NLG(18)099. DATE OF MEETING 27 March Trust Board of Directors Public REPORT FOR. Dr Kate Wood, Acting Medical Director REPORT FROM

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1 NLG(18)099 DATE OF MEETING 27 March 2018 REPORT FOR Trust Board of Directors Public REPORT FROM Dr Kate Wood, Acting Medical Director CONTACT OFFICER Jeremy Daws, Head of Quality Assurance Jan Lowry, Improvement Delivery Manager SUBJECT Mortality Improvement Plan BACKGROUND DOCUMENT (IF ANY) Monthly Mortality Report PURPOSE OF THE PAPER: EXECUTIVE SUMMARY (PLEASE INCLUDE A BRIEF SUMMARY OF THE PAPER, KEY POINTS & ANY RISK ISSUES AND MITIGATING ACTIONS WHERE APPROPRIATE) For Assurance The paper provides an update on the Trust s current mortality improvement plan focusing on the outcomes from the first Mortality Improvement Group meeting held on Friday 9 March 2018 and key outcomes from this meeting including: Setting of the terms of reference, Agreement for the group to meet fortnightly, Initially to be chaired by the Acting Medical Director, Clinical attendance agreed, including AMDs (or representatives) from each group, Consideration for the inclusion of trainee grade doctors and GPs, Confirmation of two clinical leads for mortality, Dr Kamath at DPoW and Dr Balchandra at SGH. The mortality improvement plan was reviewed and the following items were confirmed: Reinforce the use of safety huddles (Tara Filby) Deteriorating patient and sepsis (to also include Acute Kidney Injury, Critical Care Outreach) (Jenn Orton) Hydration (Tara Filby) Medical assessment (including board rounds, specialty inreach) (Dr Baugh, Dr Ali, Dr Mysore) Multi-disciplinary Team learning from mortality Structured Judgement Reviews (Dr Kamath) Consultant of the week model (Dr Baugh, Dr Ali, Dr Mysore) Engagement, awareness and understanding (Dr Kate Wood) Patient flow (a critical element but covered by other Workstreams under Improving Together) In addition, several other elements were felt by the group as needing to be included within the improvement plan, these were: Specific focus on learning lessons from mortality case note review and sharing this learning with front line clinicians, Inclusion within the plan of a coding/information quality work stream to focus on the data components that are crucial to the SMR mortality indicators. The Improvement Team PMO will provide project management oversight to the Mortality Improvement Plan including all of the above Workstreams. Project delivery support will be provided by the Quality Assurance Team, in the Directorate of Governance & Assurance. The Improving Together Mortality Board Highlight Report is included as appendix 1. HAVE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS?

2 ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? NO IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? NO WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE? THE PROPOSALS OR ARRANGEMNTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) YES LINKS TO QUALITY & SAFETY THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER ENSURE COMPLIANCE WITH THE REGULATORY OR GOVERNANCE REQUIREMENTS LISTED THE PROPOSALS OR ARRAGEMENTS OUTLINED IN THIS PAPER TAKE ACCOUNT OF REQUIREMENTS IN RESPECT OF EQUALITY & DIVERSITY ACTION REQUIRED BY THE BOARD The Board is asked to note the contents for assurance purposes.

3 Medical Director s Office Mortality Improvement Plan: Update 1. Mortality Improvement Group Oversight arrangements The Mortality Improvement Group has been established and met for the first time on Friday 9 March This was later than had been planned, with the first meeting scheduled during February having to be cancelled due to extreme operational pressures. The first meeting reviewed and set the terms of reference, key points included: Group to meet fortnightly to begin with until established and reporting and oversight arrangements established, To be chaired initially by the Acting Medical Director, Attendees to include AMDs (or deputies) from each group, alongside work stream leads with support from coding, information and improvement teams, Consideration is also being given to the inclusion of a trainee grade doctor and also a GP, following feedback from the Trust s Governors at a recent stakeholder event, Confirmation of two clinical leads for mortality, one at either site (DPoW: Dr Kamath, Consultant in Elderly Medicine and SGH: Dr Balchandra, Consultant in Obstetrics & Gynaecology). The group will oversee the reporting of mortality and understanding of trends and relevant analyses. The group received an update on two mortality outlier alerts, one from CQC and the other from the Dr Foster Unit at Imperial College London. Both relate to different cardiology diagnoses. The Trust is in the process of investigating and will respond to CQC by the stated deadline of the 23 March. The outcomes of both will be reported to the Mortality Improvement Group. 2. Mortality Improvement Project Plan The priorities within the improvement plan were reviewed and confirmed by the group as follows: Reinforce the use of safety huddles (Tara Filby) Deteriorating patient and sepsis (to also include Acute Kidney Injury and Critical Care Outreach) (Jenn Orton) Hydration (Tara Filby) Medical assessment (including board rounds, specialty in-reach) (Dr Baugh, Dr Ali, Dr Mysore) Multi-disciplinary Team learning from mortality Structured Judgement Reviews (Dr Kamath) Consultant of the week model (Dr Baugh, Dr Ali, Dr Mysore) Engagement, awareness and understanding (Dr Kate Wood) Patient flow (a critical element but covered by other work streams under Improving Together) In addition, the group approved a number of other improvement work streams to be added to the mortality improvement plan, these were: Specific focus on learning lessons and sharing the learning from mortality case note reviews: o Online learning, o Ward based morbidity and mortality meetings with the mortality clinical leads working with clinical teams to establish and adopt effective arrangements, o External learning events with CCGs/GPs, wider community forums.

4 Specific inclusion in the work plan of coding and information quality : o Co-morbidities being carried forward from previous episodes & inclusion as part of the electronic patient record in WebV or SystmOne, o Mortality clinical leads and coding manager to visit local Trusts with effective clinician and coder relationships, o SystmOne access for front line clinicians. These work streams are being collated together within an Improving Together project workbook. Support to the Project Management and Project Delivery: The Improvement Team PMO are in the process of supporting the scoping of these individual priorities, and due to the scale of the work, have advised that each of these, whilst sitting beneath the Mortality Improvement Project umbrella need to have their own project workbook. The Improvement Team will support the scoping and project management now underway. Support will be offered to the project in terms of supporting the delivery of the plan from the Directorate of Governance & Assurance, specifically from the Quality Assurance team. This support will consist of data analytics (through the recruitment of an analyst post underway) both of the data collected by clinicians undertaking case note review work, to support learning from mortality work, and of existing data systems (i.e. DATIX incident reports) and audit resource to help provide greater understanding of the data and provide assurance. This support is being provided now, focussed at present on the Multi-disciplinary team learning from mortality Structured Judgement Reviews. Dr Kate Wood 19 March 2018 Appendix 1: Mortality Board Highlight Report March 18

5 Next RAG Current RAG Previous RAG Workstream: Quality and Safety - Mortality Senior Responsible Officer: Tara Filby Month: March 2018 Improving Together Board Update Project Risk Rating Blue Green Amber Red Project Title Complete and embedded. Completed. Not yet fully embedded/evidenced. In progress/ on track. Not yet completed/ significantly behind agreed timescales. Comments (explanation of RAG, progress update etc.) QS5 Mortality QS5.1 Deteriorating Patients and Sepsis A A All handhelds now rolled out in all areas, 5 x tablets for Sepsis screening will be piloting on SAU DPOW from w/c 19 th March x part time band 6 appointed with a start date of 19 th and 24 th March to focus NEWS 2 implementation and DP/Sepsis dashboards. NEWS2 roll out will commence 9 th April 2018; a Comms plan is currently being drawn up to ensure that every person with clinical input is fully aware. NEWS/OEWS KPI performance gauges being developed by Robin Howes. QS5.2 Critical Care Outreach A Phase 2 Improvement Team support now assigned to set up project. First meeting will be held on 23 rd March QS5.3 Learning from Deaths A Phase 2 Improvement Team support now assigned to set up project. First meeting will be held as part of the revised Mortality oversight group to be held on 9 th March QS5.4 Clinical Leadership of Mortality A Appointed Clinical Lead for DPOW, awaiting appointment at SGH, mortality governance group to be convened in February Issues For Escalation Financial Delivery None. 1

6 Workstream: Quality and Safety - Mortality Senior Responsible Officer: Tara Filby Month: March 2018 Level 1 KPIs Ref 1 Date Risk Added Risk Description RAG Mitigation/Controls Date Mitigation Occurred Some of the work stream projects remits have grown since we audited milestones within plans A (10) Test of each project plan (phase 1) with PMO lead to focus capacity onto key priorities within each work stream RAG G (3) 2

7 Workstream: Quality and Safety - Mortality Senior Responsible Officer: Tara Filby Month: March Data quality and/or audit methodology of level 1 and level 2 KPIs is not robust R (20) 1. Review all level 1 KPI s for effectiveness 2. Data collection method identified for each KPI 3. Data validation method agree for each KPI 4. Develop data dictionary for all KPI s (previous actions undertaken) Capacity of workstream leads to deliver improvements at pace required. The Deteriorating Patient project has incorporated the Sepsis workstream. This has increased the size, complexity and priorities in the project. Specific risks areas include compliance with Sepsis Training ( 34%); % of death certificates that may inappropriately identify sepsis as primary cause of death; inappropriate anti-biotic use; assessment of likely patient harm due to non-escalation; the sepsis pathway needs further development in ED to capture self-presenting patients. R (20) Consideration of additional resource from PMO and using NHSI agreed funding. An audit of medical notes is being conducted ( completion due 17/11/17) which will identify current performance against national standards and likely barriers to compliance. Recommendations will be made for ward level action plans by 31/11/17. Escalated to SRO for dedicated project resource to accelerate delivery. A (12) A (8) 4 5 Sepsis 6 - Need to ensure that Sepsis 6 bundle is compliant in all areas (within 1 hour receive all 6 elements) Progress is being potentially hampered by operational pressures/opel 3 which is focussing key staff members time on managing operational issues R (16) A (12) Both A&E to have discussions regarding process and also look at what we are auditing when looking at sepsis screening need to ensure that staff are understanding national standards. Divisional nurse leads and project managers asked to prioritise key meetings or use other opportunities to engage/feedback A (12) G (3) Risk Rating Matrix None/Near Miss (1) Severity / Impact /Consequence Low (2) Moderate (3) Severe (4) Catastrophic (5) Likelihood of recurrence Rare (1) Unlike (2) Possible (3) Likely (4) Certain (5)