community based services.

• Critical care – planning the provisionof critical care including CCU, ITU,HDU and theatres recovery andunderstanding linkages to emergency /non-elective care, in particular.

• Diagnostic and therapies – planninghow clinical support services might beprovided recognising the potential ofsecondary and primary care andensuring consistency with the otherservice design group principles.

• Discharge process - confirming the‘care route’, which incorporates thedischarge planning process andensuring the elderly and intermediatecare group, is consistent with thedischarge principles developed.

04


3.2 The diagram below demonstrates the relationship between groups:

Diagnostic &therapies

Chronic diseasemanagement

Emergency/non-elective

Elective admission

Elderly &intermediatecare

Primary, community,ambulatory &pre-admission

Criticalcare Discharge

05


3.3 The relationship of the Task Groups to the overall delivery of the projectis shown in the diagram below

ParticipationReference

Group

Diagnosticand

Therapies

ChronicDisease

Management

CriticalCare

DischargeProcess

ServiceRedesign Project

Board

Primary CommunityAmbulatory

Pre Admission

ElectiveAdmission

EmergencyNon Elective

ExternalConsultants

Elderly &Intermediate

Care

Par

tner

ship

Bo

ard

Pro

ject

Dire

ctor

Pro

ject

Man

agem

ent

Tea

m

IM&

T D

evel

opm

ent

Su

b G

rou

p

Wor

kfor

ce P

lann

ing/

HR

Dev

elop

men

t S

ub G

roup

Com

mun

icat

ions

PR

Sub

Gro

up

Fac

ilitie

sS

ub

Gro

up

ProcurementProject Board

StakeholdersGroup

Finance OBCSub Group

BusinessCase Group

06

4. Service Design Group Aims and Outputs

4.1 Service Design Groups for each ofthese service streams have thereforebeen established to discuss anddetermine the practical application ofthe proposed model of care.

4.2 Within the given constraints ofaffordability set out in the SOC, theService Design Groups are being askedto determine principles upon which thedetailed facility planning can beundertaken.

4.3 The outputs of the clinical planningprocess comprise of:

• High level care routes setting outoverall principles governing howemergency and non elective careprocesses as a whole will bedeveloped, provided and configurede.g. the paper may articulate therelationship between medical andsurgical admissions. These will thenbe supplemented by:

• Departmental output specificationstaking this to a level of detail further,the group will help to refine and signoff more detailed outputspecifications for specificdepartments where these are to benewly built, refurbished or left in situ.For example, the emergency andnon-elective service design group willagree specifications for A&E, MAUand emergency theatres. These willbe cross referenced and consistentwith other related policies by otherService Design Groups e.g. ITUdeveloped by the critical care servicedesign group, recognising this keyinterlinkage.

07

5. Service Design Group Workplan

5.1 The Emergency and Non Elective Service Design Group suggested workplan is setout below:

Meeting Draft agenda/areas to be covered Outputs

1 v Brief introduction to the service design groups

v Role of the service design groups

v Timescales and outputs and agree work for meetings

v Brief group on bed modelling requirements (depending onwhich SDG) and introduce examples from elsewhere

v Initial debate around high level care routes

• Clear understanding of the clinicalplanning process and its outputs

• Agreed work plan

• Draft high level care routeprinciples

2 v Debate patient flows, highlighting areas of doubt/contentionor areas requiring further work outside the session (N.B.Meetings 1 and 2 should be covered in first day)

• Second draft high level care routeprinciples and material to enablehigh level patient flow charts

• Identify issues and leads for furtherdiscussion/work outside the groups

3 v Review high level patient flow diagrams and review bedmodelling

v Sign off main care route principles contained in initial draft

v Identify amendments/further work required for final meetings

• Patient flow charts

• Updated log of outstanding issuesalong with resolution plan

4 v Present second draft of care route policies and discuss,either sign off or agree final amendments

• High level care route policies

5 v Receive draft departmental clinical specifications

v Identify amendments/further work required for final meetings

• Material to revise policies

6 v Receive and sign off completed departmental clinicalspecifications

• Departmental clinical specifications

08

6. Issues to consider

6.1 The Group will be expected to provide aclear strategic framework for theirservice area based upon service andfacilities principles established in theSOC.

6.2 Subjects of consideration for eachService Design Group will include:

• Future service models and levels ofcare

• Physical setting;

• Quality issues;

• Emerging technologies;

• Workforce Planning

• University Teaching and Research.

6.3 Issues for consideration under each ofthese subject areas for the emergencyand non-elective Service Design Groupwill include:

Future service models and level of care

6.4 The group should use theunderstanding of current practiceswithin the health economy as a baselineagainst which to compare different waysof providing the service to ensure thatpatients are treated appropriately anddealt with as expeditiously as possible.Factors to consider include:

• Impact of development in primarycare services on the demand for A/Eservices i.e. primary care centres,

• Impact on emergency admissions ofGPs staggering urgent transfers ofpatients following urgent home visits;

• Impact of NHS direct on demand foremergency services;

• What effect will the development ofan emergency admission call centrehave on demand for emergencyservices/admission?

• Establishment of an emergency carevillage as a focal point for allunplanned demand for hospital care;

• Single emergency admissions ward/svs separate Medical Admissions Unitand Surgical Admissions Unit;

• Policy for children;

• Development of primary care ledprimary care centre and emergencycall centre to separate out minorinjuries and enable scheduled accessto emergency clinics as an alternativeto acute admission;

• The provision of separate anddiscrete diagnostic and treatmentfacilities in support of emergencycare;

09


• Pre and post procedure care.

• The provision and role of short termobservation beds as distinct fromassessment beds.

• The Royal College of Physiciansrecommends that a MedicalAdmissions Unit should be close tothe medical wards, CCU andRadiology facilities.

• Designated emergency lists can beallocated in theatres to avoiddisruption to elective work.

• Potential expansion in the duties androles of nurses e.g. development ofnurse practitioners, especially inA&E.

• The assessment, treatment andobservation of patients can beundertaken in a wide variety ofdifferent units, including observation,assessment and admission units

• Patients may stay in admissions unitsfor up to 72 hours, intensively treatedand then discharged or transferred toa less acute setting: these can thenassess and treat medical, surgicaland trauma patients in a single unit,or separate units could be provided.

• Assessment units may servemedicine, surgery, obstetrics and

paediatrics and can be managed byA&E or the specialty concerned.

• The current scale of admissions andthose which could be avoided. Themost significant areas in which theremight be opportunities for change aremedical specialties (in particular careof the elderly) and orthopaedics.

• Rapid Response Teams: Usuallytargeted at children or elderly peoplewho are assessed to be potentially atrisk. Patients can be assessed byGPs or in the hospital and are thensent home and cared for by RapidResponse Teams. These teams canconsist of nurses with expanded skillsalongside other professionals, inparticular PAMs and communitybased staff.

• Telephone advice: a system which isprotocol driven and designed for useby trained nurses and consists ofcomputerised decision supportprotocols to aid consistent and safetelephone consultation and triage.

• Emergency out patient clinics:patients can be sent home from A&Ehaving been scheduled forattendance at an urgent out patientclinic or in the day surgery unit thefollowing day.

010


6.5 The work of the other service designgroups will have to take into accountand consider the impact of emergencyadmissions and ensure that informationis shared between the relevant groups.

Physical Setting

6.6 The group should consider the physicalsetting for services, including on site andoff site options and issues of quality:

• Physically separate facilities fromelective care with discrete treatmentand diagnostic facilities;

• Facilities for children;• Emergency ambulance facilities;• Waiting areas;• Innovative use of circulation space• Requirements for research/education

in these areas;

Emerging Technologies

6.7 The group should consider:

• I.T. links with primary careproviders/impact of shared electronichealth record;

• Telemedicine links;• Patient record management;• NHS Direct.

Workforce planning

6.8 As a consequence of considering theissues relating to future service models,what impact would be had on staff interms of:

• Roles and responsibilities• Working patterns• Skill mixes• Training and development

considerations• Physical deployment• Impact of employment law /

European policies

University Teaching and Research

6.9 Developments in the management ofemergency services may haveimplications for training and researchthat should be considered by the Group.

Anywhere NHS Trust

Model of Care

Table of Contents

Section Page

1. Introduction .....................................................................................................01

2. Whole System Principles ................................................................................02

3. Whole System Model Of Care ........................................................................03

4. Acute Setting Model Of Care ..........................................................................14

5. Impact Of The Model Of Care ........................................................................26

6. Next Steps .......................................................................................................30

01

1. Introduction

This document provides an example modelof care and represents a whole systemsmodel that provides context for future serviceand infrastructure developments.

The objective of this paper is to ensure thework of Service Design Groups is co-ordinated into a meaningful and consistentoverarching vision for the way services willbe delivered in the future.

The remainder of this document is structuredas follows:

• Whole system principles – setting outthe principles developed that underpin thedevelopment of the model of care;

• Whole system model of care – settingout the clinical vision for the provision ofhealth and social care for the people;

• Acute setting model of care –describing how services will be arrangedon the acute site in the context of theoverall model of care;

• Impact assessment – in terms ofinfrastructure, staffing issues andcapacity;

• Next steps – suggesting a way forward.

02

2. Whole System Principles

Vision Objective

People 1a: Provide people centred services that meet needs and expectations

2a: Provide services that address inequalities and promote inclusion

2b: Provide services and facilities that create pride and confidence amongstlocal people

2c: Provide services that are clear, logical and easy to accessRegeneration

2d: Deliver services and buildings that integrate with and complement otherinitiatives taking place

3a: Invest in people

3b: Improve availability and quality of informationInvestment

3c: Improve local buildings

4a: Improve overall quality of service

4b: Provide an uplifting and inspirational environment which promotes well-beingDesign4c: Provide a modern & sustainable environment which promotes well –being

5a: Provide seamless effective services

5b: Provide efficient servicesExcellence

5c: Promote local initiatives

The Strategic Outline Case aims to achievea range of benefits for the people of the cityand these include:

• creating a system of health and socialcare infrastructure which is amongst thebest in the UK;

• improving access to health care throughlocal and responsive services;

• promoting independence and support forpatients to regain their health quickly;

• co-ordinating and designing careprocesses to meet the needs of patients;

• building partnership working for the mostefficient system of care possible;

• delivering the benefits of improvedservices for clinicians and patientsthrough investment in IM&T throughoutthe community.

03


The ‘whole system’ model of care builds on arange of modernising projects and servicedevelopments, which are already, or willshortly, be in place. It also reflects the workof the Service Design Groups.

Any future whole system model needs toreflect the national health and social careagenda, which provides a framework withinwhich local health services need to bedeveloped and delivered. In particular,Service Design Groups have considered thecontent and conclusions of the:

• National Plan which sets out theGovernment’s health priorities andmodernisation agenda;

• National Bed Inquiry which providescontext for how to plan acute andintermediate care services;

• National Service Frameworks, which, forkey groups and conditions, providenational strategies for providing anddelivering services.

Mission Statement

People will be seen by the most suitableprofessional at the most appropriate timeand place for their needs with the minimumnumber of transfers between professionalsand locations.

The aim is to simplify and streamline thepresentation to treatment process in order toreduce the time to diagnosis and treatment.Clear and consistent pathways will bedeveloped and followed to deliver therequired care that will be delivered fromwithin a suitable culture.

The following principles will be taken intoconsideration during the redesign ofservices.

Safety EffectivenessFlexibility EfficiencyChoice CertaintyAccessibility ResponsivenessAppropriateness Relevance

04


Whole systems Model of Care (Using Diabetes NSF as an example)

PREVENTION

Eye disease Foot disease

MI/ Angina

Events

IP admission

Renal Stroke

Public healthprimary care

Integrated Multidisciplinary/Multi

Self care behaviour/shared records/protocol

ScreeningcommunityPrimary careSecondary care

Primary careSecondary careDirect access

Direct access servicesPrimary careSecondary careSelf care

Diagnosis Initial management Continuing care

Empowerment

Education

05


The suggested model of care is based onthe process outlined in the Diabetes NationalService Framework, (see diagram). Mostcommon conditions will fall within thepathway outlined, with some exceptionssuch as non-pathological ill health e.g.chronic pain, alcoholism, requiring morespecialised pathways.

The diagram highlights the main pathwaythat most chronic disease patients couldfollow, during the course of theirdisease/condition. The model requires thatcontinuity of care is protocol driven, withmulti-disciplinary, multi-agency, integratedcare, focused on maximising the opportunityfor staff and patients to make informeddecisions, in order to manage their care at allstages of the care pathway.

"The Expert Patient", an important documentrecently published by the Department ofHealth, proposes, with support fromhealthcare professionals, greater use of thepatient's expertise in managing their owndisease and in supporting others with thesame condition. This concept will be animportant feature of the model.

Key changes to the current system include:

• there is an essential requirement for thedevelopment of electronic sharedrecords across the whole healtheconomy, which needs to be availableto both primary and secondary careproviders.

• development of the role of GPs withspecial interests has been shown to bevery successful.

• further development of the roles andresponsibilities of Direct AccessServices e.g. health centres or at pointsof delivery such as pharmacies.

• improved communication with citizens,informing them of what services areavailable, where and when.

• continuing care could be managedcloser to the patient by being based inand co-ordinated from primary caresettings.

• provision of the correct skill mix, in allsettings, across the whole spectrum ofcare.

06


• agreement on shared whole systemsprotocols across the whole continuum ofcare that all health professionals aresigned up to.

• improved continuity of care - a “Keyworker” / “Care Co-ordinator” could belocated in the community, who would actas a one call gateway into chronicdisease management. The managementof people with non-pathological chronic illhealth could also be helped using this keyworker approach e.g. alcoholism, chronicpain.

The whole system model is now furtherdescribed in terms of:

• Ambulatory and elective care;

• Emergency assessment and care;

• Intermediate care and older people.

Ambulatory care

Key criteria for providing further ambulatoryand elective/scheduled services withincommunity settings that are currentlyprovided in the acute sector have beendeveloped . These include:

• equity;

• accessibility;

• social acceptability;

• added value regeneration;

• integration with non NHS developments;

• current and planned developments;

• availability of sites;

• deliverability;

• efficiency.

Primary care centres will be provided in alocal environment. They will be designed tobe flexible, responding to local communityrequirements and will enable increasing jointprovision of services.

The concept of how the ambulatory serviceswill be provided across all settings is set outin the diagram overleaf:

07


Level One

Level Two

Level Three

• Surgery requiring GA• Patients who have multiple

complications/risk factors• Diagnostics requiring access

to MR/CT scanner

• Children’s facilities• Minor surgery (LA/sedation)• Library/lecture theatre• Some therapy services• Rehab/intermediate care

facilities

• GP/Nursing• Some out patients• Pharmacy/GDP• Self care/expert patients• Health promotion• Community cafe

• Low risk cases/procedures/consultations• Frequently used services/equipment

• Medium riak cases/procedures• Specialised/expensive

resources when limited to a few• Medium numbers

• Higher risk cases• Higher risk procedures

• GA• Low numbers

• Specialised/expensive/sharedresources (limited to one)

Services/functions

HospitalSpecialistServices

LocalSpecialistServices

UniversalServices

08


The diagram illustrates the range ofuniversal services that will comprise levelthree Primary Care Centres (PCCs). Leveltwo PCCs will provide a range of localspecialist services including Children’sresource centre, diagnostics and treatmentservices, therapy services and learning andeducation services. Level one will beprovided from the acute hospital site.

Level 2 PCCs will have a particular specialistfocus as shown in the diagram below:

Children and Young People

DTC

Therapies and Re-hab.

Res

earc

h an

d Le

arni

ng

Local

Centres

Car

e

Health

and Social

Children and Young People

DTC

Therapies and Re-hab.

Res

earc

h an

d Le

arni

ng

Local

Centres

Car

e

Health

and Social

09


Emergency assessment and care

The whole system model developed for themanagement of emergency care ischaracterised as follows:

• appropriate care, delivered in appropriatesettings;

• fast track assessment and diagnostics;

• direct GP referrals to diagnostic services;

• Ambulance referrals to the rapid responseteams;

• holistic approach to the management ofpatients with emergency and urgentneeds;

• recognising the different requirements ofpatients, the development of streamingprocesses for emergency and electivepatients;

• co-ordination and coherence of service /organisational improvements betweenhealthcare professionals and across thehealth system;

• development of single assessment ofpatients to avoid multiple clerking andduplication of tasks;

• empowerment of the appropriatehealthcare professional to assesspatients.

In addition to their current role, the RapidResponse Teams would also “screen”patients in the community that wouldotherwise be sent to the A&E Department.Rapid Response Teams would furtherprovide packages of care to preventadmissions to the A&E Department.

10


The diagram below illustrates the balance ofwhere care will be provided:

Level 1 & 2

A&E

Emergencyadmissions and

assessment

ITU/HDU

Surgicalmedical

specialty beds

Diagnostic

RapidResponse

teams

NHSDirect

SpecialistGPs

GP Outof Hoursservice

GP directreferral

Intermediate careservices e.g. step

up bedsRehabService

AmbulanceService

Walk inCentre

11


Intermediate care and older people

Various publications have highlighted thepotential way forward for elderly andintermediate care services and theseinclude:

• The NHS Plan;

• National Service Framework;

• Intermediate Care Guidance;

• Audit Commission Report – “The Way toGo Home”.

Intermediate care model based on thefollowing principles/criteria:

• Patient centred and recognise needs ofcarers;

• Apply a whole system approach;

• emphasis on service redesign andredistribution of resources with somelimited new investment;

• use of evidence wherever possible;

• sound reasoning and experience whereno evidence exists;

• be flexible in defining use of resourcesand not restrict intermediate care to olderpeople only;

• fit in with the National Service Framework(NSF) for Older People;

• fit with the Strategy for Services for OlderPeople;

• map services using the patient care routeprinciple;

• recognition of manpower and trainingneeds to support services

• engage users and carers in the process.

The model emerging around the delivery ofolder peoples and intermediate care isdepicted below:

12


AcuteSingle contact point•Rapid Response Team•Specialist elderly assessment centre•Reduce age threshold for for acute elderly caredirectorate admissions to 75 and ?needs based 65-75 via A& triage• RRT/step up bed resource – in Primary CareCentre or Independent Sector•Old age psychiatry community Rapid responseteam•Olde age psychiatry in patient service•Old age psychiatry hospital liaison service

A New Service Model

Post-Acute Rehabilitation

•Ring-fenced hospital rehabilitationbeds•Community Rehabilitation unit•Enhanced Day Services

IntermediateServices•Single contact point with links to all intermediatecare services•Slow-stream beds – step down-(including socialcare)•Transitional Care beds•Expanded EPICS•Direct referral for primary care into communityservices•Outreach teams•Palliative care teams•Support from specialist secondary care services•Old age psychiatry services including hybridworkers, EMI resource centres and slow streambeds

Long-Term Support and Review

•Health promotion and prevention•Single contact point•Anticipatory Care/targetted over75s checks•Multi-disciplinary review and support andkeyworker system•More home care including 24 hr care•Other support services (e.g. housing)•Long-term support for older people with mentalhealth problems through Old age psychiatrycommunity services•Development of ‘hybrid’ mental health worker inprimary care•Specialist GPs• Community equipment services• Continuing health care

13


The whole system

The co -existence of the whole system isdepicted in the diagram set out below.

Intermediatecare

Level 2 –PCC

Intermediatecare

Intermediatecare

Level 3 –PCC

Level 2 –PCC

Level 3 –PCC

Level 2 –PCC

Intermediatecare

Level 2 –PCC

Level 3 –PCC

Level 1 –SpecialistDTC

Criticalcare

Emergencycare

The Acute Hospital

14

4. Acute Setting Model of Care

Current situation

The SOC describes a range of challengesand issues the acute sector faces currently.These include:

• waiting time challenges that are furtherexacerbated by national plan targets;

• capacity problems hindering the acutesectors ability to manage emergenciesand achieve waiting time targets;

• infrastructure deficiencies in terms ofcondition of some buildings.

Current service profile

Current acute services are characterised by:

• ambulatory care – up to 90% of allelective episodes have a length of stayduration that is less than 72 hours(around 70% of all elective episodesrequire no overnight stay).

• emergency care – most emergencies(66%), both medical and surgical, stay inthe acute setting for less than 72 hours.

• critical care – evidence shows thebenefits of specialist units for complexcare.

• intermediate care – the pointsprevalence exercise, and evidence fromelsewhere, suggests at least 20% ofacute beds could be re-focused to provideintensive rehabilitation or intermediatecare services.

• condition based strategies – CHD,cancer, older people places an emphasison prevention and ensuring needs areappropriately met in the right setting.

15


These profiles of both emergency andelective acute patients have length of staydistributions that can be delineated betweenthe core elements of acute and postacute/intermediate care as shown below:

Ambulatory care

Critical care

Post acute care

The distribution of length of stay - elective admissions

Length of stay (days)

Ambulatory care

Critical care

Post acute care

Ambulatory care

Critical care

Post acute care

The distribution of length of stay - elective admissions

Nu

mb

er

o

f

ad

mi

ss

io

ns


Emergency care

Critical care

Post acute care

The distribution of length of stay - emergency admissions


Emergency care

Critical care

Post acute care

Emergency care

Critical care

Post acute care

The distribution of length of stay - emergency admissions


JGrahat

Number of admissions

JGrahat

Number of admissions

16


Acute service model

In the context of the overarching principlescontained in Section 2, the current serviceprofile, current challenges and issues, anacute model of care has been developed,which is depicted below

Emergency Elective

Critical Care Centre

Emergency Beds eg.• Trauma• Complex emergency

surgery

Emergency Theatre Elective Theatres

Elective beds eg.• Cancer surgery• Joint replacement

Diagnostics andtherapies

Emergency Care Centre• A & E• Admissions wards• Observation beds• Short stay beds

Diagnostic & Treatment Centre• Some OP• Day/72 hour surgery• Medical day care

HDUITU

Post AcuteCare

17


The key characteristic of this acute sectormodel of care is a clear separation ofelective and emergency work streams. Themodel:

• recognises the very different processesinvolved in caring for patients withdifferent needs;

• enables a better assessment of capacityrequired;

• provides an ability to ‘ring-fence’ beds;

• ensures appropriate concentration ofspecialist skills;

• delineates fast stream (short stay) andslow stream (complex needs) patients.

Elements of the acute model of care arefurther described below:

Diagnostic and treatment centre

A focus around planned, non complextreatments and investigations for patientsrequiring no overnight stay and potentiallythose requiring stays of less than 72 hours.

The term ‘Diagnostic and Treatment Centres’encompasses a wide range of healthcareactivities and types of facility. What theyhave in common is the opportunity toachieve the following benefits for patients:

• Fast and convenient access – DTCs willdeliver additional capacity, which in itselfwill reduce waiting times, but the conceptdelivers much more than this. DTCsseparate the bulk of routine elective carefrom competing emergency pressuresand can provide such services at timesconvenient to patients.

• Reliable booked appointments –separating elective and emergency careenables greater predictability. Bookedadmissions can be honoured to a fargreater degree than in circumstanceswhere electives and emergencies areunder the same units of management andin the same facilities.

18


• Modern environments – these patientsare generally not seriously ill. Theyrequire facilities that they will probablywalk into and walk out of. The typicalacute ward – designed to accommodatemore seriously ill patients and emergencyadmissions – is far from an idealenvironment from the patient’sperspective and day case units rarelyhave the full range of facilities needed toachieve radical service redesign. DTCsoffer easily accessible modernenvironments without the institutional feelit is hard to avoid in bigger hospitals.

• Co-ordinated, one stop care – DTCsprovide an environment conducive to newways or working, bringing down thebarriers between general practice andspecialist care, between specialists ofdifferent disciplines and between medicaland other professions. This is the rightenvironment for staff of all professions towork closely alongside each other toprovide what these patients want – fasteffective care delivered at convenienttimes.

Key principles are summarised below:

• a focus around those ambulatory servicesthat need to be provided from an acutesetting;

• ring - fenced generic beds to ensureplanned work can be managedappropriately and given this ability to planwork at higher bed occupancy rates;

• organisation of beds to reflect thesignificant ambulatory nature of electiveand short stay beds reflecting theproportion of patients who stay in anacute environment less than 72 hours;

• same day admission of patients ensuringbeds are used efficiently (currentlyaround 14 beds a year are used to admitpatients prior to the day of electivesurgery);

• appropriate provision and co-location tohigh tech diagnostics;

• centralisation of core staff including, forexample, therapies input.

19


Emergency care centre

Concentration of facilities, skills, equipmentto manage all emergency admissions and‘house’ those patients who stay in an acuteenvironment for less than 72 hours ingeneric assessment or observation bedswith senior multi-disciplinary and multi-specialty input.

A summary of the key points is set outbelow:

• constant availability of medical supportand close proximity to all diagnosticservices;

• emergency admissions are located in asingle area for clinicalobservation/assessment;

• acts as a dedicated buffer for acutespecialty based medical & surgical wardsand includes observation of vulnerablepatient groups;

• minimises number of inappropriateemergency admissions;

• places patients to appropriate wardsminimising transfers thereafter andensuring needs are most appropriatelymet;

• trauma patients are adjacent or as closeto theatres as possible;

• minimises trolley waits in A&E pendingtransfer to acute admissions ward;

• single focus for first 24 hours ofemergency care with the opportunity todischarge within that period and for GPenquiries of overnight emergencyadmissions. Requirement to plan thisfacility at 75% occupancy;

• integration of this unit with a GP unit(particularly ‘out of hours’ service) isdesirable and would help maximizeresources dealing with emergency patientflows into the area;

20


Diagnostics and therapies

The principle is that the separation of acute(urgent) work and booked (non-urgent) workshould be achieved. This could be doneeither by separate facilities or separateworking practice. This should improvepatient access and give a measure of controlto the workflow to the diagnostic services.

This would include a fast track approach todiagnostics on the acute site to allow rapidassessment of emergency admissions, butshould be set up so as not to interfere withscheduled activity. Current services aredistributed across the health care systemand key co-locations have been identified.The concentration of diagnostic facilities andskills would help to achieve the principlesunderpinning the diagnostic and treatmentcentre concept.

There are advantages to be gained fromcentralising diagnostic services, particularlyradiology. There are certain critical co-relationships of this service; emergency care;critical care (ICU, CCU, theatres etc) whichrelies on a rapid turnaround of investigationsand results service to enable immediatedecisions to be taken on the next stage of apatient’s care.

In physical terms, centralised diagnostics willalso need to be close to ambulatory care.

Pathology services shall be integrated into asingle laboratory complex with a singlecentralised reception.

Key principles relating to acute provision ofdiagnostics are summarised below:

• Assumes the implementation of PACS(Picture Archiving and CommunicationSystems); this underpins the provision ofdiagnostic services across the whole ofthe area.

• Separate steams for the elective (booked)patients and the acute (urgent) patient.

21


• Improving patient access; this includes‘one stop’ services as changes occur inclinical practice; improvements in patientscheduling to allow patients to choice inbooking their appointments; provision ofappropriate if limited diagnostic services‘off’ a central site; Pathology servicesrequire strong IM&T links with two wayflow of information.

• Improved IM&T to ensure improvementsin patient scheduling and further serviceefficiencies; integration of the Radiologypatient system with EPR and PAS isessential for improvement in-patienthandling.

• Centralising diagnostics as far as possiblegiven constraints of the capitaldevelopment. The site is not ideal for acentral service but it would improveefficiency of use of equipment and staff ifachieved. Some satellite services couldbe supported with appropriate IM&T

Benefits exist of providing pharmacydispensing stations on wards capable ofsupporting a computer terminal and printer,access to a vacuum tube system linked to arobotic Pharmacy dispensing system andensure that every patient bed has its ownlockable medicine cupboard. This ensuresrapid dispensing of discharge prescriptionsand the ability for patients to self-administertheir own medicines.

Ideally, the whole of the PharmacyDepartment apart from OutpatientsDispensary would be located together i.e.Aseptics/TPN, Purchasing, Stores(containing robotic dispensing machine),Clinical Trials, Dispensary, MedicinesInformation Unit, Staff room, Educationalfacilities and Offices.

Therapies (Allied Health Professions)provision within the acute sector needs tosupport the management of the patientprocess. Also, where appropriate, they areincreasingly taking a lead role in the patientprocess. Many opportunities are emerging toincrease direct access to these services,thereby streamlining care and avoidingunnecessary referral to the hospital.

22


• Therapy and rehabilitation services arecurrently fragmented and scatteredaround hospital and community settings.These could be delivered more effectivelyby developing a hub and spoke modelwhich would facilitate a more patientcentred, whole systems approach to care.

A number of key issues emerged relating tothe provision of therapy services include:

• Many Therapy-led outpatient clinics couldbe more appropriately provided withinCommunity settings, even in the shortterm, provided that suitable facilities wereavailable e.g.: Orthoptics and Dietetics;

• In some instances a non-health settingmight ensure a more effective delivery ofcare e.g.: “healthy living” services andelements of Speech and LanguageTherapy

23


The diagram set out below shows the visionfor the provision of therapies service acrossall settings:

HUB for rehabilitation service

• One stop multi-disciplinary assessmentand treatment (whole systems) includingGait Lab, Gym and Pool

• Hub or Spoke for Orthotic Services• Centre store for rehabilitation aids and

Orthotics

• Spoke local citizens

Hub for allied professionals

• Management and admin base• Main staff base

Education centre

• For staff, students and patients

Primary Care Centre

• Multiple locations for local deliveryeg. schools, libraries, local sports centre,homes, day centres

• “Healthy Living Centre”• Local repair services

eg. Surgical, footwear, hearing aids

Non-Health Settings

• Surgical facility including SurgicalPodiatry

• Orthopaedic Triage

• Videofluroscopy• Hub or Spoke for Orthotics Services• Spoke for local citizens

• Base for relevant AHP’s

PCC or D&T Centre

• Multiple locations for local deliveryof AHP services eg. Health Centres,GP Practices, PCC

• Intermediate Services

NHS Health Settings

• Complex/Acute/Critical• Hub or Spoke Orthotic Services• Base for relevant AHPs

D&T Centre In-Patients

Acute Hospital

Locations and bases dependent on outputsfrom relevant SDGs

OutreachTeam

Other Multi-Disciplinary Teams

Neuro RehabTeam

RapidResponse

Team

SpecialNeedsTeam

PaediatricFeedingTeam

EPICSTeam

24


Critical care centre

Theatres, ICU, HDU for patients withcomplex needs and requiring ongoingspecialist care.

A centralised critical care centre will bedeveloped , incorporating ITU, HDU andCCU (recognising the latter’s requirementsfor a discreet area). Features of this systeminclude:

• critical care services co-located with A&Eand theatres within facility constraints thatexist;

• graduated critical care model i.e. step upfrom HDU to ICU;

• concentration of limited specialist ITUnursing skills;

• flexibility in bed usage between HDUand ITU;

• most efficient use of limited staff resource;

• recognition of the requirement ofneurosurgery HDU within the unit.

Implementation of the model around criticalcare needs to be considered carefully. Theacute development is a mixture of new buildand refurbishment and therefore limitationsexist as to what can be achieved.

Specialty Bed Base

Complex inpatient care facilities foremergency patients and remaining electivecases. This allows specialisation andensures a critical mass of patients toaggregate beds into defined specialty wardswhere appropriate.

Features of the model relating to the use andmanagement of patients within the specialtybeds include:

• the current bed base will need to be re-aligned to reflect the need to sizeappropriately the emergency and electiveshort stay facilities.

• allows development of centres ofexcellence/ concentration of expertise;

• centralisation of specialist services;

• bed occupancy levels at 82% as definedin the National Plan.

25


Specialty wards will transfer both electiveand emergency care to a post acute careenvironment when medically fit fordischarge, unless there are over ridingreasons not to do so (for example, the needfor specialist ward-based therapy orequipment which it is not feasible to movewith the patient to post acute care).

Post acute/rehabilitation centre

Services and beds focused around patientrehabilitation with key links to other settingsand intermediate care services.

Scope exists to increase the post acute /rehabilitation beds on the acute site. Thisreflects the current service profile thatillustrates the levels of patients in a postacute phase who are currently cared for inspecialty beds.

The model is founded, in part, onrecognising patient’s needs at every point oftheir hospital stay. Benefits of this approachinclude:

• concentrating therapy skills and expertisein a dedicated, fit for purpose area;

• a focus for discharging patients and anopportunity to make the process moreefficient;

• opportunity for better liaison with otherservices and agencies.

26

5. Impact of the Model of Care

The proposed model of care needs to beassessed in terms of its impact on:

• Capacity;

• Workforce;

• IM & T.

Capacity

The Strategic Outline Case contained theresults of a detailed demand modellingexercise to allow a forecast to be made offuture health care requirements.

Key messages include:

• an overall requirement of XXXX beds/bedequivalents.

• the future acute bed base is in the regionof XXX.

• intermediate care provision is defined asbed equivalents and is calculated at XXXbed equivalents.

27


In terms of acute setting capacity the chartbelow provides a view of how the acutesector capacity will be delineated:

Emergencyshort stay

8%

Electiveshort stay

3%

Electiveday cases

5%

Post-acute20%

Specialty base64%

Based on data from 2000/01

28


Workforce

The key workforce issues are summarisedbelow:

• GP’s with a specialist interest – thisrole continues to develop and the modelassumes a significant rise in specialists inprimary care;

• “Key worker” / “Care Co-ordinator”could be located in the community, whowould act as a one call gateway intochronic disease management;

• the emergency admissions acutemodel will only be achieved by having inplace:

– continuous professional development;– training;– rotations between the general /

specialist wards;– leadership (both Nurse and

Consultant);– development of Clinical Nurse

Specialist roles.

• Staffing levels/skill mix/ways ofworking – The model will need tomaximise the use of all skills and willrequire a re-distribution, and in somecases, extension, of roles. It will includechanges to the roles of doctors, nurses,pharmacists, allied health professionalsand a wide range of other healthcareworkers such as laboratory technicians,assistants and clerical staff. (ref. TheNational Plan, Changing WorkforceProgramme)

The ability to recruit and transfer any servicefrom a central hospital base to one or morecommunity bases will be dependent uponthe ability initially to recruit staff. There willcontinue to be a need to ensure that clinicalquality standards are maintained and thatstaff are supported on a daily basis.Mechanisms for ensuring their continuingprofessional development will also need tobe developed.

29


IM & T

There is a clear requirement for acomprehensive Information ManagementSystem with associated technology toensure that patient records and clinicalmanagement decisions can be stored safelyand accessed at all relevant points in thepatient pathway.

The diagram below outlines the concept ofthe proposed EHR system:

Whole System SharedElectronic Health Record

The overall model of care assumes thefollowing infrastructure is in place:

• Electronic Health record across the wholehealth economy.

• A Patient Scheduling system is needed toensure that effective use is made ofclinician and equipment time.

• The Patient Archive and Storage System(PACS) is considered vital if diagnosticservices are to be located within aPrimary Care Centre. This would ensurethat patient records are available digitallyat any point across the local network,without the need for these to betransported manually, with all of theinherent problems that can lead to loss ofrecords and duplication of tests.

ElectronicHealth Recordand Scheduling(inc. Community

Support)

GPSystem

PatientView

SocialServices

ChildHealth

MentalHealth

GPView

HospitalEPR

CommunityWideMPI

View(via EHR)

Input& View

(via EPR)

Input (viaGP System)

View (via Webbased EHR)

30

6. Next Steps

The model of care will be submitted toPartner organisations for sign off andinclusion in the Outline Business Case. Atthis stage the model of care paper will beendorsed subject to ongoing scrutiny beingcompleted.

The ‘scrutiny role’ will be deployed to ensurethe model reflects latest best practice, isevidenced based where possible, accords tonational policy and frameworks.

01

Theatre Utilisation Model

The table below demonstrates a theatreutilisation model using average proceduretimes by specialty multiplied by workload andapplying utilisation (occupancy hours ofworking etc) assumptions to generatetheatre requirements.

Theatre requirements estimated Theatre requirements estimated

Average time in theatre (mins) from 2000/01 episode data from 2000/01 episode data

Elective IP Non-elect IP DC Elective IP Non-elect IP DC Elective IP Non-elect IP DC

General Surgery 90 90 30 1.4 0.8 0.4 1.4 0.8 0.6

Urology 45 45 30 0.4 0.3 0.2 0.3 0.3 0.2

Orthopaedics 75 75 45 0.8 0.9 0.6 1.4 0.9 0.7

ENT 40 40 35 0.4 0.1 0.1 0.4 0.1 0.1

Oral Surgery 30 60 40 0.0 0.0 0.3 0.0 0.0 0.3

Neurosurgery 160 160 60 0.7 0.7 0.0 1.6 0.3 0.0

Pain Management 25 25 25 0.0 0.1 0.0 0.1

Gynaecology 40 65 30 0.3 0.4 0.5 0.4 0.4 0.5

Excludes endoscopies 4.1 3.2 2.2 5.6 2.9 2.6

Theatre availability

Elective IP Non-elect IP DC

Hours per session: 3.5 3.5 3.5

Sessions per day: 2 2 2

Days per week: 5 7 5

Weeks per year: 48 52 48

Utilisation: 80% 65% 80%

02

Bed Requirement Model

The table below outlines the summary sheetfor a model, which would be used tocalculate the number of elective bedsrequired depending on the mix of specialtiesthat an organisation would wish to provide:

Elective Admissions Unit planningSurgical admissionsSpecialties includedGeneral Surgery 1 Surgical

UnitOBDs Beds

Urology 1 Number of daycases 6,200 3,720 12

Orthopaedics 1 Number of stays of 1 day 1,073 1,073 4

ENT 1 Number of stays of 2 days 1,299 2,598 9

Oral Surgery 1 Number of stays of 3 days 507 1,521 5

Neurosurgery 1Pain relief

Gynaecology 8,912 30 beds

Assumptions Occupied bed days allocated to daycases: 0.6

Maximum days stay in surgical elective unit: 3

Number of days open per year: 365

Occupancy: 82%

Medical AdmissionsSpecialties includedGeneral Medicine 1 Medical Admissions Unit OBDs BedsHaematology 1 Number of daycases 5,534 4,151 14

Cardiology Number of stays of 1 day 245 245 1

Dermatology Number of stays of 2 days 124 248 1

Nephrology 1 Number of stays of 3 days 41 123 0

Neurology Number of stays of 4 days 33 132 0

Rheumatology Number of stays of 5 days 19 95 0

Geriatric Medicine 4,994 17 beds

Immunopathology Assumptions Occupied bed days allocated to daycases: 0.75

Maximum days stay in medical elective unit: 5

Number of days open per year: 365

Occupancy: 82%

03

Radiology/Diagnostic Model

The table below details the workingsrequired to calculate the provision of variousmodalities of Radiology Services. It alsoallows for an element of equipment usageper modality:

RADIOLOGY DEPARTMENT PROJECTIONS

AssumptionsHours of Operation 8Days of Operation 5Weeks of Operation 48

Utilisation in Minutes 115200Per YearHrs per year 1920Actual Utilisation @ 80% 92160CT/MRI Utilisation = 90% 103680

Non-Interventional

Modality TotalExams

Procedure Fractional Equipment Inpatient

Outpatient

Equipment requirementsTimes Equipment Demand %s IP OP

Demand

CT 10352 10 0.9984568

1 1 0MRI 0 45 0 0 1 0Obs Ultrasound 13441 20 2.916883

73 1 0

Non-Obs Ultrasound 26208 20 5.6875 6 1 0Radioisotopes

2866 45 1.3994141

2 1 0Radiographs

136311 15 22.186035

23 1 0Fluoroscopy

5496 30 1.7890625

2 1 0

01

Operational Principles

An example operational principles proformais set out overleaf. This example coversambulatory care including:

• day surgery• day investigations• outpatients

1 Scope of Service

Ambulatory services will consist of 3 elements

• outpatients

• day surgery

• day investigations

Outpatient services to provide a focus for patients referred for a specialised opinion

Undertake the diagnosis of disease by means of specialist consultation and examinationsupported by a range of diagnostic tests

• provide follow up and monitoring of the condition of outpatients, day patients anddischarged inpatients

• Day surgery services to:

• provide suggested intervention to those who can be discharged on the same day (within23 hours)

• provide facility for primary care to undertake minor procedures

• Day investigations

• The priorities of a day care facility for

– Endoscopy/gastroscopy procedures

– Medical day procedures

02


2 Workload/activity indicators

Estimated day case bed requirement based on current activity levels (2000/01 is 85bed/places

Projected day case bed requirement is 100 bed/places. This figure takes account ofdemographic changes, changes in LoS and requirements to meet waiting time targets asset out in the National Plan

3 Configuration

Outpatients to be located at XXX

Outpatients to have diagnostic support of plain film and ultrasound, ? CT

OPD at XXX to include:

• women’s (obstetrics and gynaecology)

• vascular requiring Medical Physics support

• oncology/haematology based within a dedicated unit

• Day surgery to be located to allow single site surgery

Endoscopy 26 places 3 rooms

ECRP utilizing 16 rooms

Oncology and Haematology investigations to remain in own unit

Paediatric investigations in one unit and day surgery patients in discrete unit on the ward

03


4 Key relationships

OPD to be contiguous with outpatient diagnostic support

Potential for near patient testing in OPD

East of access between OPD and therapy areas

Dedicated area for day case theatres

Day theatres contiguous with reception and bed/trolley access

Emergency/inpatient medical investigations to be located with main diagnostic onBRI site

Elective medical investigations to be in discrete areas

5 Work Patterns

OPD 2 sessions per day (9.00 – 1.0 and 1.00 – 5.00) Mon – Fri

OPD sized in 2 sessions but future could include evening/weekend department ordirect access and needs of primary care

Day surgery 8am – 10pm Mon – Fri overnight stays admitted to specialty beds

6 Patient Flow

04


1 Medical Investigations Elective

Chair/trolley recovery

change

ReceptionMain Waiting

Other scopingSub wait

EndoscopySub wait

ProceduresSub wait

Other scopingEndoscopy Procedures

change

Post procedurewait

Interview/consult

Radiology

AdmissionsHome

05


2 Day surgery

Reception

Prep room

Theatre/induced

Recovery on table

Trolley/Recliner

Chair

Change

Departure lounge

1st stage

2nd stage

3rd stage

Adults

Children’scubicles

Adult lounge

Children’s

Children’schange

Children’slounge/play area

06

Example functional content

Functional ContentRef. Aggregation/Department Size m² New Existing Total 1.00 In Patient Accommodation 1,01 General Surgery 1,729 1.02 Orthopaedic Surgery 1,687 1.03 Maxillo-Facial/ENT 701 Sub-Total 4,117 0 4,1171.04 Intensive Care Unit 730 0 7301.05 High Dependency Unit 528 0 5281.06 Coronary Care Unit 552 0 5521.07 Medical /Surgical Admissions Unit 1,140 0 1,1401.08 Urology Unit 917 0 9171.09 Children's Accommodation 250 1,590 1,8401.10 Gynae Unit 530 5301.11 Decant Facilities 530 530 Sub-Total 8,234 2,650 10,8842.00 Out Patient Accommodation 2.01 General Outpatient Clinic 1,566 1,5662.02 Chest Clinic 80 802.03 Chronic Pain Clinic 0 285 2852.04 ENT Clinic 524 5242.05 Audiology and Hearing Aid Clinic 336 3362.06 Fracture & Orthopaedic Clinic 755 7552.07 Genito Urinary Clinic 166 1662.08 Ophthalmology Clinic 636 6362.09 Oral, Maxillo, Dental Clinic 402 4022.10 Cardilology/ECG Clinic 257 2572.11 Early Pregnancy Unit 0 370 3702.12 Dietetics 0 164 1642.13 Rehabilitation 163 0 1632.14 Diabetes Unit 0 0 0 Sub-Total 4,885 819 5,7043.00 Treatment & Diagnostic Facilities 3.01 Accident & Emergency 1,221 0 1,2213.02 Operating Theatre Department 2,630 0 2,6303.03 Day Surgery 852 0 8523.04 Radiology 2,039 0 2,0393.05 Endoscopy 606 0 606

07

Example functional content

3.06 Vascular 0 0 03.07 Planned Investigations Unit 681 0 681 Sub-Total 8,029 0 8,0294.00 Clinical Support 4.01 Pathology Department 1,538 0 1,5384.02 Pharmacy 690 0 6904.03 Mortuary 492 0 4924.03 Electro-Biomedical Equipment 0 0 0 Sub-Total 2,720 0 2,7205.00 Non-Clinical Support 5.01 Main Entrance (excluding Retail) 442 0 4425.02 Clinical Administration Department 1,213 0 1,2135.03 Directorate Administration Department 0 190 1905.04 Anaesthetics Admin. Department 262 0 2625.05 Medical Records Department 985 0 9855.06 On Call Suite 374 0 3745.07 Spirtual Care Centre 165 0 1655.08 Receipt and Distribution 0 255 2555.09 Porters Department 0 175 175 Sub-Total 3,441 620 4,061 Costing Net Totals 27,308 4,089 31,397 Retail adjustment 300 300 Adjusted Totals for Comparison 27,608 4,089 31,697 Add 12% Communications 3,277 0 3,277 Add 12% Plant Accommodation 3,277 0 3,277 Energy Centre 900 Retail / Food 700 Gross Total Areas 34,162 4,089 39,851

01

Operational Policy and Schedule of Accommodation

An example operational policy and scheduleof accommodation for acute ward/bed areasis provided overleaf. It is the policies andschedules which form the core of the designbrief and the key headings/sections of thisexample should be followed.

Anywhere NHS Trust


OPERATIONAL POLICY ANDSCHEDULE OF ACCOMMODATION:ACUTE WARDS

Anywhere NHS Trust


OPERATIONAL POLICY AND SCHEDULEOF ACCOMMODATION: ACUTE WARDS

Table of Contents

Section Page

1. Scope Of Service............................................................................................ 01

2. Activity Indicators ............................................................................................ 02

3. Functional Content .......................................................................................... 03

4. Functional Relationships ................................................................................. 04

5. Operational Policies ........................................................................................ 05

6. Supporting Services ........................................................................................ 07

7. Facility Requirements ..................................................................................... 09

8. Description Of Accommodation ...................................................................... 11

01

1. Scope of Service

The general acute wards provide in patientaccommodation for all medical and surgicalspecialties with the exception of:

• In-patients in the EmergencyAdmissions Unit

• In-patients in Post Acute wards

• Obstetrics and Gynaecology – newwomen’s unit

• Neonatology

• Children – new children’s unit

• Day Case / Short Stay Beds

• Critical Care (including CCU)

• Dermatology

• Renal

• Rheumatology

• Urology

The acute wards will be split into dedicatedmedical wards and dedicated surgical wards.

This policy assumes that the wards requiredare general in nature and can be applied toany of the specialties included e.g.

• General Surgery

• T&O

• General Medicine

• Geriatric Medicine

• Neurosciences

02

2. Activity Indicators

The following table details the current andprojected activity of the acute in patientspecialties covered by this operationalpolicy:

Specialty Current(Elective &Emergency)ExcludingDay Cases

Projected*(Elective +Non Elective)

GeneralSurgery

3587 3623

T&O 2595 3257

GeneralMedicine

9097 6290

GeriatricMedicine

5043 5447

Service Trends

The following points detail both local andnational issues which will have an impact onservice provision:

• The National Beds Inquiry prescribes thatacute wards should be planned at 82%occupancy level;

• There is increasing support for theseparation of emergency and electivestreams of patients. This is reflected inthe developments of DTCs.

Change

03

3. Functional Content

The overall level of provision on the acutesite amounts to XXXX beds.

The new capacity is comprised of:

Existing Build Beds XXX(plus XX electiveshort stay beds)

New Build Beds XXX

Off site XXX

Total XXXX

Following analysis and taking intoconsideration the requirements for the Daycase / short stay unit, paediatrics,dermatology, emergency admissions unit,renal unit, urology unit, women’s unit andpaediatric SCBU services, calculations haveshown that X wards of general medical,general surgical and post acute need to beprovided within the new build.

This policy relates to the general and acutewards only.

The acute beds will be configured in X XXbed wards, which will be provided in the newaccommodation.

The beds on the wards will be configured inthe following way:

• 4 bed bays

• Single rooms

• Assisted single rooms (en suite)

04

4. Functional Relationships

The six new specialty wards should belocated with direct access from the EAU andin close proximity to A&E, ITU and HDU,Operating theatres, Imaging department andEndoscopy suite. This is summarised asfollows:

Relationship Reason Category

Operating theatres For surgical beds Essential

Imaging Dept Ease of access Important

EAU Ease of access Important

Endoscopy Ease of access Important

A&E Ease of Access Desirable

ITU / HDU Ease of Access Essential

05

5. Operational Policies

General

Patients can be nursed either in a multi-bedroom or a single room and can be groupedaccording to speciality or nursingdependency.

The design should allow for nursing maleand female patients in the same section yetat the same time giving them privacy. Inprinciple, however, male and female patientsshould be nursed on separate wardswherever possible.

There must be sufficient space in singlerooms and behind curtains in multi-bedrooms to attend a patient in privacy with thebed partially stripped and a dressings trolleyand other equipment in position.

Patients should also be able to sit out of thebed for short periods within the bed area,and there should be space for personalbelongings within easy reach of the bed.

If doors are provided in the four bedrooms,they are likely to stand open most of thetime. Patients should be able to see andspeak to nurses as they move around theward.

Patients can receive treatment in bed, at thebedside, in a bathroom or in a treatmentroom. A treatment room will be required foreach ward. It will be used for dressings andother treatments, and also as anexamination / interview room.

Sanitary facilities should not be groupedtogether but be sited within twelve meters ofevery bed and day area. All of the singlerooms should have WCs and showers ensuite. Disabled WC facilities (low sinks /hand rails etc) should be provided on each ofthe wards.

A patient / nurse call system is essential, butconsideration must be given to the design ofthe handset. Seriously ill patients need onlya simple pear-shaped bell push to call anurse.

A change of environment is also desirableand this can be obtained in the day / diningareas.

Nursing staff will require easy supervision ofand access to patients. There should begood observation of patients in the four-bedded bays, which should be groupedclose to the staff base.

06

5. Operational Policies

The staff base should be as simple aspossible providing sitting space for twopeople only. Patients’ notes and x-rays willbe stored in a trolley at this point.

Patient admissions will be managed andundertaken at ward level. This function willbe undertaken by the ward clerk.

Access to the Ward

The ward will function as a separate unit.The ward should not be used as apassageway to other areas. Where there ismore than one entrance to the ward, themain entrance must be easily identifiable.

Internal noise should be kept to a minimum.Some noise can be eliminated by carefulselection of materials and equipment. Whenit cannot be eliminated at source, carefulplanning may ensure that noises occur withinenclosures separated from bed areas.

The ward will operate a visiting policy.

Consideration should be given to the securityof the ward (especially wards with a higherpotential for accommodating violent patients/relatives), with possible access via intercomand CCTV surveillance of the entrances.

Staffing

The following table details the WTErequirements for the current general surgicalwards:

Staff Member Current WTE

G Grade 0.9

F Grade 2.8

E Grade 18.99

D Grade 11.22

A Grade 6.99

Support Worker 3 10.82

A&C 4 1.0

A&C 2 2.0

07

6. Supporting Services

Linen

Linen will be delivered on a “top up” systemto the linen cupboard on the ward. Thefrequency of top up should be on a dailybasis. Dirty linen will be collected andplaced in bags for collection within thedisposal holding area. This area should beclose to the entrance of the ward to facilitateease of removal by appropriate staff.

Catering

See catering policy.

Pharmacy

A clinical pharmacy service will be inoperation to the wards. Clinical pharmacistswill agree stock levels with nursing staff andbe responsible for regular top-up to theselevels.

Rehabilitation

Rehabilitation for inpatients will generally beundertaken within the ward environmenteither at the bedside or in the treatmentrooms. Occasionally patients will transfer tothe main rehabilitation department.

Pathology

It is anticipated that extensive use will bemade of the pneumatic tube network for thedelivery of samples to Pathology andPharmacy. A pneumatic tube station may belocated immediately outside the ward areaand serve more than one ward.

Sterile Supplies

Sterile Supplies from the hospitals CSSD willbe supplied on a “topping up “ basis.

08

6. Supporting Services

Waste Disposal

All items for disposal / linen for cleaning willbe bagged on the ward and placed in thedisposal holding area closer to the wardentrance.

General Supplies

See Supplies policy.

Domestic Services

See Domestics policy.

Portering Services

See portering policy

Maintenance

Routine maintenance services will beundertaken by estates staff. Certain items ofplanned preventative maintenance, such asair-conditioning filter changing will beundertaken on a cyclical basis and will beagreed with the ward sister in advance.Other items of maintenance, such aschanging light bulbs and minor repairs will beinitiated on a requisition system and orderedby the ward sister or appropriate designatedperson e.g. ward clerk.

09

7. Facility Requirements

Schedule of Accommodation for the acute wards

Activity Space Area ofEach (sq.m)

NumberRequired

Total Area(sq.m.)

Multi-bed bay (4 beds) 58 2 116

En-suite bath/shower/ wc/washbasin 4.50 2 9

En-suite bath/shower/ wc/washbasin – assisted 4.50 2 9

Multi-bed bay (2 beds) 24 2 48

En-suite bath/shower/ wc/washbasin 4.50 1 4.50

En-suite bath/shower/ wc/washbasin – assisted 4.50 1 4.50

Single Rooms 16 12 192

En-suite bath/shower/ wc/washbasin 4.50 12 54

Patients Bath / WC / Wash 8.50 1 8.50

Day room/dining 20 1 20

Quiet sitting space 9 1 9

Quiet sitting space (women only) 10 1 10

Multi purpose rehabilitation room (5 cubicles) 50 1 50

Ward Clerk Station/Reception 10 1 1

Waiting Area 16 1 16

Nurse Station 10 1 10

Pharmaceuticals storage room 6 1 6

Treatment room 16 1 16

Clean utility 12 1 12

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7. Facility Requirements

Activity Space Area ofEach (sq.m)

NumberRequired

Total Area(sq.m.)

Interview room 8 1 8Resuscitation Trolley Bay 2 1 2Wheelchair/Stretcher Bay 3 1 3Pantry/beverage making 12 1 12Linen Store 3 1 3Supplies Trolley Bay 3 1 3Controlled drug cupboard 1.5 1 1.5Equipment Store 15 1 15

Dirty Utility 9 1 9Disposal Hold 10 1 10Cleaners Room 8 1 8Staff Lockers 2 1 2Staff Rest Room & Beverages 20 1 20Staff WC 4 2 8Staff Shower 6 2 12Switchroom 1 1 1

Doctors Office 11 1 11Ward Co-ordinators Office 11 1 11

Sub total 734

Circulation at 30% 220Acute Ward Accommodation (per ward) 9543 Wards 2862.50

Note: this schedule does not include visitors waiting areas outside the ward

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8. Description of Accommodation

Bed Areas

The four-bedded bays should be directlyopposite the nurse station; the single roomsshould be sited as near to the nurse’s stationas possible and have viewing windows;

Each four-bed bay will contain clinical handwashing facilities for medical and nursingstaff;

Each bed will have a bed curtain which canbe drawn around the bed to provide privacyfor patients who are being examined, or whorequire privacy to perform ablutions etc.

Each bed should have at least two chairsassociated with it for use by visitors;

Each bed will have storage facilities forclothes, personal effects etc. This could takethe form of a built-in cupboard or afreestanding mobile cupboard;

Each bed should also have a small bedsidelocker on which a water jug and glasses canbe stood for use by patients. If the storagecupboard chosen is freestanding,consideration should be given to making thebedside locker and clothes locker a singleunit;

Each bed will also require an over-bed tableupon which patients can receive their meals.

One of the four single bedrooms will have ananteroom with wash hand basin andchanging space.

Each bed should have a dedicated locker forthe patient’s medication.

Nurse Base

A nurse base will be provided immediately infront of two four bed bays. The nurse baseshould also have good visual access to thefour single rooms which should be split eitherside of the two four bed bays in front of thenurse base.

The nurse base will provide facilities for twostaff to sit and undertake administrativeduties. Space should be provided for acomputer terminal and printer.

The clean utility should be directly adjacentto the nurse base. The controlled drugscupboard should be accessed from thenursing station or the clean utility.

Adequate storage cupboards for stationeryetc should be provided under the nurse basecounter and wall mounted behind it.

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The patient notes trolley (which should belockable) will be kept at the nurse base andthe resuscitation trolley should be easilyaccessible.

A separate office for the ward manager isrequired, situated close to the nurse base.

Sanitary and Washing Facilities

In order to economise on space, everybathroom should contain an associated W.C.and wash-hand basin. A height adjustablebath should also be provided in eachbathroom.

Excluding the two single rooms with WCsand “wheel-in” shower en suite, washing andtoilet facilities should be provided on thebasis of one facility per bed bay;

All of the sanitary facilities, which relate tobed bays should be large enough to provideassistance for patients with limited mobility /disability and also include facilities such aslow sinks / towel dispensers etc.

Day Room

A day/dining facility will be provided. Onearea will have two tables and four chairs pertable for those patients who do not wish todine in their beds.

A television and six easy chairs will also beprovided for patients to sit and watchtelevision. The room may also be used forthose patients with large numbers of visitors.

Ward Clerk Station / Reception

This facility should be provided at theentrance to the wards. The ward clerk willsupervise entry to the wards in accordancewith the ward sister in charge. This shouldbe a small office facility with a receptioncounter opening up on to the ward entrance.Only emergency admissions will be admittedto the wards.

Facilities will be provided for limited storageof stationery and the requisite admittingforms. If a computerised patientadministration is to be utilised, there shouldbe a computer terminal at this point foradmissions to be recorded via the PASsystem. There should be at least one chairat the reception for use by patients / visitors.

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Waiting Area

A small waiting area for up to 6 patients /visitors should be provided directly adjacentto the reception area.

A waiting area for visitors should also belocated outside the ward. These areasshould be provided for a group of wardsdepending on the design solution and thespaces should be based on 6-7 peoplewaiting per ward served.

Interview Room

An interview room will be provided on eachward for use by multi-disciplinary teams tomeet and interview patients and / or theirfamilies.

Seating should be provided for 4-5 persons

This room could also be used by psychiatricstaff to interview patients

This room should be close to the wardreception area

Clean Utility

This room should be directly associated withthe nurses station. It will be used for:

• Reception and storage of sterile packs,syringes and needles

• Storage of intravenous fluids

• Storage of lotions and medicines

• Storage of drugs including dangerous andscheduled drugs

• Assembly of items for patient treatment

• Washing of hands

Access to this room should be controlled bydigital lock

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Treatment Room

This room should preferably be sited near tothe clean utility. It will be used for:

• Routine examinations and dressings

• Carrying out clean clinical procedures

• Carrying out sterile procedures – changeof dressing etc

• Interviewing and examining patients onadmission and other occasions asnecessary.

Dirty Utility

This room should be near the treatmentroom and within easy distance of the highdependency area. It will be used for:

• Macerating disposable bed pans andurinals

• Storage of bed pans and urinals

• Urine testing

• Disposal of fluid waste – dirty water,vomit, etc.

Ward Pantry

A water boiler should be included to enablebeverages to be made; a tap for drinkingwater should be included. A handwashbasin, food disposal unit anddishwasher are also provided. Only cupsand other small items of crockery etc are tobe washed at ward level.

Cleaners Room

This room should preferably be near theentrance to the ward and will be used forstoring and cleaning materials. A high / lowsink will be provided.

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Offices

The following offices will be required:

• An office will be required near to theentrance for the ward clerk and should bedirectly linked to the ward.

• A doctor’s office should be provided inwhich medical staff can hold confidentialdiscussions, make telephone calls andwrite up medical notes. This should belocated in close proximity to the nurse’sbase.

• Nursing staff / sisters office will beprovided in which the ward sister canundertake administrative duties and holdsmall staff meetings with other staff. Thisshould also be located in close proximityto the nurse’s base.

Storage

Storage will be required for the following:

• Linen

• Items such as bed cradles, drip standsetc.

• Wheelchairs

• Resuscitation equipment

• Supplies trolley

Other Accommodation

The following rooms are to be provided onthe ward:

• Staff cloaks and toilets

• Facilities for teaching, seminars andclinical investigations for medical studentsand nurses. These facilities could beshared between wards.

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