Developing Day Case Units - Imperative for Optimal Patient Care in Interventional Radiology

IR DAY CASE UNIT (*please alter/transpose onto local Trust document)

Business Case Originator / Lead Contact:

General Manager:

Directorate:

RADIOLOGY

Ref:

Review Panel Authorisation:

1. Exec Summary Exec summary should be limited to half page max, Further background detail should be provided in Section 8: Background to proposal. Please be clear about specifically what this proposal is requesting.

This business case document has been prepared to propose the development of a dedicated Interventional Radiology (IR) daycase unit - to be located in the *** (complete as necessary) at *** (complete as necessary) Trust, with the aim to release capacity in the *Surgical Day Unit (SDM) or *Inpatient Wards (*delete as appropriate), which is a Trust priority. It will also improve patient flow and increase efficiency for the IR service.

(N.B. If part of a phased development, list the phased stages with supporting evidence in the Appendix clearly outlining overall strategy.)

An IR daycase unit will deliver the following core benefits to the Trust:

• Release capacity in *SDU/Inpatient Wards (*delete as appropriate) which is under pressure, by decreasing the flow of IR patients through these areas
• Streamline pathways for IR patients with quicker transfers, maximising list capacity
• Increase ability to day case more patients through streamlined care and improve list efficiency reducing pressure on inpatient beds
• Improve patient safety and standard of care by co-locating recovery within the allocated IR floor space by the IR team
• Reduce pressure on portering and staff escorts from other clinical areas
• IR daycase units are considered standard in hospitals with an IR service and *** Trust is currently an outlier in this area.

Due to the minimally invasive nature of image guided IR procedures, procedures are commonly performed under local anaesthesia and consequently, patients recover rapidly with over 90% of procedures requiring day case admission only. Reconfiguration of IR services through a dedicated IR daycase unit is vital to ensure best medical practice in line with the GIRFT National Day Surgery Delivery Pack (Link: https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2021/08/National-Day-Surgery-Delivery-Pack_Aug2021_final.pdf).

If requesting funding from Charity please also complete Section 5

2. Financial Headlines: Briefly outline key costs, net surplus / loss and source(s) of funding

To deliver this service development, we will require capital costs totaling £*** and revenue pay costs of £*** k for the increased staff detailed in Appendix *** – ‘Workforce’. Additional funds for £*** of ward consumables and £*** for IT will also be required. Full summary breakdown in table format included in Section 3.

Daycase service provision is well established at *** (complete as necessary) evidence based by excellence in clinical outcomes, efficiencies and financial savings as demonstrated by existing Surgery and Endoscopy Daycase Units.

(*Liaise with Day Surgery Unit/Endoscopy - ask for any audit data they can share to support the application).

Please see the funding summary sourced from alternative hospital sites (*Contact SUHT/East Midlands who have recently had successful applications accepted if required).

3. Estimate Resource Implications

Capital & Non recurrent Costs                                      

                                         £k

Income (per annum)    

                                    £k

Recurrent & Non-Recurrent Costs (per annum)

                                                                 £k

Building* ex. VAT

PBR

Recurrent Costs (per annum)

Building* inc. VAT

Non-PBR income

Staff

Other

Non-staff (inc. VAT)

Clinical Support

Non-clinical support (inc. VAT)

Maintenance : Total inc. VAT

Capital charge (dep + ROC)

Non recurrent revenue costs :

Staff

Equipment

Other

Total exc. VAT

Total Recurrent inc. VAT

Total inc. VAT

Total Non Recurrent inc. VAT

4. Net Surplus / Loss

* Note that for Building work, ballpark quotes only are required for the initial concept form submission and ballpark quotes only will be provided by Estates unless business case / concept has already been agreed by Review Panel.

5. Charity Funding Requests:

Not applicable - no charity funding requested OR complete if part of a charitable application.

6. Type of Business Case (please indicate Y / N as appropriate)

a. Capital Cost: Y

If Y: Is this on the capital plan: Y / N

b. Revenue Cost: Y

c. Non recurrent: N

d. Income: Y

e. Invest to Save: Y

f. Quality Bid: Y

g. Risk management: N

If Y: Risk Register Ref no.:                      

Risk Register Score:

h. Equipment: Y

If Y: Is it replacement: N

If Y is it :   “like for like” Y / N

                  or  upgrade Y / N

For equipment, please ensure that section 20 is completed with info that will be required for MEC/ Purchasing.

7. Has this project been considered for joint working with *** Trust: Not applicable as no IR service at *** Trust or Yes this is a joint business case working in collaboration with ***.

8. Please confirm Directorate General Manager sign off for the paper (insert name): ***

9. Background to Proposal and Rationale for Proposal:

Interventional radiology (IR) is a specialty providing life-saving and cost effective services integral to patient care. It has shifted from a procedure based field to a more clinical specialty in which interventional radiologists take primary responsibility for patients.

Due to the minimally invasive nature of image guided IR procedures, the majority are performed under local anaesthesia, and as a result patients recover rapidly with over 90% of procedures requiring day case admission only. Reconfiguration of IR services to provide patient care through a dedicated IR daycase unit would:

1. Increase efficiency and capacity in IR service provision: a co-located IR daycase unit would ensure patients are ready sooner, and co-location would remove delays related to portering and transfer times. These factors would address proven delays as per the ‘IR Downtime Audit’ (*Include local data as an Appendix) and prevent procedural cancellations due to delays on the ward (*Include ‘Cancellation Audit’ as an Appendix - where it is postulated that there would be a reduction in cancellations from *** per month due to delay in patient preparation, lack of available bed post procedure or out of date blood tests to *** per month for clinical exceptions only).
2. Increase capacity in Surgical Daycase Unit (SDU)* or Inpatient Wards* (*Delete as appropriate): which are currently under pressure particularly during COVID Recovery. Re-location of IR patients will free up bed space, nursing preparation time easing clinical pressures.
3. Improve patient safety: patient management in a bespoke IR daycase unit would also ensure that patients are being managed by staff that regularly work with and understand IR specific requirements, therefore improving patient safety. Handover would be direct from the operating IR team to IR recovery and daycase staff. Patients would also be in close proximity to the IR clinical team ensuring optimal management in the event of any unexpected complication.
4. Improve patient experience: our aim is that patients will have been pre-assessed, seen in IR clinic and meet staff from the IR daycase unit prior to admission. This will provide continuity of care. There will be reduced patient movement around the hospital and reduction in bed wait delays. Evidence also suggests that dedicated care within an IR daycase unit will reduce the time spent in hospital by patients during their treatment due to a streamlined admission process using a single departmental preparation policy from 10 to 6 hours - minimising the time each patient needs to be away from home (Audit completed by University Hospital of North Midlands, 2014).
5. Provide dedicated IR pre-assessment: IR daycase unit staff would be in a position to pre-assess, in addition to admit and recover patients freeing capacity from surgical pre-assessment and ensuring any potential issues are picked up, communicated and dealt with immediately by the IR clinical team.
6. Provide IR team co-location: co-location of IR administrative staff, IR daycase staff, IR theatre staff, IR Consultants, Fellows and Nurse Specialists would have the benefit of improved team dynamics and collaborative input to provide excellence in clinical care.

IR daycase units are now standard practice UK-wide, and have been a prioritised development during COVID learning to a) facilitate and streamline inpatient care pathways and to b) accommodate altered care pathways in an attempt to relieve strain on hospital beds, which has in turn, redirected additional patient inflow to IR from other medical specialties.

Most importantly, in line with the GIRFT National Day Surgery Delivery Pack (Link: https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2021/08/National-Day-Surgery-Delivery-Pack_Aug2021_final.pdf), day surgery service provision is recognised as a priority due to its benefits for both patients and system-wide efficiencies related to patient quality and experience, reduced waiting times, release of valuable bed stock and significant financial implications. Specifically, best practice recommendations state that the entire daycase service, ‘IR Daycase’ for the purpose of this business case, should be provided in a standalone dedicated unit, discrete from inpatient activity, containing pathways that incorporate the complete day case process (from pre assessment to discharge).

Activity and demand:

Projection and forecast analysis estimates a local annual increase of **% for oncological/vascular/embolisation (*audit and complete) referrals due to the innovation and expansion within the IR field globally. This annual increase in IR demand and innovation expansion, needs to be a central focus for streamlining the IR service to ensure referral waits can be managed for now and the future.

To future proof the IR service, and ensure increasing annual capacity is addressed, it is realised that a multifaceted approach has required (which may include options such as weekend working and extended days), however a significant proportion of this demand can be alleviated by service provision through an efficient, streamlined, dedicated IR daycase unit.

Using current proposals for an IR daycase unit with *** beds, opening from *** until ***, predictions suggest the IR daycase unit would enable the team to increase throughput of the patients by *** per day. (*Calculate and insert).

Plans:

*Insert here detailed design of plans and requirements.

*Possibly include capital funding predictions and any other additional costs (structural surveys/air units/offices/clinic room/staff room etc).

Commercial Strategy:

A dedicated IR daycase unit would enable the IR service to participate in more funded patient trials due to increased capacity, which would in turn income generate to support the allocation of increased staff support.

10. Alternative Approaches Considered: (why do we need to take this approach – what alternative to achieving the goals have been considered. Please spell out the consequences relating to each of the alternatives of not implementing the proposal.)

1. Option 1: Do nothing

Advantages 

• Reduced capital costs to the Trust
• Area can be used for something else

Disadvantages

• No additional capacity for IR day cases despite rising IR procedural demand
• Does not release capacity in the Surgical Day Unit/Inpatient Wards (*delete as appropriate)
• Does not bring any additional income into the Trust 
• Ongoing service efficiency and patient flow issues
• Limits capacity and therefore the opportunity to offer suitable patients a minimally invasive and cost-effective treatment option
• Continued clinical pressures, cancellations and inefficiencies impact on staff morale and fulfilment - making staff retention and recruitment vulnerable

b. Option 2: Recommended per this proposal - PREFERRED OPTION

Advantages

• Release capacity in the *Surgical Day Unit (SDU) or Inpatient Wards (*delete as appropriate)
• Create additional capacity for IR day cases - creating an approximate *** additional IR cases per annum and assisting with RTT targets avoiding associated fines
• Improve patient safety - due to specialist IR monitoring post procedure
• Improve patient experience - due to improved waiting times and familiarity of IR procedures by IR daycase staff 
• Improve service efficiency and patient flow issues (decreased downtime, cancellations due to patients arriving late from admitting wards and overruns)
• Brings *** Trust IR service structure and provision in line with other IR units nationwide
• Brings additional activity to the Trust due to increased efficiencies
• Allows staff development in recovery care, the opportunity for extended roles and education, which in turn improves staff satisfaction, recruitment and retention
• Ensures *** Trust is aligned with national strategic fit and GIRFT recommendations for daycase surgical provision preventing it from being an outlier

Disadvantages

• Additional capital and revenue costs to the Trust.

11. Alternative Approaches Considered: (why do we need to take this approach – what alternative to achieving the goals have been considered. Please spell out the consequences relating to each of the alternatives of not implementing the proposal.)

By not offering this service development:

1. There is a potential negative impact on revenue budgets if clinical demand cannot be met as patients may require referral out of area
2. Inability to meet RTT targets may incur hospital fines
3. Lack of capacity may limit future innovations and service improvement within the IR Specialty - with a negative impact on comprehensive clinical care provision, limiting patient choice (postcode lottery), and staff employment (recruitment and retention)
4. Clinical pressures to all areas (SDU, Inpatient Wards, IR), in the midst of COVID recovery, will continue. If further waves ensue, opportunity for strengthening clinical workflow pathways to counter pandemic impact will be missed.

12. Option Scoring

Option1

Option 2

Option 3

Option 4

Description

Do nothing

Recommended

↓ Scoring Criteria (/10)

Criteria 1

Reduce waiting times/RTT

Criteria 2

Improve patient experience

(GS-PEQ)

Criteria 3

Increase IR throughput whilst increasing SDU/inpatient capacity

Total

13. Quality Impact Assessment on Preferred Option

Area of Quality Description of Quality Impact (list all applicable in each section)       Quality Aim (Improve, Maintain, Reduce)        Quality Metric  Impact if not achieved (1-5)     Likelihood of not achieving (1-5)            Risk Rating      Monitoring Arrangement

Patient Experience

• Improved patient safety due to specialist monitoring post procedure
• Improved patient experience due to reduced waiting times and improved patient flow
• Quality metrics: Patient Experience Questionnaire (GS-PEQ), VAS pain scores and other standard hospital metrics

Patient Safety 

• Reduced complications rates and shorter recovery/discharge times. Prospective audit on clinical outcomes

Patient Outcome

• Additional capacity for IR and SDU/Inpatient Wards which will help to meet RTT and avoid associated fines - RTT figures from CCG

Performance

• Creates additional capacity for IR and SDU/Inpatient Wards which will help to meet RTT and avoid associated fines
• Decrease in downtime and cancellations due to patient delays from other clinical areas - patients receive timely clinical care
• Decrease IR list overruns - less impact on staff tiredness and goodwill
• Helps to reduce waiting times and backlog, and any associated clinical risks.

14. Outcome Measures

Additional Activity

HRG

Volume

OPD

Volume

New

FUP

Key Performance Indicators

Date(s) Delivered

Unplanned overnight admission

Re-admission rates (including A and E)

Length of stay

Post-operative GP visits

Index procedures

Key Quality Indicators (CQUIN, risk management etc)

Date(s) Delivered

Key Patient Indicators (PROMS, survey results, audit results)

Date(s) Delivered

Satisfaction questionnaire (GS-PEQ)

15. Financial commentary: (Additional explanatory comment for the table above. Has purchaser support been sought or agreed?)

16. Timetable: When could the development be implemented? This should include an assessment of procurement time required, capital build etc.)

Milestone 1

Milestone 2

Milestone 3

Estimated Project Commencement Date

Estimated Finance and Performance Committee Date

17. Extent of Purchaser / Commissioner Interest? (Has the purchaser instigated this, are they aware of it)

18 Please indicate extent of patient and public involvement in support of the proposal if applicable.  Has any involvement been sought or views obtained from governors and PPI forums? Has the level or public consultation required been determined?

19. Strategic Fit:

Please tick (✓) which of the following strategic objectives or quality priorities are supported by this proposal

Valuing our Staff - Recognising the contribution of our staff and helping them develop and achieve their potential

✓

Improving Quality and Reducing Harm - Focusing on continuous improvement and reduction of waste

✓

Strengthening Team Working - Developing and strengthening Team RBCH to deliver safe and compassionate care for our patients and shaping future health care across Dorset

✓

Listening to Patients - Ensuring meaningful engagement to improve patient experience

✓

Hospital Flow

✓

Escalation of the Deteriorating Patient

Sepsis

20. Impact on support services: Outline any impacts on support services, i.e. portering, housekeeping, other facilities, estates, etc. either during implementation (non-recurrent) or ongoing (recurrent).

Is there any impact on support services?

Reduced demand on SDU/inpatient beds and associated clinical staff

No requirement for escort nursing

No requirement for portering services

Increased demand on housekeeping needs and food services

Increased demand on maintenance.

If Y, please provide details of support services agreed:

Further consultation will be required to finalise demand and service provision required once bed numbers confirmed.

Is there any support required from IT? IT hardware and support for access to patient electronic records.

If Y, please ensure you have raised an IT Change Request (using the e-form on the E-Forms portal) in advance of submitting this business case.

Projects requiring Facilities support need to have their support agreed prior to submitting the business case; this includes agreeing a figure for any resulting costs. For Facilities please contact the Facilities Deputy Manager.

Please note that it is the responsibility of the Concept Paper Originator to ensure that costs incurred by support services as a result of the project are recorded in Section 3 of this form. All such costs will be charged to the project.

21. Equipment Information: To be completed for all equipment (or other purchasing) proposals:

It is the Directorate’s responsibility to ensure that the relevant competency based training has been put in place for the staff that will be using this equipment and that the financial implications of this are included within this submission.

1. Please confirm that you have obtained any indicative costs via procurement and have been advised by your procurement lead of the appropriate purchasing process for this requirement.
2. b. Name of procurement contact who is fully engaged on this project:

Please note that this bid will not proceed unless you have involved procurement

Please attach indicative quotations for equipment, maintenance and consumables

c. Total Lifetime cost:

Total of capital equipment, plus 5 years maintenance and consumables. £………

NB If equates to over £181k then will require OJEU tender.

d. Maintenance costs: Are there any maintenance costs for this proposal:

If Y, please ensure these are included in the financial summary table on page 1

Please indicate where the maintenance charges will be funded from:

e. Consumables: Are there any consumables costs associated with this equipment

If Y; Please include in lifecycle cost. If these costs are incremental costs, please include in financials table on p1.

f. Asset life: Number years asset life for the new equipment:……..

Please ensure capital charges are included in the financials summary table on page 1. Note applies to all capital except charity funded.

22. Sustainability Considerations: to be completed for all papers

Please briefly describe how the proposed project will improve/ has taken into account the following considerations:

a. Operational:  (direct cost savings, reduced material inputs/ waste, reduced utility costs etc.)

Reduced demand on SDU/Inpatient Ward beds

Reduced demand on hospital inpatient stay days for treatment

Reduced demand on anaesthetic pre-assessment service provision

b. Social:  (increased staff wellbeing, stakeholder relations, promotes health, sustainable food etc.)

Closer working between two clinical areas (even when using the same clinical team), IR theatres and an IR daycase unit, will promote continuity of care and a holistic team approach to the patient care pathway - building on the Trusts aim of ‘Strengthening team working’* (*adapt to local strategic aims)

Opportunity for staff to get involved in new patient pathways and treatment offering an exciting streamlined service to the *** population.

Staff development - the opportunity to learn and develop highly transferable skill sets (recovery and daycase care provision) to diversify the nature of work undertaken, contributing to staff retention by promoting personal development, motivation and enthusiasm

Improving patient recovery and quality of life is the key component to ensure optimal patient health and fitness, and mental well-being - thus promoting overall health and welfare

c. Brand/ Reputational: (risk management, legislative compliance, increased awareness, Good Corporate Citizenship etc.)

Ensures Trust is seen to provide ‘state of the art’ and GIRFT compliant Daycase IR services to a wide patient group, many of whom are still working and physically active - fulfilling the Trusts strategic aim of ‘Improving quality and reducing harm’* (*adapt to local strategic aims)

Shows the Trust is listening to patients (large local demand for daycase procedural intervention to allow recovery at home) - offering patient choice, particularly to those who are either still working or do not wish to stay overnight in hospital evidence based by ‘Otte DI. Patients’ perspectives and experiences of day case surgery. J Adv Nursing 1996; 23: 1228-1237’. (*if you have any evidence of this from local audit or PPI work also include)

Opportunities to enhance brand reputation through research and collaboration with other centres in proposed multi-centre trials if capacity allows

d. Carbon Reduction/ Environmental: (energy efficiency, waste minimisation, travel minimisation etc.)

Day case procedure - minimal travel and reduced energy requirements as overnight stay not required

Increasing capacity of IR and continuing the introduction of newer IR innovations for minimally invasive procedures will reduce need for higher energy/waste procedure such as robotic surgery.

23. Equality Impact Assessment: to be completed for all papers except “like for like” equipment.

Please note that it is the responsibility of the concept paper originator / project lead  to undertake an EIA screening exercise on this project PRIOR to this form being submitted, (unless this is for “like for like” equipment replacement, in which case an EIA is not required). Audits will be undertaken to ensure compliance.

Yes/No

Rationale

The ‘Rationale’ box must be completed whether the answer is Yes or No

1. Does the proposal affect one group less or more favourably than another on the basis of:

• Race

N

• Gender (including transgender)

N

• Religion or belief

N

• Sexual orientation, to include heterosexual, lesbian, gay and bisexual people

N

• Age

N

• Disability – learning disabilities, physical disabilities, sensory impairment and mental health issues

N

• Marriage and Civil Partnership

N

• Pregnancy and Maternity

N

2. Does this proposal affect an individual’s human rights?

N

3. If you have identified potential discrimination, are the exceptions valid, legal and/or justified?

N/A

If you answered “No” to Q3: You must refer this project to the Diversity Committee (email to Catherine Paton, HR Dept). You may still proceed with submitting this business case to the Review Panel and other committees within the business planning process, but any outcome of those committees will be subject to the review by the Diversity Committee.