kay n Be y He Annua al Qu y S uality 13-2 Statem

Transcription

1 kay An neu urin n Be eva an Un nive ers sity y He ealth Board d Annua A al Qu uality y S Statem mentt

2 Chair and Interim Chief Executive Welcome from the Chair and Interim Chief Executive Started year with Ended year with Francis Report Trusted to Care was framed by the publication of two key reports sadly both highlight failings in the NHS. The year started with the publication of the Francis Report on the failings in Mid Staffordshire NHS Trust. It ended with Trusted to Care which has shown that there can be problems much closer to home, here in Wales. Reports like these can make us all feel like we are not making any progresss in improving the quality and safety of treatment and care for our patients. What these reports tell us is that we must focus even more on the purpose of the Aneurin Bevan University Health Board (ABUHB): Put the Patient First Continually Improve with Every Action We want everyone who works in Aneurin Bevan University Health Board to focus on the humanity of care and getting the basics right so that everyone is providing the care that they would want a member of their family to receive. To do this, we all have to effectively have 2 jobs: to do our job and also to improve the way we do our job. This report showss that we have been making progress in many areas that reflect our purpose and focus. We have revised our values and behaviours framework after talking to staff, so that everyone knows how we expect them to behave towards patients and towards each other. You can read more about this in the 2 P age

3 staff section on page 30. We have continued to support the Aneurin Bevan Centre for Improvement (ABCi), which has facilitated large organisational improvement programmes, like the Flow Programme, described on page 25, as well as many smaller improvement projects and much of our work on engaging with patients. They have also lead the developm ment of staff skillss in quality improvement methods, using the Improving Quality Together resources, so that staff are able to make sustained changes that improve services. The commitment of our staff to improving quality is shown in their successs in winning numerous awards, which you can read about in the ABUHB Annual Report. We continue, however, to face financial challenges, and we therefore need to make sure that all the care and treatment we provide will give the best outcomes for the patient for the money we spend on it, and that it is the care and treatment that the patients want for themselves. We are therefore embracing Professor Mark Drakeford, the Minister for Health and Social Services, initiative of Prudent Healthcare making sure that we use the resources entrusted to us in the most effectivee way as we move into In May 2014 our Chief Executive, Dr Andrew Goodall, was appointed as the Welsh Government s new Director General for Health and Social Services and Chief Executive of NHS Wales, and left the Health Board in June Andrew has been our Chief Executive since the establishment of the Health Board in Many of the approaches and achievements outlined in this report have been whilst Andrew was our Chief Executive. We wish to thank Andrew and acknowledge his huge contributionn to the development of health services within the Aneurin Bevan University Health Board area, we all wish him well in his new role. We are proud of our achievements, in taking forward much of what we said we would do last year and tackling new challenges as they have arisen. We hope that this report provides you with information about how we are doing, and our next steps along the journey of improvement. David Jenkins Chairman Judith Paget Interim Chief Executive 3 P age

4 INTRODUCTION This Quality Statement from the Aneurin Bevan University Health Board to the public in our area, is our opportunity to tell you how we use our services and about the quality of those services what we have done well, where we need to improve and what we plan to do over the next year. Sometimes changing our services takes more than a year, because healthcare services are complex, but we can set out the milestones for the changes each year. This is a short summary of all that we have been doing. Our services are complex. Using a budget of circa 1 billion, over 13, 000 staff provide services in a range of facilities and care for 1000s of people: Our main Facilities: 3 Main Acute Hospitals 5 Community hospitals 4 Mental Health Facilities 1 Primary Care Resource Centre 89 GP practices These services see an enormous number of people in a year: Emergency admissions Planned admissions, usually for operations new outpatients seen follow up outpatients seen A&E attendances 4 P age

5 We care for people of all ages, from babies, even beforee they are born, to older people over 1000 years old, and they need a range of services from very technical, emergency, life saving treatments to everyday care for long term conditions. To provide this complex healthcare, we need to work closely with our patients and our partners in Local Authorities, the Third Sector and with carers. You will find examples of this partnership working throughout this AQS. The overall quality framework that we work within is Doing Well, Doing Better, the Standards for Health Services in Wales, and all parts of the Health Board have processes to assess themselves against these standards, and identify gaps and riskss and put in place improvements. We are monitored by a range of external bodies to provide assurance about whether we are meeting clinical standards and provide a good patient experience, and to highlight where we need to improve. In particular, the Aneurin Bevan Community Health Council (CHC) provides invaluable support to the people of our health board area, and feedback to the Health Board about how we are doing. Our hospitals thatt are referred to in the report using their acronyms, are: RGH - Royal Gwent Hospital in Newport NHH Nevill Hall Hospital in Abergavenny YYF Ysbyty Ystrad Fawr in Ystrad Mynach YAB Ysbyty Aneurin Bevan in Ebbw Vale WHAT DO YOU THINK? We want to know what you think about this Quality Statement,? whether you think our priorities for next year are the right priorities and how we can best engagee with you and your local community about your healthh issues. Over the winter, we will meet with a range of patient groups in a range of locations to listen to your answers to these questions. But we would love to hear your views via our abhb.enquiries@wales.nhs.uk. You can also find us on Twitter: or Facebook: com/aneurinbevanhealthboard 5 Page

6 CONTENTS Looking Back - Staying Healthy o What are the health needs of our population o What are we doing? Everybody needs a healthy heart Making Every Contact Count Keeping our hospitals smoke free Swansea Measles Outbreak 2013 Stopping the Spread Looking Back - Safe Care Page 10 o How are we doing? Mortality Data o How do we know where we need to improve safety? Mortality reviews Incident Reporting o What have we done? Reducing Hospital Infections Reducing Pressure Ulcers Reducing Falls in Hospital Reducing the number of medicines people are taking in the Community Looking Back - Effective Care Page 16 o What have we done? Effective Stroke Care Effective Care for Patients with Sepsis Effective Care to Prevent Hospital Acquired Thrombosis Effective Care in Primary Care Atrial Fibrillation Looking Back - Dignified Care Page 18 6 P age o How are we doing? Fundamentals of Care o What have we done? Dignified Care Training Dignified Care for people with Dementia End of Life Care

7 Looking Back - Timely Care & Services Page 20 o What have we done? Timely Care Getting to see your GP Timely Care Waiting Times for all Referrals Timely Care Waiting Times for Cancer Patients Timely Care in A&E Timely Care Improving how patients move through the hospital services Timely Care and Follow-up Outpatient Appointments Looking Back - Treating Peoplee as Individuals Page 24 o How are we doing? Patient Experience e Survey and Concerns o What have we done? Treating People as Individuals People with sensory loss Treating People as Individuals People with Learning Disabilities Treating People as Individuals Carers Treating People as Individuals Older People Treating People as Individuals Patient Engagement and Co-production Looking Back - Our Staff Page 28 Who are our staff Our Staff Wellbeing Our Response to the Francis Report Our Staff experience Our Volunteers Summary of Progress and Looking Forward Page 34 7 P age

8 LOOKING BACK OVER LAST YEAR Staying Healthy What are the health Needs of Our Population? Whilst life expectancy has increased over time, life expectancy for people living in the more deprived areas of Gwent has risen more slowly. In the least deprived area of Gwent, people can expect to live around 8 years longer and have 20 years longer spent in good health than those living in the most deprived areas. Lifestyless impact on health. The table below shows that lifestyles in local authority areas in the Health Board area tend to be worse than in Wales as a whole: Lifestyles in Adults in Gwent LOCAL AUTHORITY AREA Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport ABUHB Wales % OF POPULATION CURRENT SMOKER % OF POPULATION EATING 5 FRUIT AND VEG A DAY % OF POPULATION THAT IS OBESE ALCOHOL SPECIFIC ADMISSION RATE RED Statistically significantly WORSE than Wales GREEN Statistically significantly BETTER than Wales We have introduced a number of initiatives to promote healthy lifestyles so thatt people in all areas live longer and spend more years in good health. What are we doing? Everybody needs a healthy heart to screening and How healthy is your heart? The Healthy Heart Screening Programme identifies apparently healthy people at increased risk of coronary heart disease, stroke and diabetes. It has been expanded from Caerphilly to the Pen y Cae Surgery in Blaenau Gwent. Of 4080 patients in the Surgery, 870 were invited approximately half of them took up the offer. The screening 8 P age

9 identifies people that would benefit from any medical treatments, such as for high blood pressure. It also encourages people to make lifestyle changes and gives support such as sign posting to local services like adult weight management, smoking cessation and exercise on referral/ leisure services. Making Every Contact Count Encouraging healthier lifestyles at Every Opportunity Staff in the NHS have thousands of contacts every day with individual members of the public district nurses in people s own homes, physiotherapists in out-patients, midwives in hospitals. Through these contacts, staff can help improve health and well being by making their conversations count through encouraging people to have healthier lifestyles as well as dealing with the health issue that triggered the contact. In , 166 GPs, 83 Practice Nurses, 79 Health Visitorss and 12 midwives have been trained and are discussing lifestyles with individuals and motivating and empoweri ng them to change their behaviour. Keeping our hospitals smoke free Protecting our Patients and Visitors from Passive Smoking It does not seem right to promote healthy behaviours in the community and then to allow smoking within our hospitals and clinics. ABUHB introduced a Smoke-Fr ree Environment Policy. The no-smoking smoke, it is about stopping smoking on a hospital site. The Health Board recruited two Smoke-free Environment Officers who work mainly at RGH and NHH. They patrol the sites and talk to smokers about the policy, discussing the litter issue and reminding smokers that they can be issued with a 75 fixed penalty. They have also been trained in brief interventions in smoking cessation. policy is not about telling smokers not to Measles Outbreak in Swansea Area 2013 Stopping the Spread In 2013, Wales saw the biggest outbreak of measles since the introduction of the Measles, Mumps and Rubella (MMR) immunisation. Althoughh centred in Swansea, it was possible that the measles outbreak could spread to the ABUHB area. To prevent the spread of measles, ABUHB implemented a MMR catch up campaign from April to June This was supported and promoted by the Third Sector and community networks. Special MMR Vaccination Clinics were held in 9 P age

10 schools, Colleges, GP Practices and Hospitals. Some clinics were held on Saturdays to make it easier for parents to attend with their children. The support from our dedicated stafff to run the clinics, and the uptake was excellent. Between April and July 2013, 14,432 dosess of MMR were given in these special vaccination clinics. As an outcome of this catch up, our local population is less vulnerable to an outbreak of measles, although the Health Board is still working towards the 95% uptake rate of 2 doses of MMR vaccine which would confer immunity to the population against measles, mumps and rubella. Safe Care How are we doing? Mortality Data The Health Board monitors mortality data as a highh level indicator to show how safe and effectivee our care is. The mortality data we use the Risk Adjusted Mortality Index (RAMI) - is a way of measuring whether people are more at risk of dying than they should be. This is risk adjusted, which means that if the average death rate for a particularr condition is very low and someonee dies from it, that death scores more highly than if someone dies from an illness that is usually fatal. Risk-adjusted mortality rates are complex, but are used to give a general indicator of how safe healthcare is. 100 is the level at whichh the actual number of deaths is the same as the expected number of deaths. Above 100 and there have been more deaths than expected. Below 100 and there have been fewer deaths than was expected. The RAMI for RGH has decreased in the last year compared to the previous year, and NHHH and YYF have stayed much the same, which shows that we have made progresss overall in improving the safety of our care acrosss our 3 main acute sites. However, we are not complacent, and we have developed a Patient Safety Improvement Plan which focuses on many of the issues in the Quality Statement, to continue to improve the safety and effectiveness of our healthcare. 10 Page

11 How do we know where we need to improve safety? Mortality reviews To help us understand more about how we can prevent harm to patients in our hospitals, senior doctors have been analysing the patient care records of patients that have died at the RGH or NHH in order to make sure they received the best care possible. In , we introduced the All Wales process at RGH and NHH, and started the mortality review process at YYF. We also developed the process to include experienced nurses are part of the team reviewing the patient records, so that there is a nursing view of the care given as well as a medical view. The key things that we have found in mortality reviews are considered alongside learning from complaints and incidents and other quality triggers. Together, these have influenced the priorities that we are working on and that are described in this Quality Statement and are part of the Patient Safety Improvement Plan. As a result of the mortality reviews, there has been: New work with GPs and in Medical Admission Unit at RGH to speed up our recognition of and response to sepsis Training for our Consultants on end of life care, Changes in practice to improve Anticipatory Care Planning at our Community Hospitals Discussion of issues found at many clinical meetings to raise the awareness of clinical staff, Discussions with the Universities so that the education of clinical staff can be changed. Incident Reporting Although we do all we can to keep patients safe while they are in hospital or using services in the community, healthcare is a complex and risky business and so sometimes things go wrong and incidents happen. It is important that staff feel confident that they can report incidents within a culture of listening and learning. It is through analysing the incidents reported, that we know where we need to improve patient safety. A high number of incidents reported does not therefore mean that an area is unsafe it usually means it has a good culture of caring about patient safety. The bar graphs below are from our Datix incident reporting system, as at The number of incidents reported was lower in 2010 and 2011 as we changed from a paper based system to the electronic Datix system at this time. As staff have become more familiar with the electronic system, the level of reporting is now approximately the same as it was prior to the change. All incidents are reviewed locally to ensure that there is learning to prevent this happening again. 11 P age

12 Patient Incidents by Incident date (Financial Year Commencing) Incidents affecting or potentially affecting PATIENT (incl Staffing issues) Incidents by Detail and Type Incidents affecting or potentially affecting PATIENT Slips, trips and falls are consistently the highest number of incidents reported. You can see what we are doing to prevent patients falling in hospital on page 16. Some incidents are very serious, and yet are preventable, so that we call them Never Events as they should never happen. They include for example, issues such as wrong site surgery (for example, operating on the right leg rather than the left), retained foreign object post operation and wrong route chemotherapy administration (for example, via the spinal route rather than the vein). Regrettably, sometimes even thesee Never Events do happen. In the last year in ABUHB there were 3 Never Events recorded and investigated. These all involved procedures where proper checks during an operation were not carried out. All three cases have been fully investigated, the teams involved have reviewed their practice in depth and improvements to the checking procedures in the operating theatres have been implemented. What have we done? Reducing Hospital Infections Two infections thatt many people have heard about are Methicillin Resistant Staphylococcus Aureus - MRSA and Clostridium Difficile C. diff. MRSA is a bacterium that often infects wounds, but can also be an infection that gets into the bloodstream, which is then very serious. We have been very successful over recent years, in reducing the number of cases of MRSA in We had 222 cases of MRSA in our hospitals, so that the numbers of cases are now low , a reduction of 1 case on the number the previous year. 12 Page

13 We have experienced considerable challenges in reducing C. diff, particularly in the last year. C. diff. causes very unpleasant and sometimes severe diarrhoea, and stomach cramps and tenderness. This can be serious, particularly in older people who are already unwell. Whilst in , we were able to reduce the number of hospital acquired C.diff cases in those over the age of 66 by 24% from 286 in to 215 in , we noticed that from early in , the number of cases per month had stopped decreasing and had even increased. By taking immediate action to reverse this, we reduced the number of cases per month in the second half of the year. Another infection that can cause very unpleasant symptoms for patients is norovirus a bug which can cause diarrhoea and vomiting. It can spread very easily amongst hospital 23 outbreaks of norovirus were identified in the winter of , 14 in the winter of and 8 in Over the year we had a total of 216 cases of C. diff., 1 case more than the previous year and an increase of 0.5% patients and delays recovery and discharge. It is essential to recognise a potential norovirus problem as soon as possible as swift action can prevent the bug spreading and stop ward closures. The Infection Prevention Team has focussed a lot of attention on early detection resulting in a steady year on year decline of outbreaks. If you do have to come in to hospital, our staff will be doing all they can to make sure you are safe and reduce the chances of catching an infection. But if you really want to make sure, you should ask staff whether they have washed their hands before they touch you or examine you. All our staff know how important this is, and even if they have washed their hands beforehand, where you could not see them do it, they will welcome your question and reassure you. It is OK to ask! 13 P age

14 Reducing Pressure Ulcers Older, frail patients are particularly vulnerablee to pressure ulcers, which range from patches of red skin to open wounds. They result from an area of This year we have had 413 skin being under constant cases of pressure ulcers thatt pressure for example if have developed in hospital. someonee is unable to change their position This is below our interim themselves. Some patients come into hospital target for the year of with a pressure ulcer, but unfortunately some do develop in hospital althoughh these are reducing cases of pressure usually at the lesss serious end of the range. ulcers to fewer than 416 Every case of pressure damage is reviewed to see whether everything was done to prevent the pressure damage developing, and then changes are made to our processes if necessary. Reducing Falls in Hospital By far the greatest number of incidents reported are about patients falling whilst they are in hospital. We know that we will never totally prevent everyone from falling in hospital as when people are in their own homes, 30% of people older than 65 will fall during a year, and 50% of people over 80 years old. We want to prevent as many falls as possible, and ensuree that falls result in the minimum harm. We have therefore: o Developed a new falls policy thatt has: Robust Risk Assessment Falls Prevention in Hospital Information leaflet Protocol following an Inpatientt Falls Flowchart showing what to do is a patient that falls is on Anticoagulants A falls monitoring form linked to the new policy has been piloted in one area YAB, and initial results have shown an encouragingg reduction in the number falls. If this is sustained, it will be spread to other areas. in of 14 Page

15 Reducing the number of medicines people are taking in the Community Polypharmacy is one person taking many different drugs or medicines at the same time. Polypharmacy patients are at increased risk of an adverse reaction or drug to drug interactions. Those at greatest risk include older people, patients taking five or more different drugs at the same time, those hospitalis sed and individuals with several long term conditions. In order to seee what works to reduce polypharmacy, two medication review schemes were piloted by primary care pharmacists. Medication review is a check to see that all the medicines prescribed are still needed. It is particularly important for people with regular (repeat) prescriptions. Patients From a safety perspective, on multiple medications in a care home and GP practice setting were targeted for a pharmacist 15 20% of the interventions medication review. Analysis of the results were classed as significant demonstrated that stopping medicines that were not needed was the most common intervention made, reducing the risk of in improving safety for the individual. potentially harmful interactions and medication related admissions to hospital. 15 Page

16 Effective Care Effectivee Care is care and treatment that complies with evidence from research that has shown which treatment gives the best results for most patients. What have we done? Effective Stroke Care The ABUHB Stroke Delivery Plan sets out the ambitious plan to change the way Stroke Services are organised so that we can consistently deliver effective, high quality care of all stroke patients, from prevention of stroke through acute care for people who have just suffered a stroke, to long term care for stroke survivors. High quality stroke care means meeting the evidence based standardss set out in the Sentinel Stroke National Audit Programme (SSNAP). The Royal Gwent and Nevill Hall Stroke Units have struggled to maintain the target of 95% compliance with the SSNAP standards this year. However, changes have been made to the movement of patients through the different parts of the current stroke service, whilst the longer term changes to the organisation of stroke services are made. These have significantly improved compliance with the stroke care bundles for the first hours, the first day, the first 3 days and the first 7 days, as shown in the graph above. A care bundle is a structured way of improving the process of care and patient outcomes: a small, straightforward set of evidence- to improve patient outcomes. based practices that, when performed collectively and reliably, have been proven Effective Care for Patients with Sepsis Sepsiss is a potentially life threatening effect of an infection. Chemicals released into the blood stream to fight the infection trigger inflammation throughout the body, which can damage organs, causing them to fail. It is estimated that up to 1850 peoplee die from sepsis in Wales each year. We know from our mortality reviews, from complaints and incidents, thatt for some patients, we do not recognise and 16 Page

17 respond as quickly as we could to deterioration in their condition that could mean they have sepsis. Beating sepsis involves alll our services and will take time. In previous years we have focussed on acute services and have continued to implement the sepsis care bundles across RGH, NHH and YYF. We are learning what makes it easier for our staff to respond appropriately to deterioration in a patient, and have introduced sepsis bags on to all the acute wards. Thesee contain all that is needed to treat the patient and complete the required blood tests on a patient that is thought to have sepsis. This year we have expanded training and tools into community hospitals, and to GPs. If all health practitioners use the same tools in the community and hospitals, it helps the early recognition of sepsis when a GP sends a patient into hospital. Effective Care to Prevent Hospital Acquired Thrombosis (HAT) A thrombosis is a blood clot that develops inside a vein and can travel through the bloodstream to the heart or lungs, causing a serious illness. In order to try and prevent clots developing in hospital (which is called a hospital acquired thrombosiss or HAT) we first need to assess every person s risk of developing a clot. Depending on the assessed risk, some simple interventions are made, including wearing leg stockings, taking small doses of medication to thin the blood and keeping mobile. Unfortunately, even when we have done everything correctly, there will still be some casess of HAT as they are not all preventable. So we know how we are doing, this year, we have put in place a process to count how many cases of HAT happen each month in the Health Board. For each HAT that happens we are putting in place a process to check whether we have done everything we should have done the risk assessment and all the appropriate interventions and to continue to learn from any cases of HAT. Effective Care in Primary Care Atrial Fibrillation Nine practices signed up to work as a collaborative to share practice dataa and support each other in making changes within their practices to make an improvement in the detection and care of patients with Atrial Fibrillation. Atrial Fibrillation is an arrhythmia resulting from irregular, disorganised electrical activity in the heart. 17 Page

18 It is a significant risk factor for stroke. This is the first time in Wales that this improvement methodology has been used in a collaborative of GP practices. An example of the improvements being made is an increase in the number of patients being detected with Atrial Fibrillation who did not have any symptoms. This allows earlierr treatment and better outcomes for patients. Dignified Care How are we doing? Fundamentals of Care All Health Boards in Wales have been assessing themselves since 2003 to see how well they are delivering the basic care that all patients should receive, using the Fundamentals of Care Standards and Audit System. In response to the Francis Report, the Welsh Government have updated the Fundamentals of Care Standards to include 3 things: Staff Experience (what it is like to work here), which complements the original Operational Component (policies, procedures and record keeping) and User Experience (what it feels like to be a patient receiving care) which looks at 12 fundamental areas of clinical practice. In this year s assessment, the overall User Experience score was above the expected standard, at 94%. The standardd that patients and users were most satisfied with, at 99%, was Ensuring Safety. Rest and sleep was the area that patients and users were most concerned about, with comments like: Some patients are noisy at night The ward is sometimes nois from other patients and othe patients being transferred in the bays. In response, we are in the final stages of developing new guidance for maintaining a restful environment at night, and an information patients. staff about leaflet for 18 Page

19 Overall, in the operational component, three standards were above the expected standardd of 85% (preventing pressure ulcers, eating and drinking, ensuring safety), with the others all below this. This means we need to improve our processes, record keeping and documentation standards. Changes are being made to the design of the current nursing documentation, in response to feedback from staff, so that it provides the record that care has been assessed, planned and given, and is easy for staff to complete. The stafff experience is important as there is a relationship between how staff feel about going to work and the quality of care given. The results of the staff experience survey in the Fundamentals of Care audit are similar to the results from the 2013 All Wales Staff Survey and so the results of this survey will influencee the direction of the work of the Staff Survey Action Group. What have we done? Dignified Care Training The Health Board has been delighted to work collaboratively with the NHS Wales Centre for Equality and Human Rights to produce an all Wales e-learning programme called Treat Me Fairly. This course helps staff to recognisee the value of their own contribution in providing an excellent standard of service that is fair, meets individual needs and treats everyone with dignity and respect. Dignified Care for People with Dementia Some of the most vulnerable people in our hospitalss and communities are those with cognitive impairments, like dementia. Where as in the past, people with dementia would be seen in the mental health services, the increasing numbers in the population mean that they are now accessing all our services, in hospital and in the community, and so all our staff need to understandd dementia and the specific needs of those living with dementia, and their carers. This has led to increased collaboration between general and mental health staff which has been extremely beneficial in ensuring knowledge, skills and learning are shared across both disciplines. 19 Page

20 Based on training provided by experienced staff from the mental health services, two key things have been achieved this year in general services: o The Health Board has introduced the Daisy symbol, as a discreet way of being able to identify at a glance that a patient has a cognitive impairment. This symbol will only be used in liaison with the patient as and family members, and where it is in the patient s best interests. o The General Wards are all using Alzheimer s Society s This is me document, which gives the ward staff information about the patient as an individual and their family, and helps them to care appropriately for each person. End of Life Care ABUHB has worked in partnership with our partners in the third sector: St David s Hospice Care, Marie Curie Cancer Care and Hospice of the Valleys, to develop a Service Delivery Plan for End of Life Care. The ongoing engagement from all organisations and the continuing partnership approach to service development has been one of our greatest achievements this year. In addition, we have been working in particular on advance care planning so that we can identify those people that are coming towards their last weeks of life, and ensure that plans are in place to support them to have a good death. The focus has been on training for staff in Nursing Homes, and in Community Nursing. We have also continued to increase the number of people cared for at home rather than hospital in their last days of life. 20 P age

21 Timely Care & Services What have we done? Timely Care Getting to see your GP There are 89 GP practices in the Health Board area. However, for some patients it remains difficult to get to see your GP at a convenient time. The 5 As for Access are locally agreed standards of access to improve the patient experience of access to primary care services. Achievement of these standards demonstrates a practice s commitment to accessible primary care services. The standards in the 5 As for Access are summarised below, with the percentage of practices achieving this standard: 57% of practices in Gwent attain 5 As for access 1. Number of GP Practices open at 8.00am with first appointment with GP at 8.30 = 69.6% 2. Number of GP Practices open Lunchtime = 94.3% 3. Number of GP Practices with the last bookable appointment of 17:50 = 86.5% 4. Number of GP Practices with telephone access from = 98.8% 5. Number of GP Practices that provide "Sort in one call" or My Health OnLine = 91% Timely Care Waiting Times for all Referrals The target set by the Welsh Government is that 95% of referrals should wait less than 26 weeks from referral to treatment (RTT), with a maximum wait of 36 weeks. At the end of March 2014, 91.4% of patients waited less than 26 weeks and 891 patients had waited more than 36 weeks for treatment. 21 P age

22 Timely Care Waiting Times for Cancer Patients At March 2014, 99% of patients met the 31 day standard for referral to treatment for peoplee referred for reasons other than suspected cancer who are subsequently diagnosed with cancer, against the national target of 98% 95% of patients were treated within the 62 day standard for patients referred with suspected cancer, which was equal to the national target of 95% Timely Care in A&E This year, we have seen and people in our A&E departments, a slight fall on number the previous year. Within this total though, the number of majors (the seriously ill patients) has increased, and these are the sickest people, requiring a lot of skilled and complex care from the staff in A&E. A& &E 4 hour Target - Whilst we didd not meet the Welsh Government target of 95% of people waiting less than 4hrs, we have reduced the number of people waiting more than 4hrs this year, and consisten tly performed better than the all Wales average. The chart below shows the percentage of people waiting less than 4 hours in the A &E Departments at NHH and RGH. 22 Page

23 A&E 12 hour Target - There are some people who wait in A&E for 12 hours or longer. This is unacceptable, because this is not just a poor patient experienc ce, but can have a negative impact on the patient s health. We have therefore prioritised reducing the number of people waiting in the department for 12 or more hours. Exception reports are producedd for each patient who remains in A& &E longer than 12 hours to identify the reasonss and understand how we can prevent this in future. The numbers from May 13 onwards are lower compared to the 2 previous years. But the target has to be for zero 12 hour waits in A&E. Timely Care Improving how patients move through the hospital services A team from RGH is working with a national expert on flow to use their data to understand where improvements can be made right through the hospital, to decide the changes that can be made, to test the changes and to monitor the impact of the changes, to make sure that they benefit patients. It is early days for such an ambitious programme, and this is a priority for next year. The Stepping Stones Programme, facilitated by ABCi, on improving quality through co-ordinating and monitoring the different activities needed to lead to a timely and effective discharge from a community hospital, complements this programme in the acute services. Timely Care and Follow-up Outpatient Appointments There are high numbers of follow-up appointments across all specialties. This has led to the situation where many people have not been followed up within the timescalee specified by the doctor. There has therefore been a central approach to managing this issue, focusing on the waiting lists with the highest priority. This work has so far reduced the waiting list from to This has particularly impacted on the numbers of follow-ups that are more than a year beyond their due date, which is very welcome. However, we know we have much more to do to reduce these numbers. 23 Page

24 Ophthalmology has had a particular problem with the number of follow up appointments beyond the due date. This is a risk within ophthalmology because some conditions have potential for clinical deterioration which, if not spotted, can mean permanent harm to the patient. The priority was to reduce the number of people waiting more than 12 months to zero. Although the numbers have reduced from over 600 to 235, this target has not been met because more people have been coming on to this list than anticipated. Consultant Ophthalmologists are working with Community Opticians to identify patients that can safely be followed up by the opticians, leaving the Ophthalmologists with more time to see the higher risk patients. Treating peoplee as individuals How are we doing? Patient Experience Survey There is now a standardd survey that all Health Boards in Wales are using regularly to get a picture of patientt experience across all their services. Patients are asked to rate their overall experience from 0 (very bad) to 10 (excellent). We have decided that we want all our areas to achieve 85% of patients rating the experience between In Scheduled care, the first area to complete a larger scale survey, 89% of patients rated their overall experience as In Unscheduled Care, 91% of patients rated their overall experience As we develop a picture of patient experience acrosss the whole organisation, and repeat the survey, we will start to get a picture of differences in the services from the patient s point of view, which will give us a clear idea of where we need to focus our efforts to improve patientt experience. How are we doing? Individual Patient Concerns and Putting Things Right The underlying principle of Putting Things Right is that whenever concerns are raised by an individual about treatment and care, whether through a complaint, claim or clinical incident, the individual involved can expect us to be: open and honest, to give a prompt acknowledgement, to complete a thorough and appropriate investigation and to give a clear response about how the matter will be taken forward. 24 Page

25 During 2013/2014, we received 1133 formal complaints. Although we regret that people had the need to complain, this is 1133 opportunities to see our care from the patient s point of view and learn about what we need to change to improve the care for all patients. The main issues that patients made complaints about were communication failures, clinical care, waiting times and cancellations. During this year the Board received an Ombudsman report that was critical of our services because we had not taken into account fully that a patient was hard of hearing which resulted in poor communication with the patient. We have looked in detail at how we respond to the increasing numbers of people who have hearing loss and we have determined across the Health Board: o to put hearing loops where we need them, o to see whether staff are aware of hearing loss problems and ensuring that staff are mindful of the need to consider hearing deficits o to make the simple changes that Action for Hearing Wales have shown can make all the difference. The Executive Nurse Director has set up a multidisciplinary Accessibility Group to improve access to the service for all patients with special needs. There are many examples of what we are doing to improve clinical care and reduce waiting times and cancellations in this report. However, a number of complaints have shown us how we can fail to communicate well with patients. To improve communication across this broad range of areas, the Health Board has developed a customer care course which is available to all staff, clinical and nonclinical. In addition, for clinical staff, we have recently bought in a package called Sage and Thyme training. This focuses on responding to patients concerns and fears to encourage improved communication and support patients who are upset and frightened. 25 P age

26 What have we done? Treating People as Individuals People with sensory loss Small things can make it hard for people to find their way around hospitals and get to the services they need in the community. The Welsh Government has introduced new accessibility standards for patients with sensory loss things like poor hearing or eyesight. The Executive Nurse Director is leading the implementation of these standards and a multidisciplinary Accessibility Group has been set up to put in place the changes needed across the Health Board. The need for changes is illustrated by the Ombudsman case described above, but there is a lot of enthusiasm and willingness to improve the accessibility of services for patients with sensory loss. Treating People as Individuals People with Learning Disabilities Other people find it difficult when they come into hospital, particularly people with a learning disability. In order to improve access to services for people with a learning disability, we have appointed 2 Health Liaison Nurses. They work with staff in the acute services, and with the service user and their family, and provide specific assistance to improve the patient experience and outcomes. This enables people to receive the procedures and treatment that they need, as illustrated in the patient story: PATIENT STORY Mr D. is a 26 year old gentleman with Autistic spectrum disorder. He was referred to the hospital as he needed a scan. His parents were worried that he would find the ultra sound department very frightening as it was unfamiliar, as well as the procedure itself. Mr. D does not tell people when he has pain and it was identified that there were significant risks to his health if he was not able to have the ultrasound scan because he was too frightened. The Health Liaison Nurse and Community Learning Disability Nurse, who was known to the patient and his family, therefore visited him and his family together. They discussed and agreed what they could change in the department that would help him to go through the scan procedure without being too frightened. The Plan: His parents provided nursing staff with bedding from Mr D s bedroom so that the examination table would look like his own bed. Mr D was allowed to hold his toy monkey throughout the procedure and his parents were able to stay with him. Result: Mr D was not frightened and had a successful scan. 26 P age

27 Treating People as Individuals Carers Many people in our communities are supporting someone who is ill, frail or disabled. These people are carers, and the support they give day by day complements the work of the Health and social services organisations. Without them, these organisations simply could not cope with the demand. Many carers are older people, possibly in declining health themselve es. It is vital that we support carers in every way we can. Working together with Carers we aim to achievee the national and local vision, towards improving the quality of life for Carers in the ABUHB area. One way we are doing this is with the effective provision of relevant, up to date and targeted information to Carers at every point of their journey through the NHS. This can have a big impact, as shown by the quote from a carer: My wife suffers with dementia and I am her Carer. I was feeling very unwell myself and I gave my sister in law the Carers Information card which has contact details of the Local Authorities. She rang the number and I was able to get all the help I needed. Being able to get information quickly at the right time relieved me of worry. I wanted to tell you that it works. I keep the card in my wallet and I have been telling everyone I meet how helpful it is. Treating People as Individuals Older people As older people often have a number of problems when they come to A&E, they are some of the most complex patients we see, and becausee of this, can be the people that have the longest waiting times in the department. We know that this can be particularly difficult for an older person and that in many cases, their health problems, even though they are complex, could be better managed 27 Page

28 through support at home. We have therefore introduced a Consultant with special expertise in the complex problems of older people into the A and E Department Frailty at the Front Door. Older people are seen by this Consultant, and an personal plan is put in place. Either they go straight home with the care they need arranged for them over the next few days, or they are admitted to hospital, but with a personal plan which means that they get the hospital care they need within 24-48hrs, and then go home with the support they need already in place. This is all co-ordinated through the Frailty Service in the Community, and is providing a much better service for older people as it is designed for their particular needs. Treating People as Individuals Co-production and Patient Engagement We have held a number of events, where the focus is on hearing from patients and staff so that we have a shared understanding of what needs to be done to improve the services. These events have included a learning event for the Fractured Neck of Femur Service and a Prudent Healthcare Workshop to look at what applying Prudent Healthcare principles in elective knee surgery would look like. Prudent Healthcare means making sure that we use the resources entrusted to us in the most effective way. We have learned a lot from these workshops about the overwhelming benefits of engaging with our patients. This is a small start, but we need to work towards patient engagement in all aspects and at all levels of our service design and delivery, so that it underpins all our practice and patients are able to engage effectively as individuals and collectively. 28 P age

29 OUR STAFF Who are our staff The Health Board employs 13,483 people, some of whom work part time. This therefore equates to 10, Whole Time Equivalents (WTE s) as at the 31st March The largest staff groups are: o Registered Nurses and Midwives at 3, WTE s (32%) and o Additional Clinical Services (health care support worker for nursing and other clinical services like physiotherapy) at 2, WTE s (20%). Although the Health Board is facing great challenges financially, we have increased the number of staff we employ by WTE (1.42%) over the last 12 months. 29 P age

30 Our Stafff Achievements We are proud that our staff have been rewarded with recognition of their skill and commitment, through winning a number of awards this year. Although some awards are high profile, we are also very aware of the praise received by other staff in the letters of thanks we receive, and the comments on the wall of thanks, for the care they provide every day to patients. The detail of these awards can be seen in our Annual Report. Our Staff Wellbeing We cannot expect staff to demonstrate care and compassion towards patients if we do not as an organisation demonstrate these values in the way in which we behave towards our staff. As part of this, we need to ensuree that every member of staff has a development review, so they have opportunities to develop their skills and knowledge, both in the ways that they want to grow, but also in the ways that we need to change as an organisation. We also need to care for the wellbeing of staff. We therefore monitor a number of key staff-related indicators: Sickness Absence If staff are not enjoying their work then they can go off sick more frequently. The sickness absence % for 2013/2014 was 5.24%, which is 0.25% above the target of 4.99% %. 30 Page

31 Performance Appraisal and Development Reviews (PADR) Undertaken Every member of staff should have a PADR every year. We made a consistent improvement in our PADR compliance throughout early 2013/14, however, this dropped off over the winter period. We aim to build on the experience gained this year to meet the PADR target of 85% compliance across all areas. Percentage of Staff in Post with Annual PADR by Division Medical Appraisals As at 31st March 2014, the percentage of secondary care doctors who have had an appraisal (excluding trainees and clinical fellows) is 89%. Our Response to the Francis Report In July 2013, the Welsh Government published Delivering Safe Care, Compassionate Care which demonstrated the commitment to compassionate care to all who delivering safe and use our healthcare services in Wales. Central to this was ensuring we have a culture that focuses, at all times, on the needs and rights of patients. Values and Behaviours Framework The revised values and behaviours framework was developed following feedback from the staff thatt it should be meaningful, memorable and measurable. 31 Page

32 In response to this, the revised values are: o Patient first o Personal responsibility o Passion for improvement o Pride in what we do In addition to the values there is a framework of behaviours that positively support these values, and negativee behaviours which are not acceptable as they do not support the values. Nursing Principles The All Wales Nursing Staffing Principles describe the nursing staffing levels that should be in place. These nursing levels are currently being adopted, leading to an increase in the number of nurses and health care support workers on many wards. It is important that we can show that increasing the number of nurses leads to an improvement in the quality of care. A number of important outcomes for patients are therefore being monitored. Developing our Leaders A new programme Enhanced Leadership and Management - has been developed for Senior Leaders, Clinical Directors, Medical Managers, Neighbourhood Care Network Leads, Senior Nurses and Midwives, Heads of Service and Senior Managers in a partnership between ABCi and the Organisational Development Department. Training Staff to Improve Quality Improving Quality Together is a National training initiative so that throughout Wales, we have a national approach to quality improvement. The training ensures that everyone in the NHS in Wales has a common language for quality improvement so we can all take part in it. The training has 3 levels bronze, silver and gold, which allows staff to develop their skills in quality improvement as they move through the levels. The ABCi Team have taken the lead for the roll out of the IQT training at all levels across the organisation. By March, over 1250 staff had completed the bronze level training, with a certificatee presented to the 1000th and the 1250th staff members to completee their bronze training. 32 Page

33 Our Staff Experience Words Speak Louder With Actions Staff Survey, have YOUR say The staff survey in 2013 showed that we need to improve engagement between staff and senior managers: to improve communication, ensure staff are involved in important decisions and make sure that changes are made, based on feedback from staff about what it is like to work in ABUHB. At an organisational level, we are therefore: o Looking at how we can use external frameworks like Investors in People to improve all aspects of staff engagement o Using more ways to gain feedback, regularly on the issues identified in the staff survey o Agreeing standards for how we will engage with staff that can be monitored and reviewed o Repeating the staff survey in 2015 Scheduled Care is an example of the changes that are been made in the Divisions. In this Division there is: o A Staff Council to design and put in place improvements in communication and engagement within the Division o Pulse Surveys, which are short, focussed staff experience questionnaires, undertaken particularly in areas where there have been a number of concerns o A Staff Forum for managers, clinical directors and senior nurses and a junior doctors forum to discuss operational, clinical and strategic issues o A Scheduled Care Newsletter o Local Team meetings to discuss local issues that are important to staff. 33 P age

34 Our Volunteers In the last year, we have further developed the Strategy and Policy for volunteers within the organisation, which will be finalised in the next year. Volunteers are working in over 40 different projects across the services, with children, young people new mums right through to older people. A great example of our volunteers are those that go into wards at YYF and YAB as part of the Sunflower Scheme. This is a BIG lottery funded scheme, run by Gwent Association of Voluntary Associations (GAVO). There are some patients in those hospitals who find that a single room makes them feel isolated. So groups of volunteers are going on to the wards, and bringingg the patients together to play bingo, or paint or other group activities. They also organise a hairdresser (supported by Coleg Gwent for the patients, or nail painting things that make a person feel much better about themselves, but are not a core part of a nurses role. Both the patients and their relatives are enthusiastic about the support from volunteers: I m very pleased to have a chat with you. Please come again. I ve not played bingo for years. It s lovely to seee peoplee like you come and chat with the patients. i If you would be interested in being a volunteer in one of our hospitals, please look on the pages in the internet site or contact Rhian Lewis, Volunteering Development Manager - rhian.lewis2@wales.nhs.uk or Page