Health Board 25 TH SEPTEMBER 2014 AGENDA ITEM: 3 (II)

Transcription

1 SUMMARY REPORT ABM University Health Board Health Board 25 TH SEPTEMBER 2014 AGENDA ITEM: 3 (II) Subject Prepared by Approved & Presented by Update on Implementation of the Andrews Report - Trusted to Care Joanne Davies, Action after Andrews Taskforce Leader Paul Roberts, Chief Executive Purpose To update the Board on progress with implementation of the Andrews Report Trusted to Care the independent review of care at Princess of Wales Hospital and Neath Port Talbot Hospital commissioned by the Minister for Health and Social Services in the Welsh Government to the Board four months post publication. Decision Approval Information Other X Corporate Objectives Excellent Population Health Executive Summary Excellent Population Outcomes Sustainable & Accessible Services Strong Partnerships Excellent People Effective Governance X X X X The Action after Andrews Taskforce has been working with colleagues across the Health Board to address the recommendations of the Trusted to Care report. This paper outlines progress against the work to give the Board assurance that care standards are improving in line with the timescales in the report so that confidence in the Health Board s services can be regained. Key Recommendations The Board is asked to: Note the progress made against Recommendation 1 and the achievement of the 3 month target for the development of clear standards for the care of frail older people and the plans to audit these from November 2014 onwards. Note the progress made against Recommendation 8 and the achievement of the adoption of a zero tolerance approach to the improper administration of sedation and medicines for all clinical staff, drawing a clear line in the sand within three months of the publication of the report. Note the progress to date on implementing the remaining 12 recommendations within Trusted to Care. Note the work which has been underway across the Health Board to ensure that care standards for patients receiving our services is improving while work on implementing the recommendations is still in progress. Note the progress to date in developing a Values and Behaviours Framework for the Health Board. 1

2 MAIN REPORT ABM University Health Board Health Board 25 th September 2014 AGENDA ITEM: 3 (II) Subject Prepared by Approved & Presented by Update on Implementation of the Andrews Report Trusted to Care Joanne Davies, Action after Andrews Taskforce Leader Paul Roberts, Chief Executive 1. PURPOSE To update the Board on progress with implementation of the Andrews Report Trusted to Care the independent review of care at Princess of Wales Hospital and Neath Port Talbot Hospital commissioned by the Minister for Health and Social Services in the Welsh Government to the Board four months post publication. 2. BACKGROUND At each Health Board meeting since the publication of the Andrews Report Trusted to Care there has been a report on progress against the recommendations and update on work to date by the Action after Andrews Taskforce. The report was published on 13 th May 2014 and so the 3 month deadline for achievement of some recommendations fell on 13 th August. The last report to the Health Board in July 2014 outlined progress as at 8 weeks post publication of the report and noted that feedback on the unannounced Ministerial spot checks would be provided at this Board meeting. These spot checks focused on the following four areas of care: In giving patients their medication; In ensuring that patients are kept hydrated; In the overuse of night-time sedation; and In basic continence care. 2

3 1. PROGRESS MADE AGAINST RECOMMENDATION 1 Recommendation 1 The Board should create a set of clear standards for the care of frail older people in Accident and Emergency, general medical and surgical wards within the two hospitals, within three months of receipt of this Report, and audit them quarterly thereafter. Summary of Progress to Date: Achieved Standards for the care of frail older people IN ALL SERVICES AND ACROSS THE WHOLE HEALTH BOARD have been developed by a consensus method through a series of staff and stakeholder workshops with external support from a Consultant Nurse from Kings College Hospital and the RCN s National Lead for Older People. Commentary on Progress to Date: To support the development of these standards an assurance framework was developed based on established best practice across and beyond the UK which was tested out on 3 wards initially by three teams representing different clinical and non clinical backgrounds and lay members. These teams spent a two day period, including early mornings (to observe handovers) and evenings (to observe meal times and interview visiting relatives). This process utilised the assurance framework alongside interviews with staff, patients & relatives to identify issues systematically in these wards which informed the process and the issues which needed to be included in the care standards. Staff agreed a structure based on the principles of person-centred care and domains of comprehensive old age assessment and recognition of frailty. They used the domains to develop process standard statements, from a service perspective. The standards then underwent amendment and scrutiny through a workshop engagement process with staff, patient groups and other key stakeholders from health, social care, education and third sector organisations. The outcome of this process was then written up as a set of standards in plain English and circulated to these stakeholders for further review & comment. As a result the standards were amended to reflect this feedback and are now being rolled out across the organisation. The standards are listed below: As an older person in hospital I expect that. I will be treated with dignity, care and compassion and supported to feel safe at all times If I have carers, their needs will be taken into account, and they will be involved in my care and discharge planning with my consent If I am in pain or discomfort, it will be recognised, and I will have help to manage it I will have choice about what I can eat and drink any time I wish and will be given support with eating and drinking if I need it. My skin will be looked after and not damaged If I am anxious or depressed, staff will recognise my mood, listen to me, and my carers, and support me to feel as well as possible I will be able to get to the toilet when I need it, but if I am incontinent, I can expect to feel clean, comfortable and dry (quickly) If I have difficulty understanding or expressing myself, this will be recognised, I will be listened to and supported to make choices and decisions by appropriately trained staff I will be able to move about easily and safely, or to be helped to do this comfortably I will have the right medicine at the right time My care will take account of any sight or hearing loss I may have If I am at the end of my life, my wishes and spiritual beliefs, and those of my carers, will be assessed and met wherever possible 3

4 Based on this work, the Health Board considers it has fully achieved the first deliverable against Recommendation 1 that is, the development of the standards for the care of frail older people. Next Steps: In order to keep the standards focused and in plain English the detail within them has been limited so they are not overly complicated. However it has been suggested that a set of more detailed guidance should be available alongside the standards to ensure that each statement is more fully explained so that there can be no misunderstandings regarding how they should be interpreted. For example this would give the opportunity to explicitly state that the standard relating to a patient s difficulty understanding or expressing him/herself could mean using different languages to communicate with patients, including sign language, or using large print documentation for those with sight loss. This work is now underway. In line with the Andrews Report recommendation 17, Welsh Government wrote to the Health Board in early August to ask us to develop a model dashboard and guidance for Board assessment of frail and elderly care for adoption across NHS Wales by the end of This links to the second component of action required under Recommendation 1 - the auditing against the standards for the care of frail older people quarterly which is on target for the timescale set in the report from mid November 2014 onwards. A task and finish group has been established within the Health Board to develop this model dashboard, which will be based on monitoring a range of outcome indicators to demonstrate adherence with the standards for the care of frail older people plus a range of other key performance indicators including measures of clinical outcome and those suggested in the Andrews Report which will be triangulated to give a rounded dashboard in draft form for Welsh Government to consider in October ABMU will then audit against these indicators as required for the second component of Recommendation 1 to the Health Board at its November meeting. The Health Board has written to Welsh Government in response to the request for work to be carried out on recommendation 17, outlining the proposed deliverables and timescales. 2. PROGRESS MADE AGAINST RECOMMENDATION 8 Recommendation 8 The Board should adopt a zero tolerance approach to the improper administration of sedation and medicines for all clinical staff, drawing a clear line in the sand within three months of the publication of this Report. Summary of Progress to Date: Achieved Never events defined upon publication of Andrews Report in May More than 2400 staff attended face to face briefings with the Chairman / Chief Executive / Chief Operating Officer within the first few days of publication where never events were clearly outlined and zero tolerance to these stressed. Commentary on Progress to Date: The never events were outlined upon publication of the Andrews Report in May 2014, but have been refined and further defined following feedback from staff, resulting in the following definitions of never events which must never happen in any of our hospitals: - Patients being given prescribed medication but then not being observed taking it ALWAYS observe your patient taking their medication. - Staff signing the medicines chart to say that a patient has taken medication when they have not seen this ALWAYS observe your patient taking their medication. Only then can you sign the medication chart. NEVER sign if you haven t seen. - Inappropriate use of sedation for aggression Understand why some patients 4

5 may become frightened or aggressive, and manage them compassionately. Only offer sedation if there is a clear clinical need (see Medication Guidance Documents). - Patients being told to go to the toilet in bed Respond quickly to toilet requests. Always respect your patient s dignity and privacy. ALWAYS offer a toilet or commode. If your patient has a continence need, use the All Wales Bladder & Bowel Pathway. - Patients not appropriately hydrated Offer your patient a drink at EVERY opportunity (unless on fluid restriction). Simplified guidance has been produced and widely disseminated throughout the organisation via Team briefings, intranet bulletins, screensavers, hard copy guidelines and flowcharts issued to all clinical areas and relating to these never events. These include flowcharts explaining access to medicines out of hours, managing patients who refuse medication, with and without capacity etc. A patient safety thermometer is being utilised to show monthly medicines management metrics, which will be linked into the work on the model dashboard outlined in (3) above. The Health Board s Pharmacist on the Action after Andrews Taskforce is participating in the national taskforce set up to look at medicines administration across Wales. Future policy guidance may result in a further adaption and adoption of the guidelines to support the ABMU Health Board s Medicines Policy for the administration of medicines in the acute setting (attached as Appendix A) All Pharmacy registrants have completed an on-line learning package, being followed by a series of face to face lectures delivered by WPPCE (will be complete by end September 2014). All Pharmacy registrants have received a letter from their Clinical Director explaining the requirements on them to identify, act on and provide guidance on medication issues. The Director of Nursing and Patient Experience has required all lead nurses to personally re-issue all nurses employed by the Health Board with details of their code of conduct and the requirements on them to ensure that never events do not occur. A clear process has been developed to ensure a standardised response when never events happen. In the first instance this involves a supportive learning discussion between the member of staff involved and their line manager explaining why this is a never event and why from a patient care and safety point of view it is completely unacceptable and constitutes substandard care which must not be repeated. This is important to ensure that the member of staff fully understands the consequences of their actions. However if a never event is then repeated by the same member of staff this is immediately dealt with through a fast-track disciplinary process as a professional practice issue. Because a number of never events were picked up in the initial months after the Andrews Report publication and some of these were carried out by agency nurses, guidance has been produced which has been issued to all agencies utilised by the Health Board, requiring them to brief all their nurses prior to them being placed in one of our hospitals, on never events and the zero tolerance to these. Feedback from staff on publication of Trusted to Care was that the major issue facing them and barrier to the zero tolerance of never events was not feeling able / supported to raise concerns / challenge practices. A series of staff briefings, screensavers etc followed on the need to speak up and for all of us to take action against unacceptable care. As a result of a staff suggestion, the See It, Say It campaign was developed to ensure that staff, patients, relatives and the public could raise concerns anonymously about poor care so that the HB could take action to resolve issues more quickly. This has involved establishing a dedicated address, text number and voic number so that the service is accessible to all. This went live in early August 2014 with 5

6 posters and pull-up banners being displayed throughout hospital sites. A steady flow of issues are being registered, passed on for action and feedback given if requested. Based on this work, the Health Board considers it has FULLY ACHIEVED the requirements of Recommendation 8 that is, adopting a zero tolerance approach to the improper administration of sedation and medicines for all clinical staff, drawing a clear line in the sand within three months of the publication of this Report. Next Steps: Work continues on an ongoing basis to enforce this zero tolerance approach to these never events, to ensure that all 16,200 staff of the Health Board adhere to these through a range of techniques including targeted training and the supported learning approach followed if required by disciplinary action. 3. PROGRESS MADE AGAINST REMAINING RECOMMENDATIONS Attached as Appendix B is a table detailing progress against the remaining 12 recommendations for the Health Board in the Andrews Report. Progress on each of these are being monitored against the programme plan which has a clear set of milestones for each recommendation to ensure that target timescales are achieved as set out in the report. Currently 10 of the remaining recommendations are progressing in accordance with their required timelines. However there are 2 recommendations where progress is slightly behind schedule. These are highlighted in the report and remedial action has been put in place to ensure that action can be accelerated to bring these back within the set timescales over the next month. 4. PROGRESS ON DEVELOPING THE VALUES AND BEHAVIOURS FRAMEWORK As the Board will be aware through the development workshops they have had facilitated by April Strategy, work is well underway on the leadership development programmes, In Our Shoes sessions for staff and just starting on the patient experience In Your Shoes workshops which are all key components of the programme plan and timeline for the development of the values and behaviours framework. Attached as Appendix C is a presentation prepared by April Strategy to update the Board on progress to date and further work planned. 5. WORK UNDERTAKEN TO IMPROVE CARE STANDARDS Whilst the above sections outline how the Health Board is ensuring that the recommendations included in the Andrews Report are achieved according to the timelines set of 3, 6, 9 or 12 months post publication, in the meantime the Health Board continues to treat hundreds of patients and has a duty to do all it can to ensure that the failings in care highlighted in the report are being addressed and measures put in place to identify poor care and to take action urgently to ensure the public can be assured that they will receive good care in future. 5.1 Out of hours spot checks programme To give assurance on care standards an extensive series of unannounced out of hours spot checks were instigated, from publication of the report, across the Health Board, by the Heads of Nursing and Corporate Nursing Team. These out-of-hours spot checks were carried out by staff from different clinical areas at different times during the evening, the night and at weekends. By the end of August 2014 a total of 63 of the wards in our four main hospitals and one community hospital 6

7 (Gorseinon) had spot checks undertaken out of normal working hours. Some wards had multiple spot checks, with in excess of 100 being carried out over 3 months. These included acute assessment areas, general medical, elderly care, psychiatric, cardiology, general surgery and orthopaedic wards. Feedback for most areas has been positive with key standards relating to dignity and privacy, hydration and nutrition, continence and medicines management being implemented. During these out of normal working hours spot checks five never events have been identified, mainly in relation to medicines management issues. As a consequence immediate action was taken, by those undertaking the spot checks. Feedback was immediately provided to the nurse in charge, and the nurse responsible for the never event. The Head of Nursing for the clinical area and the Director of Nursing were informed of the incident the following day to ensure the appropriate action was taken. A follow up, unannounced spot check has then been undertaken where never events occurred or where there were any areas for concern to ensure that practice and standards had improved. In addition to these unannounced spot checks, the Directorates and Localities continue to monitor key standards through their assurance visits and within working hours spot checks and feedback is provided to the Director of Nursing s Assurance Meeting which is held every two weeks. Since the publication of the report medicines management walkabouts by senior pharmacy staff have also been undertaken on all sites and are continuing as a regular feature with any deficiencies or issues being escalated to the ward manager / lead nurse as appropriate. Some general themes have emerged which include: The repetition and volume of documentation that clinical staff has to complete. The amount of data collection at Ward Level. Inconsistencies in some systems for the operational management of medicines at Ward Level. As a result, action is being taken in relation to rationalising the volume of nursing documentation and care metrics data collection. In addition Pharmacists have reviewed systems on Wards for the safe storage of medicines. 7.2 Introduction of 15 Step Challenge In order to widen the scope of unannounced visits to those other than nurses The 15 Step Challenge framework has been implemented and Executive Directors, Non Officer Members, Senior Clinicians, and Managers have been included in the programme of visits. The 15 Steps Challenge is a framework which has been co-produced with patients, service users, carers, relatives, volunteers, staff, governors and senior leaders, to help look at care in a variety of settings through the eyes of patients and service users, to help capture what good quality care looks, sounds and feels like. The 15 step challenge helps the organisation gain an understanding of how patients and service users feel about the care provided and what gives them confidence. It can also help organisations to understand and identify the key components of high 7

8 quality care that are important to patients, services users and carers from their first contact with a care setting. The 15 Step Challenge lasts approximately thirty minutes and provides the opportunity for the perusal of the Ward environment, and to observe whether it is welcoming, safe and calm. Those who are involved are encouraged to speak to staff, patients and visitors to ascertain dignity and respect is maintained. Both positive and negative feedback is provided to the Ward Sister following the walk around and any concerns requiring action by the senior operational management team is provided on the day, copying in the relevant Executive Director. 7.3 See It, Say It Campaign As outlined above the See It, Say It campaign was established based on a staff suggestion as a way of staff, patients, relatives and the public to quickly and easily highlight issues of concern so that action can be taken rapidly to address these and take remedial action where necessary. 7.4 Ideal Ward Assurance Framework Using the external expertise from the Consultant Nurse from Kings College Hospital and the National RCN Advisor for Older People a bespoke assurance framework has been developed focusing on care and patient experience for frail older people on 3 wards at Princess of Wales Hospital. This focused on accelerating progress on these wards to become ideal wards through taking action on training, multidisciplinary working, reducing paperwork, improving ward environments, flexible staff deployment, setting minimum standards of care and involving patients and families in their care. The approach used was to engage and empower staff, patients, visitors and stakeholders to recognise and meet the challenges presented. The Assurance Framework was based on a model originally developed by NHS London and tested in 3 acute hospitals in the region. It was then developed into a local model, drawing on Welsh guidance and triggers from Trusted to Care. The assurance framework is now being rolled out across the whole Health Board in two phases. The first phase has already started and will result in 17 wards having completed the assurance process including having action plans in place for resolving identified issues. This includes an additional 2 wards at Princess of Wales Hospital, 2 wards at NPT Hospital, 4 wards at Singleton Hospital and 6 at Morriston Hospital. These areas have been prioritised into Phase 1 either because they are areas where there have been concerns over care raised or where the majority of their patients are frail elderly. All other wards will be undertaken as Phase 2 and will have applied the Ideal Ward assurance framework by May Ministerial Unannounced Spot Checks In July 2014 Ministerial spot checks were carried out, initially at Princess of Wales Hospital and Neath Port Talbot Hospitals, and then a month later at Morriston and Singleton Hospitals. There were a small number of concerns escalated to the Chief Executive with an action plan for resolving these issues being submitted to Welsh Government the following day. The visits to the Hospitals in Swansea highlighted a number of immediate actions required which have now been addressed. 8

9 The detailed reports outlining the findings of these spot checks are expected in September but in the meantime urgent action is being taken to ensure that where concerns have been raised substantive action is being implemented so that the Board can be assured that any poor care identified has been addressed. Detailed below are the issues raised by these visits across the Health Board area alongside the action taken to address them: Princess of Wales Hospital Drugs fridge with no lock within locked room Neath Port Talbot Hospital No substantive issues raised Morriston Review patient care, including staffing levels, on Gowers Ward to ensure patient dignity is not compromised Change water jugs more than once a day on all wards Improve the considerable number of medicine management, including prescribing, storage and administration issues Temporary lock fixed to fridge. New lockable fridge on order. Staffing on Gowers Ward is in line with CNO Guiding principles. A new Ward Manager has been assigned to the ward with structured support from the Lead Nurse &Senior Nurse. The Health Board s HR team are currently undertaking a team building exercise with the ward team. From October 1 st Senior & Lead Nurses within medicine will have a changed working pattern to cover evening shifts and some nights on both Morriston and Singleton sites. Ward Managers will also be working some weekends. The Discharge Lounge, currently located, in the first bay of Gowers Ward will be relocated to another area in October 2014 which will allow Gowers to revert back to its planned template removing the bay at the far end of the ward which was identified as a potential patient safety risk. Water jugs will now be changed twice daily. We will audit this through our own continuing spot checks. All staff have been reminded of the requirement to manage the storage of medication according to Health Board policies and to ensure that drug cupboards, fridges and treatment rooms are locked. This has been re-iterated to all Pharmacy staff working in the Ward environment. At August induction all Junior Doctors have been reminded of the need to write clearly and the issues highlighted by the Andrews report were covered in a presentation given by pharmacy staff. The presentation also addresses the requirement to undertake VTE risk assessment, and consideration is also being given to pharmacy colleagues providing support to all grades of doctors via the delivery of local seminars on medication ad prescribing. The ward based pharmacy teams are working closely with ward staff to ensure medication is available on wards and if a new prescription is 9

10 Review the description of the wards against their actual function and the care delivered Review staffing levels and the holding of vacancies Address the poor photocopies of nursing documentation and assessments Improve the poor barrier nursing techniques and aseptic techniques during dressing changes observed on Ward S written out of hours, ensuring that they know how to access the medication to avoid missed doses. They are also following up on any unsigned boxes on ward drug charts. Contact has been made with Allan Wilson who has offered the support of 1000 lives to undertake a failure event mode analysis and a meeting to discuss this is currently being arranged. In relation to the broader storage/environment matters, the findings of the review team will be communicated to the Medication Administration Storage and Recording Task Group chaired by Roger Walker on behalf of Welsh Government. We believe that many of the issues identified by the review team such as ward based dispensing areas, standards for medication storage cupboards, the use of drug trolleys etc will be common to other Health Boards in Wales and a wider discussion on how these should be addressed will be beneficial. If necessary we will instigate this process. This comment specifically relates to Ward F and FEAU. Ward F is the Acute Stroke Unit at Morriston Hospital but also currently houses six Neurology Beds. As part of the Health Board s IMTP there is a plan to make Ward F the stroke unit for Swansea which will include a relocation of the neurology beds within the hospital. The role of FEAU is currently being reviewed and a patient flow audit has been undertaken examining the pathway for medical patients aged 80+ admitted to Morriston Hospital. The results of this audit will be used to inform the review but it is likely that the current unit will be re-designated as Acute Medical Unit with the Frail Elderly Team providing a daily MDT for those patients who meet frail elderly criteria and who would benefit from MDT input. The Health Board is not holding any nursing vacancies. All wards visited are staffed in accordance with CNO Guiding Principles. All vacancies are proactively recruited to and temporary nursing resource used to fill any gaps via Bank & Agency. The newly appointed Nurse Director has established a task & finish group to review current nursing documentation with a view to making this more succinct. In the interim Lead Nurses will review documentation to ensure it is of appropriate quality. The Head of Nursing for Ward S has addressed the issue of poor barrier nursing techniques with the individual nurse concerned. The Infection Control Team have undertaken teaching and education sessions for all ward staff. Staff compliance with 10

11 Singleton Change water jugs more than once a day on all wards Improve the considerable number of medicine management, including prescribing, storage and administration issues Review the staffing levels on Ward 3 & 4 Poor and inaccurate directional signs to wards Poor condition of nurse call systems and lights not working on Ward 3 Equipment available to meet the needs of patients on Ward 4 Improve the poor quality of nursing documentation available and its completion hand hygiene training is now 100% and staff compliance with standardised infection precaution training is also 100%. Water jugs will now be changed twice daily. This will be audited through our own continuing spot checks. See above. Wards 3 & 4 are staffed in accordance with the CNO Guiding Principles. In September a twilight shift will be introduced to enhance staffing during this period. The All Wales Acuity Tool has been completed for these wards and these results are currently being reviewed. All vacancies are being actively recruited to. We recognise that the directional signs at Singleton Hospital need to be reviewed and updated. A Task & Finish Group has been established to take forward this work which will report by end of September All lights are now working. The Nurse Call system at Singleton Hospital has been tested by the Estates Department and is fully functioning. The system will be upgraded as part of the ward refurbishment programme. Raised toilet seats have now been purchased. 4 steady hoists are available on this ward which the Ward Sister and Occupational Therapist consider adequate to meet patient need. See above. 7.6 Review of Governance Arrangements The Chair and Chief Executive are already taking forward a fundamental review of the arrangements that are in place at a strategic level to ensure that the governance and accountability arrangements that are in place across all our services are robust and operating as intended. To complement this the Medical Director and Director of Nursing & Patient Experience have commissioned a review of the governance and accountability arrangements at Locality and Directorate level. Work is underway on this review, with a report on findings expected by end of December

12 6. RECOMMENDATIONS The Board is asked to: Note the progress made against Recommendation 1 and the achievement of the 3 month target for the development of clear standards for the care of frail older people and the plans to audit these from November 2014 onwards. Note the progress made against Recommendation 8 and the achievement of the adoption of a zero tolerance approach to the improper administration of sedation and medicines for all clinical staff, drawing a clear line in the sand within three months of the publication of the report. Note the progress to date on implementing the remaining 12 recommendations within Trusted to Care. Note the work which has been underway across the Health Board to ensure that care standards for patients receiving our services are improving while work on implementing the recommendations is still in progress. Note the progress to date in developing a Values and Behaviours Framework for the Health Board. 12

13 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 Guidelines to support the Health Board s medicines policy for the administration of medicines in the acute setting. 1. Purpose of the supporting guidelines Practitioners authorised to administer medicinal products are accountable for their actions and omissions. In administering any medication, they must exercise their professional judgement and apply their knowledge and skill in a given situation. The purpose of this document is to inform all practitioners of their responsibilities in the safe and effective administration of medicines to a correctly identified patient. It specifically relates to the administration of medicines prescribed on Inpatient Medicines Administration Records (IMARs) [also known as the All Wales Drug Chart] and supplementary charts. The aim of this document is to provide clarity on the main issues concerning the safe administration of medicines. Further detailed information is contained within the ABMU main medicines policy i.e. the Policy on Prescribing, Supply, Ordering, Storage, Security, Administration and Disposal of Medicines. 2. Who does it apply to? This guideline applies to all practitioners who are authorised to administer medicinal products, these being: o Registered nurses o Midwives o Non-medical prescribers o Medical or dental officers o Registered Operating Department Practitioners (RODPs) This guideline does not apply to administration under Patient Group Directions, for which there is a separate ABMU Health Board policy. Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

14 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June Procedure prior to administration of medicines 3.i Be certain of the identity of the patient Check the name of the patient against the patient s IMAR. Check the hospital number and date of birth against the wristband and a verbal check of name and address. o If verbal confirmation of identity is not possible then try to get a second practitioner to confirm the identity of the patient. o Where there are difficulties in clarifying a patient s identity, an up-todate photograph should be attached to the prescription chart(s). Then, for each medication prescribed on the IMAR: 3.ii Check that the patient is not allergic to the prescribed medicine. If there is reason to suspect that a patient may be allergic to a prescribed medicine, then the matter should be referred to a member of medical staff to confirm whether the dose should be given or an alternative prescribed. Cross-reference to the allergy status on the front of the IMAR. 3.iii Read the prescription for the medication carefully. If there is any doubt about any aspect of the written prescription e.g. o Name of the drug o Dosage o Route o Time or frequency of administration o Legibility of the prescription o Not signed by an authorised prescriber the prescriber or designated out of hours medical officer must be contacted to clarify the prescription. Be aware of the therapeutic use of the medicine to be administered, its normal dosage, side effects, precautions and contra-indications. Be certain that the prescribed dose has not already been administered. Check that any stop date or review date for the medicine has not been passed e.g. antibiotics, potassium supplements. If they have been passed, refer to a member of the medical staff to establish the action to be taken. Take note of any special instructions relating to the medicine to be administered e.g. need to be taken with or after food, taken while standing upright. There are occasions when a patient s medication is delayed for clinical reasons e.g. for oral medication that must be taken with or after food. o The nurse must note that he/she needs to return to the patient to administer the dose later, with due regard to the administration time stated on the IMAR. Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

15 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June iv Select the medicine required Check the selection of the medicine. o Use caution with medicines which have similar packaging and similar names. Check the expiry date of the medicine to be administered. Repeat processes 3.ii to 3.iv for all medications on each section of the IMAR (i.e. Regular Medicines, As Required Medicines, Intravenous and Subcutaneous Infusions and the Prescription for once only medications) and any supplementary charts. 4. Procedure for the administration of medicines 4.i Administer the medicine to the correct patient. 4.ii Witness the patient taking their medicines. Do not leave medicines at the side of the bed to be taken unsupervised sometime later. 4.iii Sign for medicine administration on the patient s IMAR only after witnessing the medicine being taken. When supervising a student nurse or student midwife in the administration of medicines the Designated Practitioner must clearly countersign the signature of the student. A second person check will be required for the administration of: Controlled Drugs (schedule 2 and 3) medicinal products to children 16 years of age and under. All drugs via the parenteral route. The second person may be a registered nurse, pharmacist, RODP, radiographer Senior 1, medical or dental officer. 4.iv Report any adverse effects, or if any contra-indications are discovered. The prescriber or another authorised prescriber must be contacted without delay where contra-indications to the prescribed medicine are discovered, where the patient develops a reaction to the medicine, or where assessment of the patient indicates that the medicine is no longer suitable and a record made in the patient s notes. If deemed appropriate, an adverse drug reaction of side effect should be reported via the Yellow Card Scheme. 4.v Delegation of administration Unless there is a written protocol which has been officially agreed and implemented in accordance with the Medicines Policy to authorise others to Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

16 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 administer medicinal products to patients in specified circumstances, medicinal products must only be administered by registered nurses, midwives, non-medical prescriber s, RODPs, or dental officers. In delegating the administration of medicines to unregistered practitioners, it is the registered practitioner who must apply the principles of administration of medicinal products. They may then delegate to an unregistered practitioner to assist the patient in the ingestion or application of a medicinal product. It is the responsibility of the registered practitioner to ensure that a record is made when delegating the task of administering medicine. 5. Procedure for the non-administration of medicines 5.i If a patient refuses to take a medicine, or the medicine is not administered, the appropriate record must be made on the Patient s IMAR. The non-administration of medicine code numbers used on the all- Wales IMAR are: X. Prescriber s request (completed by prescriber only) 2. Patient not on ward 3. Patient unable to receive medicines/or no access 4. Patient refused medicine 5. Medicine unavailable 6. See Notes 5.ii Along with documenting the chart with the appropriate non-administration number, the following actions should be undertaken according to the code endorsed. Code 2: Patient not on ward When a patient returns to the ward (or on the next medicine round), it should be determined whether it is appropriate to administer the missed dose. This must be discussed with the prescriber and further advice should be sort from the pharmacist if required. o o o If deemed appropriate to administer the delayed dose, the time of administration should be documented on the chart, along with the signature of Designated Practitioner giving the medication. If deemed appropriate to omit the dose, this should be documented in the notes. Consideration must be given to those medicines where failure to administer in a defined time period would have adverse effects on patient care. Examples include, Anti-Parkinsonian Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

17 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 medication, anti epileptics and IV antibiotics. In this situation arrangements must be in place to ensure the continued administration of the medication at the times specified on the IMAR. Code 3: Patient unable to receive medicines/or no access The reason(s) why the patient is unable to the receive medicine(s) should be documented in the notes. The prescriber must be notified, as there may be alternative methods of drug administration to overcome the issue. Further advice may be obtained from the pharmacist if required. Code 4: Patient refused medicine The wishes of patients who are able to consent to receive medication but refuse to do so must be respected, even if this could have an adverse effect upon their condition. The refusal of a patient to take their medication must be discussed with the prescriber and the action taken recorded in the patient s notes in addition to the IMAR. When a patient has refused to take their medicine, whether they understand their actions or not, the medicine must not be disguised in food and drink. Where refusal is related or suspected to be related to capacity issues health practitioners must bring this to the attention of the senior medical and nursing staff. Refer to the guide in Appendix 1. Code 5: Medicine unavailable If Code 5 is entered, then the action taken to obtain the medicine and prevent further missed doses must be documented. o o The Flowchart in Appendix 2 offer guidance for obtaining medication during and outside pharmacy opening hours. All ABMU hospitals have an Emergency Drug Cupboard (EC) that may be accessed to obtain non-stock drugs outside of normal pharmacy opening hours. Follow this link to access the lists of drugs held at each EC of hospitals in ABMU. The process of accessing the EC in the ABMU hospitals is outlined in Appendix 3. Code 6: See notes If the reason for non-administration does not fall into any of the above categories, the chart should be endorsed with a code 6, and the reason for non-administration recorded in the patient s notes. o For example, this code may be used where the registered practitioner decides to withhold a medicinal product in the Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

18 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 context of the patient s condition (e.g. digoxin not usually to be given if pulse below 60) and co-existing therapies e.g. physiotherapy. 5.iv Recording of self-administration of rescue medications Certain medicines that are used for the acute relief of symptoms (e.g. GTN spray or tablets, reliever inhalers) are left in the possession of the patient to use, as required, when this is appropriate as detailed in the main ABMU Health Board Medicines Policy. The use of these medications are exempt from the definition of a never event (see point 6) if they are marked as having been taken on the drug chart without it having been witnessed, providing the following apply: There has been completion of an assessment of patient competency recorded in the nursing notes. The drug is marked (self medication) alongside the prescription entry in the drug chart. A record of the patients self administration is made on the inpatient medication chart, so that the frequency of use is recorded. 6. Never events with regard to medicines administration In relation to the Trusted to Care report, nurses should never: Sign the IMAR to indicate that a drug has been taken without witnessing its administration, unless: o a patient is self-administering medicines in line with the ABMU Self Administration of Medicines Policy, or o the nurse is recording the self-administration of rescue medications (see 5.iv). Leave medicine pots containing medication unattended at the patient bedside. 7. Oral nutrition supplements and enteral feeds These products are not administered as other medication but can be taken in different volumes and over varying time periods. Oral Nutritional Supplements The nurse signs to indicate that the supplement has been delivered to the patient bedside and the patient understands how to take the supplement. The nurse must then record the volume taken on the All Wales Food Record Chart. Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

19 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 Enteral Feeds The nurse signs to indicate that the enteral feed has been set up and commenced. The nurse must then record the volume administered on the patients Fluid Record Chart. Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

20 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 Appendix 1 Process for Patient s Refusing Medication Patient refuses medication: are you concerned that the patient lacks the mental capacity to give informed consent to taking medications? Yes No Complete a mental capacity assessment (1) Discuss reason with patient and agree care plan to support future administration Patient has mental capacity Patient lacks mental capacity Multidisciplinary team make a best interest decision on whether to administer medication (2). Record decision in patients notes (3). Patient still refuses Patient agrees to take medication Concordance problems identified Document on medication chart and in nursing records. Inform prescriber or other designated registered practitioner. Administer medication Offer alternatives e.g. liquids, dispersible tablets or mix with food or drink (4). Administer medication 1) Where it is necessary to undertake an assessment of a person s capacity please refer to the ABM Brief Guidelines on the Mental Capacity Act 2005 and the Mental Capacity Act Code of Practice ) A best interest decision must involve clinicians, nurses, family or carer and other healthcare professionals where relevant e.g. pharmacy, dietetics, speech therapists. 3) If decision is to administer medication covertly, refer to Health Boards Medicines Policy, The NMC Standards for Medicines Management and RCN Standards for Medicines Management 4) Consult pharmacy on type of food or drink appropriate for delivery of treatment. Specific instructions must be written in the special instructions box of the medication chart by the prescriber. Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

21 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 Appendix 2 Flowcharts for: What to do if you can t find a medicine on a ward? During pharmacy opening hours Outside pharmacy opening hours Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

22 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 Appendix 3 How to access Emergency Drug Cupboards Cefn Coed Cefn Coed Hospital Emergency Cupboard is located on Ward F. The nurse must contact the shift co-ordinator and arrange to meet them on ward F. The nurse should take the drug chart to ward F, and the nurse and shift co-ordinator will access the cupboard together. Morriston Contact the relevant bleep holder for the speciality area who holds the key to the emergency cupboard. The emergency cupboard is located adjacent to the pharmacy. Neath Port Talbot Contact the Out of Hours Nurse Practitioner The emergency cupboard is located in the pharmacy patient waiting area. Princess of Wales Contact the out-of-hours nurse practitioner. The Emergency Cupboard is located inside the pharmacy outpatient waiting area. Keys to the Pharmacy Outpatient waiting area and Emergency Cupboard are held in switchboard. The keys need to be signed for. Singleton Nursing staff should contact the Bed Manager who will access the Emergency Drug Cupboard. Updated: 17/06/2014 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

23 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 What to do if you can t find a medicine on a ward? (During pharmacy opening hours) If possible, ask someone else to look Still can t find Has patient just arrived from another ward? Yes Contact previous ward Medicine(s) there? No No Yes Ask ward to send Is the medicine a Fridge item? No Yes Not there Check ward fridge Has the PHARMACIST box for the drug been signed? No Contact pharmacy team Yes Has the SUPPLY box for the drug been completed? No Contact pharmacy team Yes Stock Yes Supplied Look in stock cupboard Check for any recent Pharmacy porter deliveries Still can t find drug Updated: 17/06/2014 IP&MM, 2014, v1 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

24 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 What to do if you can t find a medicine on a ward? (Outside pharmacy opening hours) If possible, ask someone else to look Still can t find Check drug cupboards and any pharmacy deliveries Still can t find Is the patient a new admission to the hospital? Yes Is it convenient for a relative to bring in patients own medication? Yes Ask relative No No Has patient just arrived from another ward? Yes Contact previous ward Medicine(s) there? No No Yes Ask ward to send Is the medicine a Fridge item? No Yes Check ward fridge Not there CHECK EMERGENCY CUPBOARD LIST Is item on the emergency cupboard (EC) list? No Yes Follow local procedure to access EC Obtain medication and make record Contact on-call pharmacist via switchboard Can t locate medication in EC Updated: 17/06/2014 IP&MM, 2014, v1 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

25 CID: 1298 Published: June 2014 Last ReviewL N/A Next Review: June 2016 CID: 1298 Published: June 2014 Last Review: N/A Next Review: June 2016 Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent. Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure that the printed version is the most recent.

26 Agenda No 3 (ii) Appx B END OF MONTH 3 PROGRESS REPORT AGAINST ACTION AFTER ANDREWS PROGRAMME PLAN Remaining Recommendations NO RECOMMENDATION MONTH 3 TARGETS MILESTONES ACHIEVED NEXT STEPS STATUS 2 The Board should develop a quality and patient safety strategy which focuses on the realities of care, connects the Board to the experience of patients, monitors standards in practice and shapes Board decisions accordingly. Scope work & integrate IMTP work with Action after Andrews timescales / actions (Programme Plan) Scoping well underway. Discussions at IMTP Refresh Group on quality & patient strategy & linkages of timeframes. Action after Andrews Programme Plan timescales amended to reflect overall IMTP deadlines / process. Focus of C4B event with key clinicians / leaders in October on this topic. Meeting with Exec Leads / Taskforce Lead to formally sign off approach & detailed timescales linked to other related activities / workstreams. GREEN ON TARGET 3 The Board should identify clear steps to generate a culture of care built on public involvement in the setting and monitoring of standards, and in the resolution of ethical issues and practical choices that arise from the need to make decisions within limited resources. Set up & implement See It, Say It Campaign Scope work on indicators for Board reporting. Scope work on reporting to Board. (Programme Plan) Posters produced for See It, Say It, widely distributed & displayed round all hospital sites. Fully implemented from beginning August Processes agreed for reporting on Datix, passing information onto relevant Lead Nurses & gaining feedback on actions taken. Spreadsheet kept of all issues raised, actions taken to address these. Steady stream of responses being received. Feedback on action given to staff / patients / public if 1 Full integration with new web based Datix system from December double running of systems in the meantime. GREEN ON TARGET

27 NO RECOMMENDATION MONTH 3 TARGETS MILESTONES ACHIEVED NEXT STEPS STATUS requested. Involvement of patient groups, voluntary sector and partner organisations in setting standards as part of recommendation 1. Discussions held on how to build on existing reporting mechanisms and information collected to develop pragmatic set of indicators for reporting to the Board linked to auditing of standards of care for frail elderly (Rec 1) and ward assurance framework. Draft KPIs discussed and revised based on engagement with Meetings being held to populate dashboard for frail elderly, linked to other Health Board work on corporate dashboards. Will inform work on Standard 17 for Welsh Government on Dashboard. Support from 1000 Lives+ requested to link with their work on dashboards. stakeholders. 4 The Board should implement a skills and knowledge programme to ensure all staff operating in its hospitals understand and are equipped to meet their obligations to older frail people. Start process for developing skills and knowledge programme & implementation plans for all staff. (Programme Plan) Scoping of work underway including mapping and integration with other existing processes / groups. Programme Plan updated with more detail on planned milestones to ensure effective monitoring. Agreement reached to consolidate this work within Training & Development in the Health Board, rather than dispersed into separate Directorates / Professions. Funding agreed for Consultant Nurse for Older People or equivalent role across the Health Board to provide leadership across the organisation. Group set up to oversee this work, including Development of skills & knowledge programme, linked to care standards for frail elderly as well as mandatory training framework. Recruitment of Consultant Nurse role. AMBER 5 The Board should run an intensive education programme on delirium, Agree scope for external dementia training review, Scope agreed and all information provided as requested for external RCN National Lead on Dementia to carry out review. Recruitment of additional posts for dementia training across the Health Board in GREEN ON TARGET 2

28 NO RECOMMENDATION MONTH 3 TARGETS MILESTONES ACHIEVED NEXT STEPS STATUS dementia and dying in hospital. 6 The Board should develop more cohesive multidisciplinary team practice in the medical wards at the two hospitals, built around shared responsibility and accountability for patient care and standards of professional behaviour. provide information & support for review. Agree additional support required for training staff on dying in hospital. Scope work on education programme & linkages with existing work. (Programme Plan) (See also Recommendation 1). Ward assurance framework in place incorporating multidisciplinary working / staffing issues etc. Care standards for frail older people developed. Report with recommendations received and report on resourcing implications of the review considered by Action after Andrews Steering Group. Funding agreed for 2.5WTE substantive posts to deliver on recommendations from RCN Advisor. Scope of additional support required on dying in hospital for staff agreed, based firmly on a patient story / experience approach in line with Health Board s approach to ensuring patients are at the centre of everything we do. Funding agreed for programme of education sessions commissioned from CRUSE to test this approach over 6 months prior to finalising the scope for this going forward and formally testing the market to ensure best value. Additional in-house training on the care needs of those dying and with delirium are being scoped currently. As outlined in Recommendation 1 above, ward assurance framework agreed and guidance produced for how to implement and subsequent action planning. Testing carried out on 3 wards initially; with further 2 clinical areas to test applicability in different settings. Two phase process being utilised for rolling out across Health Board. All-Wales acuity tool piloted on 49 medical 3 line with report so that implementation can be rolled out. CRUSE have been commissioned to run weekly training sessions for 25 staff in a variety of locations which are currently being agreed, and will therefore be able to train over 600 staff in the 6 months from September 2014 March This additional training will need to be supplemented by an in house training programme regarding the care needs of the dying. Assurance framework guidance revised to reflect testing / engagement outcomes. Roll-out of assurance framework to Phase 1 priority areas by end December Remaining clinical areas in Development of action plans for all these GREEN ON TARGET

29 NO RECOMMENDATION MONTH 3 TARGETS MILESTONES ACHIEVED NEXT STEPS STATUS All Wales acuity tool piloted. (Programme Plan) 7 The Board should introduce a coaching scheme for frontline clinical leaders provided by senior people from outside the two hospitals. 9 The Board should address hydration, mobility and feeding practice for all older patients and publish audited results on a quarterly basis. Scoping of coaching scheme and initial discussions with other Health Boards. (Programme Plan) Review of current nil by mouth practice & examples of good practice identified elsewhere. Automatic offer of water to patients in any clinical encounter or offer of care. (See Recommendation 8). Reporting arrangements being picked up as part of & surgical wards but these do not capture all elements of acuity for the frail elderly. Key Health Board wide issues identified and implementation plans developed. Initial links have been made to look at how this could be taken forward. Baseline assessment carried out of current coaching arrangements, including external network with Academy Wales. Baseline of current practice identified and examples of good practice and processes in operation in different areas sourced. Guidance incorporated in Never events information on screensavers / information for clinical areas around always taking the opportunity to ensure patients are appropriately hydrated. 4 areas within these timescales which will incorporate actions relating to multi-disciplinary practice. Implementation of HB wide issues (e.g. name badges). Activity on this recommendation timetabled for 2015 to allow a focus on recommendations 4 & 5 in Develop action plan to strengthen ABMU coaching, focusing on frontline clinical leaders. This will involve developing alliances with other Health Boards and Universities. Development of revised, simplified guidance on nil by mouth and dissemination across the organisation. Monitoring of instances where these practices are not being adhered to being included in KPIs and Dashboard work (Rec 3) to ensure it forms part of the suite of information services are audited against. GREEN ON TARGET GREEN ON TARGET

30 NO RECOMMENDATION MONTH 3 TARGETS MILESTONES ACHIEVED NEXT STEPS STATUS work on reporting to Board on indicators (see Recommendation 3) 10 The Board should review how well ward accommodation supports care for those with dementia, delirium, cognitive impairment or dying at both hospitals, covering physical design of the clinical spaces and equipment available. As part of ward assurance work, process agreed for reviewing environments & testing the relevant tool. Establish working group to oversee implementation across Health Board. (see also Recommendation 1 & 6) Kings Fund Enhancing the Healing Environment (EHE) tool was used as part of the ward assurance process with the multi-disciplinary team including lay members, evaluating how the environments supported care. A working group has been established with wide clinical, arts and estates input to oversee this work. Further detailed audits using the EHE tool have been carried out on the 3 wards which trialled the assurance framework and actions identified for each ward as well as a range of actions which need taking forward at an organisational level. 5 Specific action groups are being established / existing groups used around three particular HB wide issues: - Access for patients / families to external spaces (including courtyards) - Standardisation of information boards on entering wards - Standardisation of signage, using plain English and symbols. A meeting is also being arranged with Estates Development regarding key strategic issues such as rolling refurbishment programmes to highlight key issues such as lack of access to decant facilities to enable ward improvements making the link with the need for additional capacity for emergency pressures GREEN ON TARGET

31 NO RECOMMENDATION MONTH 3 TARGETS MILESTONES ACHIEVED NEXT STEPS STATUS issues & infection control. 11 The Board should simplify and strengthen management and clinical accountabilities and review ward staffing procedures to guarantee the right clinical and support staff are in the right place to meet the needs of older people at that time. Management and clinical accountabilities revised at POWH. Start of implementation of changes across whole HB. (See Recommendation 6 for ward staffing) Revised management and clinical accountabilities implemented at POWH and under review as part of overall changes to management arrangements across the rest of the Health Board. New Board committee structure put in place. Revised accountabilities and portfolios agreed for Executives with vacant posts filled. Series of workshops with Board, Executive Team, Delivery Board held to agree way forward in terms of improving management and clinical accountabilities. (See Recommendation 6 for ward staffing) Implementation of revised management and governance arrangements. (See Recommendation 6 for ward staffing). GREEN ON TARGET 12 The Board should overhaul local procedures on adverse incidents and complaints to build greater staff and public trust and confidence in their effectiveness. 13 The Board should introduce a fully operational 24/7 approach to services including diagnostic services, pharmacy, therapies and social work. As per key deliverables within Patient Experience Programme Plan (incorporated into AaA Programme timescales) Literature search on evidence base & requirements to meet needs of frail older people. PALS team being piloted in POWH. Concerns Clinics being scheduled on regular day each month at the 4 hospital sites to spread commitment & regularise arrangement. New arrangements for complaints process introduced, including clinical input into all complaints. Literature search carried out on requirements to meet needs of frail older people. Limited information available, but further discussions / information being sourced from other specialist sources, including advice from Consultant in Implementation of webbased Datix system. Combined programme plan / timescales to be agreed with Executive Lead / Support / taskforce. Once scoping work has been finalised in September, based on the evidence of services required, joint meeting of 2 Executive Leads planned to sign off GREEN ON TARGET AMBER 6

32 NO RECOMMENDATION MONTH 3 TARGETS MILESTONES ACHIEVED NEXT STEPS STATUS Intermediate Care on needs. scope and agree milestones / actions to take forward. 14 The Board should decide what has to be done for ABMU genuinely to put local citizens at the heart of everything we do, using external creative expertise. Implementation of the Values & Leadership work according to timescales within Programme Plan. GREEN ON TARGET Surveys launched in June for staff and separately for patients / families / public on their experiences of our services and how these should be improved, available on intranet, in hard copy & a range of accessible versions. Wide series of values & leadership workshops held across the organisation, including 450 front line managers have participated in Leading Values and by 9/9/ Senior Leaders will have participated in Leading for Values sessions these have support them in developing their leadership skills. This is in addition to Team Briefings and other targeted sessions. In Our Shoes workshops have also taken place throughout July, involving 1,650 staff, in identifying what makes a good / bad day for them, which will be used to inform the values for the organisation, alongside information from the planned In Your Shoes sessions with patients. Total of 22 In Your Shoes sessions organised throughout September in a wide variety of locations across the ABMU area. Workshops being arranged for first week in November to receive first draft of our values as part of ongoing engagement process. Values to be considered by Board in December. 7

33 Agenda No 3 (ii) Appendix C Leading for values Board Update and Next Steps Briefing 25 th September All tools and approaches April Strategy LLP 2014

34 Briefing contents Context quick refresh Leading as a Board listening to staff Next steps 2 All tools and approaches April Strategy LLP 2014

35 Context: Leadership is changing and so are we Boards and leadership teams need to be clear that changing culture also means changing themselves King s Fund, All tools and approaches April Strategy LLP 2014

36 Context: NHS leadership post Francis New Model of Leadership NHS Leadership Academy King s Fund Collective Leadership for Healthcare Leadership practices and behaviours needed to nurture a caring culture 4 All tools and approaches April Strategy LLP 2014

37 Context: our ambition 2014 Huge variations in patient experience. Data and evidence not collected, reported or acted upon in any systematic way. To fulfil our civic responsibilities by improving the health of our communities, reducing health inequalities and delivering effective and efficient healthcare in which patients and users always feel cared for, safe and confident. Excellent citizen experience every human contact Listening to / reporting on citizen / patient feedback. Real time, systematic, at scale Key transformations Fully resource patient experience, improvement and PALS teams Support leaders to listen to patients and act to resolve issues quickly Use HR processes to embed accountability for patient experience into people s jobs 2017 An excellent healthcare, teaching & research organisation for the ABM region & the wider regions that we serve We understand our patient experience at a granular level in real time, act on what we hear, and see it continuously improving Opportunity to improve levels of staff engagement, visibility of leadership and connectedness of teams across the organisation Beginning to develop a more open culture. Need to consider ABMU as going beyond staff to all citizens in our patch Engaged teams across the whole ABMU system One culture the ABMU way Introduce better ways to listen to and communicate with staff Co-create shared vision, values and behaviours with staff and citizens Development of values-driven leadership, visibility role modeling Organisational level: set expectations of staff attitude, technical, service Empower and skill teams to deliver continuous improvement Population level: engaging people in taking charge of their own health Systematic feedback and openness: celebrate successes and speaking up Keep listening to citizens, patients and staff about the outcomes they value Engaged staff, who are role models of our values, at every level, who are empowered to keep improving services Everyone is able to describe the ABMU way and how they fit into it. Citizens are more engaged in their own role in healthy living Focused on good financial performance, less visibility of quality outcomes, and not always holding people to account Compartmentalized approach focused on delivering individual services, and on delivering to WA agenda rather than citizen needs ABMU leadership one unified Board One ABMU system leading and commissioning Agree Board code of conduct / behaviours clear roles and responsibilities Agree commissioning model and strategy incorporate into IMTP Align Board operations (agendas, papers, sub committees etc.) Engage citizens in commissioning prioritisation develop priorities Ensure internal Board visibility listening and connecting Realign existing resources to commissioning priorities Establish Board connections with citizens and communities Manage as a system right care, right people, right time A Board focused on quality of care and health for ABMU citizens, role modeling values driven leadership By focusing on end-to-end patient health and wellbeing we can also see tangible improvements in productivity and efficiency 5 All tools and approaches April Strategy LLP 2014