Elaine Andrews, Assistant Director of Nursing & Safety and Caroline Booton Quality Analyst Jill Asbury, Acting Director of Nursing
|
|
- Georgina Jennings
- 5 years ago
- Views:
Transcription
1 Report to: Board of Directors Date of Meeting: 26 th October 2016 Report Title: Inpatient Falls Report Status: Mark relevant box with X Prepared by: Executive Sponsor (presenting): For information x Discussion Assurance Approval Regulatory requirement x Elaine Andrews, Assistant Director of Nursing & Safety and Caroline Booton Quality Analyst Jill Asbury, Acting Director of Nursing Purpose of the Report In-patient falls remain a great challenge within Airedale NHS Foundation Trust and we remain committed to ensure that our multidisciplinary team tailor interventions to the needs of the individual patient. Research demonstrates if this is done then falls may be reduced by 20-30%. Quality improvement work has been ongoing on Ward 4 and the approach has now been scaled up to include Wards 6, 7 and 9. Focusing on the Elderly Ward (Ward 4) and working in collaboration with the Yorkshire & Humber Improvement Academy, core safety improvement principles are being implemented, including providing support within the clinical environment and recognising the clinical expertise and knowledge of the team. Current evidence shows that multiple interventions (used in conjunction) are effective in reducing falls, including chair and mattress alarms, advice on footwear and toileting schedules (including nocturnal continence). A key intervention is a falls safety briefing (or huddle). These are led by a senior clinician with the objective of identifying those patients at high risk of falling and determining how to prevent such a fall. The report outlines the progress that we have made to date and the ongoing work that we intend to undertake. Key points for discussion Measurement over time is essential in quality improvement with benchmark data necessary to demonstrate improvement. Following key interventions that have been undertaken on Ward 4 the average number of weekly falls has improved. Work is already ongoing to scale up the QI work stream on the other wards Since March, there have been no further instances of a serious fall on Ward 4. There appears to be a cultural shift away from accepting inpatient falls as normal and part of a proactive approach to prevention. Our current falls rate in the Trust is below both the Trust and national average for the second consecutive month. (August and September 2016) (Figure 2) Continuous improvement is built on small incremental changes, using a systematic approach to
2 test their impact and feasibility - Plan-Do-Study-Act. Recommendation The Board are asked to: Acknowledge the significant work that we have already undertaken to date. Acknowledge the areas upon which we have improved upon. Continue to support the scaling up work and acknowledge that more focussed work is required.
3 Update for Trust Board October 2016 Current Position regarding inpatient falls in ANHSFT - October Introduction In-patient falls remain a great challenge within Airedale NHS Foundation Trust (ANHSFT) and we are committed to ensuring that our multidisciplinary team tailor interventions to the needs of the individual patient. Research demonstrates if this is done then falls may be reduced by 20-30%. National evidence also suggests that patient harm is likely to occur at the second fall and therefore it is paramount that interventions are put in place at this time in order to minimise the risk of a further fall. This paper will describe the focussed approach that is being taken within ANHSFT using the science of improvement. Individuals who fall tend to have multiple interacting risk factors, and so we should not be surprised that falls prevention is a complex rather than straightforward challenge. Falls prevention programmes in hospital settings are usually only successful when multiple interventions are included. The Falls Steering Group continues to coordinate the falls related work. Quality improvement work has been taking place on Ward 4 as part of the Ward Development Plan since March 2016 and is now being scaled up to include Wards 6, 7 and The falls quality improvement project on the complex medical elderly ward (4) 2.1 The challenge and aim: Falls are a cause of injury, pain, distress, delay in discharge and loss of independent living. Evidence suggests that the effect is particularly pronounced for people over the age of The aim is to effectively manage and reduce the number of falls sustained by inpatients. A key objective is a concurrent improvement in falls that result in significant harm (head injury, severe laceration) and fracture. 2.2 Interventions taken: Focusing on the Elderly Ward (Ward 4) and working in collaboration with the Yorkshire & Humber Improvement Academy, core safety improvement principles have been implemented, including providing support within the clinical environment and recognising the clinical expertise and knowledge of the team. Current evidence shows that multi-component interventions are effective in reducing falls. Ward 4 has introduced chair and mattress alarms, advice on footwear and toileting schedules with a particular focus on nocturnal continence. A key intervention is a falls safety briefing (or huddle). These are led by a senior clinician and take place each morning with 1 Department of Health (2009) Falls and Fractures: effective interventions in health and social care. Crown copyright: COI for DH. 1
4 the multidisciplinary team (MDT). The objective is to identify those patients at high risk of falling and determining how to prevent such a fall. 2.3 How we will know that a change is an improvement: Measurement over time is essential in quality improvement. Benchmark data can augment evaluation. Figure 1: Special Process Control Chart number of falls on Ward 4 commencing 26/01/15 (Week 1) Week 63 Week No of falls Overall average UCL Week 75 Source: Ulysses. The special process control chart shows the number of fall incidents reported each week on Ward 4, commencing 26 th January 2015 (Week 1). A 64 week baseline period provides a reliable value against which progress can be evaluated. In the baseline period, there were on average 2.9 falls a week. Three points in this period show the number of fall incidents above the expected range (upper control limit [UCL] denoted by the green line), a finding that cannot be explained by random variation or chance. Key project intervention milestones are as follows: Week 63 (2016) weekly safety huddles commence. Week 66 (2016) Dr Ali Cracknell from The Improvement Academy visits Ward 4. Week 75 (2016) Chair and mattress alarms are introduced. In the subsequent period (Week 65 onwards), the average number of weekly falls has improved to 1.7. Two out of three data points are more than two standard deviations below the average and three out of five points are more than one standard deviation below the 2
5 average. These are tests for special cause variation and indicate a favourable shift in performance. 2.4 The progress made: The data indicates improvement in both the number of falls and, on closer inspection, their severity. Between April 2015 and March 2016, four falls resulted in significant harm and two in fractures. Since March, there have been no further instances of such falls on Ward 4. Whilst these are small numbers and variation due to case mix between years can be expected, findings suggest a change in culture. Work to sustain the progress made is being supported by an initiative to measure the days between falls; Ward 4 has had an episode of 26 consecutive falls free days in July into August There has been a cultural shift away from accepting inpatient falls as normal and part of a proactive approach to prevention. 3.0 Current falls rate Trust-level view of performance 2016/17 The following special process control chart shows the Trust-level inpatient falls rate per 1000 occupied bed days (depicted as a blue line). The red line indicates the RCP Falls Audit national average to enable comparison. The rate in August shows variation (better than expected) below the predicted summary range (denoted by the red triangle). Whilst the September value is within expected limits, the rate is below both the Trust and national average for the second consecutive month. Figure 2: Airedale NHS FT falls per 1000 occupied bed days Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Falls per 1000 OBD Average LCL UCL RCP Falls Audit/1000 bed days Source: Information Services and Ulysses. 3
6 Of all the falls that have occurred since April 2016 (n=473), the following stack chart shows those that have resulted in significant harm (n=9) and/or fracture by location (n=7). Figure 3: Reported falls resulting in fracture and/or significant harm by location - year to date Ward 1 Ward 2 Ward 6 Ward 7 ACU Source: Ulysses. Number Ward 16 [CCU] Significant Harm Fractures It is noted that the majority of the falls that result in significant harm have occurred on the medical wards so further focussed work will be undertaken as an extension to the work described in this paper. 4.0 Progress of the Wards as part of the scaling up phase Ward 9 has had an episode of 34 consecutive falls free days in August Ward 4 has had an episode of 26 consecutive falls free days in July into August Ward 4 is presently (as of 14 th October 2016) at 9 falls free days. Ward 6 has had an episode of 14 consecutive falls free days in September Ward 7 is presently (as of 14 th October 2016) at 38 consecutive falls free days. 5.0 Next steps The Assistant Director of Nursing and Safety meets with the Senior Sisters weekly and will continue to identify any themes/trends relating to the patient falls from the preceding week. Scaling up the Quality Improvement work will continue across the wards. Work will continue as part of the scaling up to embed a cultural shift away from accepting inpatient falls as normal and part of a proactive approach to prevention. Following a further visit from Dr Ali Cracknell from the Improvement Academy in September 2016 other wards will be introducing the Safety Huddles; these being Wards 5, 6, 7 and 9. Planning is taking place to set up a local engagement event with the Improvement Academy, with Ward 4, to talk about our progress with Safety Huddles. 4
7 Dr Ali Cracknell will visit again on the 18 th November and work will commence with the rest of the inpatient areas. All patients who are at risk of falls continue to be assessed and have a higher level of observation prescribed within the Intentional Rounding/Safety Bundle A Task and Finish Group is leading work on enhanced supervision (also known as specialling ) throughout the Trust Carers and families are being encouraged to participate in care. This is part of the implementation of John s Campaign (this is a national campaign the aim of the campaign is for the right for carers and families to stay with people with dementia within the hospital setting). ANHSFT have pledged commitment to this. The Falls Steering Group have commissioned a Task & Finish Group to improve the Falls Care Plan It is noted that the majority of the falls that result in significant harm have occurred on the ground floor wards so further focussed work will be considered. The University of Portsmouth are embarking on a piece of work around cushioned flooring (Hip Hop flooring) for high risk areas in clinical wards and they are looking at Centres to participate. Airedale is hoping to participate in this. The Post falls proforma has now been rolled out Trust wide. 6.0 Summary Continuous improvement is built on small incremental changes, using a systematic approach to test their impact and feasibility - Plan-Do-Study-Act. We are intending to roll out safety huddles across Wards 5, 6, 7 and 9 in the coming weeks. To scale up and spread the lessons learned the support of the Quality Improvement Team (specialists in improvement science) is required to ensure effective implementation. 7.0 Recommendations The Trust Board is asked to receive and note the work being undertaken related to falls in order to reduce the number of falls and the severity of the same. Elaine Andrews Assistant Director of Nursing and Safety Caroline Booton, Clinical Quality Analyst 17 th October
Influence of Patient Flow on Quality Care
Influence of Patient Flow on Quality Care Patients Waiting on Trolleys for an Inpatient Bed Patients who are Medically Fit to be discharged and cared for at Home with Support or in a Nursing Home or District
More informationInfluence of Patient Flow on Quality Care
Influence of Patient Flow on Quality Care Patients Waiting on Trolleys for an Inpatient Bed Patients who are Medically Fit to be discharged and cared for at Home with Support or in a Nursing Home or District
More informationPRESSURE ULCER THEMATIC ADVERSE EVENT REPORT - MARCH The aim of this report is to provide NHS Borders Board with a thematic review of:-
Appendix-15-35 Borders NHS Board PRESSURE ULCER THEMATIC ADVERSE EVENT REPORT - MARCH 15 Aim The aim of this report is to provide NHS Borders Board with a thematic review of:- Avoidable hospital developed
More informationAyrshire and Arran NHS Board
Paper 6 Ayrshire and Arran NHS Board Monday 11 December 2017 SPSP Update: Acute Adult Programme Author: Laura Harvey, QI Lead for Acute Services, Person Centred & Customer Care Sponsoring Director: Liz
More informationNHS performance statistics
NHS performance statistics Published: 8 th February 218 Geography: England Official Statistics This monthly release aims to provide users with an overview of NHS performance statistics in key areas. Official
More informationNHS performance statistics
NHS performance statistics Published: 14 th December 217 Geography: England Official Statistics This monthly release aims to provide users with an overview of NHS performance statistics in key areas. Official
More informationNHS Performance Statistics
NHS Performance Statistics Published: 8 th March 218 Geography: England Official Statistics This monthly release aims to provide users with an overview of NHS performance statistics in key areas. Official
More informationNHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011)
NHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011) INTRODUCTION This paper provides a monthly quality dashboard for NHS Lanarkshire. This is in line with
More informationSPSP Medicines. Prepared by: NHS Ayrshire and Arran
SPSP Medicines Prepared by: NHS Ayrshire and Arran Medication Reconciliation: Story so far MR happening in primary care, acute adult, paediatrics and mental health Started in acute then mental health,
More informationBoard of Director s Meeting
Board of Director s Meeting Meeting Date: 15 November 212 Agenda item: 6.1 Title: Purpose: Summary: Recommendation: Author: Presented by: QUALITY AND PATIENT SAFETY ASSURANCE COMMITTEE To provide an exception
More informationIMPROVING TRANSITIONS FROM ACUTE CARE TO REHAB: SPREADING CHANGE ACROSS GTA HOSPITAL SITES FOR PATIENTS POST-HIP FRACTURE
IMPROVING TRANSITIONS FROM ACUTE CARE TO REHAB: SPREADING CHANGE ACROSS GTA HOSPITAL SITES FOR PATIENTS POST-HIP FRACTURE GTA Rehab Network Charissa Levy, Sharon Ocampo-Chan, Donna Renzetti October 2016
More informationLeadership for quality improvement
Leadership for quality improvement @ELFT_QI qi.elft.nhs.uk qi@elft.nhs.uk What is the context within which we lead? What type of leadership behaviours are best suited for this context? Culture is a set
More informationNorthern Health - Acute Services. Evidence Based Practice Venous Thromboembolism Prevention
Northern Health - Acute Services Evidence Based Practice Venous Thromboembolism Prevention (VTE) Jeannette Kamar Christine Lamotte, Liam Carter Improving Patient Safety Preventing and Managing Venous Thromboembolism
More informationA new integrated model for Care Homes from Walsall CCG/Healthcare NHS Trust
A new integrated model for Care Homes from Walsall CCG/Healthcare NHS Trust Sally Roberts - Director of Governance, Quality & Safety. Walsall CCG Katie Welborn Advanced Nurse Practitioner- Walsall Healthcare
More informationFalls Prevention In Rehabilitation
Falls Prevention In Rehabilitation Robyn Walker Rankin Park Centre Greater Newcastle Cluster March 2008 1 Frequency of Falls A total of 157 patients fell in Rankin Park Centre during the 12 months from
More informationEvaluation of NHS111 pilot sites. Second Interim Report
Evaluation of NHS111 pilot sites Second Interim Report Janette Turner Claire Ginn Emma Knowles Alicia O Cathain Craig Irwin Lindsey Blank Joanne Coster October 2011 This is an independent report commissioned
More informationSafety in Mental Health Collaborative
NHS Tayside Safety in Mental Health Collaborative Improving Safety in Mental Health Programme Aims supported by an Improvement Advisor: Dr Noeleen Devaney Support 4 UK organisations to: reduce harm improving
More informationUrgent Care Short Term Actions to Improve Performance
To: Trust Board From: Chief Operating Officer Date: March 2017 Healthcare standard Title: Urgent Care Short Term Actions to Improve Performance Author/Responsible Director: Michael Woods / Andrew Prydderch
More informationQuarter /13 Quality Account (Quality and Safety)
Airedale NHS Foundation Trust Board of Directors:23 rd January 213 Title: Quarter 2 212/13 Quality Account (Quality and Safety) Author: Alison Fuller, Assistant Director Healthcare Quarter 2 212/13 Quality
More informationSheffield Teaching Hospitals NHS Foundation Trust
Sheffield Teaching Hospitals NHS Foundation Trust @seamlesssurgery Seamless Surgery Team Sheffield Teaching Hospitals NHS Foundation Trust July 2017 PROUD TO MAKE A DIFFERENCE PROUD TO MAKE A DIFFERENCE
More informationTHE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST REDUCING HARM TISSUE VIABILITY PROGRESS REPORT
Agenda item A5(iv) THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST REDUCING HARM TISSUE VIABILITY PROGRESS REPORT EXECUTIVE SUMMARY The Tissue Viability Team assists wards and departments to reduce
More informationLearning from Deaths; Mortality Review Policy
Learning from Deaths; Mortality Review Policy Version: 4.0 New or Replacement: Replacement Policy number: CESC/2012/066 (Version 4) Document author(s): Executive Sponsor: Non-Executive Sponsor: Title of
More informationBoard Briefing. Board Briefing of Nursing and Midwifery Staffing Levels. Date of Briefing August 2017 (July 2017 data)
Board Briefing Board Briefing of Nursing and Midwifery Staffing Levels Date of Briefing August 2017 (July 2017 data) This paper is for: Sponsor: Chief Nurse- Dame Eileen Sills (DBE) Decision Author: Workforce
More informationLearning from Patient Deaths: Update on Implementation and Reporting of Data: 5 th January 2018
Learning from Patient Deaths: Update on Implementation and Reporting of Data: 5 th January 218 Purpose The purpose of this paper is to update the Trust Board on progress with implementing the mandatory
More informationNational Trends Winter 2016
National Trends Winter 216 About the National Trends data This report presents a unique and real-time view of trends within temporary nursing including bank and agency usage. The data used has been drawn
More informationCorporate Services Employment Report: January Employment by Staff Group. Jan 2018 (Jan 2017 figure: 1,462) Overall 1,
Corporate Services Employment Report: January Employment by Staff Group Jan (Jan 20 figure: 1,462) Jan % Overall 1,520 +58 +4.0% 8 Management (VIII+) 403 +52 4.8% Clerical & Supervisory (III to VII) 907
More informationThe Royal Wolverhampton NHS Trust
Title: Safe Staffing; Planned Versus Actual Staffing by Ward September 2016 data The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 31 st October 2016 Title: Nursing Workforce Report Executive
More informationASPIRE. Allied Health Professions Supporting and Promoting Improvement, Rehabilitation and Enabling Others ADVANCED PRACTICE SPECIALIST GENERALIST
ASPIRE Allied Health Professions Supporting and Promoting Improvement, Rehabilitation and Enabling Others ADVANCED PRACTICE SPECIALIST GENERALIST ENABLING OTHERS AHP Strategy 2017 2021 CONTENTS Introduction
More information4. Risk (Threats or opportunities, link to a risk on the Risk Register, Board Assurance Framework etc) None.
Report to: Management Board Agenda item: 12 Date of Meeting: 22 July 2015 Title of Report: Annual Tissue Viability Report 2014/15 Status: To Note Board Sponsor: Helen Blanchard, Director of Nursing and
More informationService Transformation Report. Resource and Performance
SUMMARY REPORT Meeting Date: 31 May 2018 Agenda Item: 9.1 Enclosure Number: 9 Meeting: Trust Board (Part 1) Title: Author: Accountable Director: Other meetings presented to or previously agreed at: Service
More informationBOARD MEETING. Document is for: (indicate with an x) Assurance x Information Decision. Executive Summary
Document Title: Presenter: Author: Contact details for further information: BOARD MEETING Review of Pressure Ulcer Prevalence across DCHS services March June 2012 Kath Henderson, Chief Nurse Michelle O
More informationIssue 5: January 2015
A trial to evaluate an extended rehabilitation service for stroke patients EXTRAS News Issue 5: January 2015 Happy New Year from the EXTRAS co-ordinating centre! Here is some more EXTRAS news to share.
More informationPrime Contractor Model King s Fund Nick Boyle Consultant Surgeon 27 March 2014
Prime Contractor Model King s Fund Nick Boyle Consultant Surgeon 27 March 2014 Current Referral Route options - Information 1. Horizon Health Choices Horizon Musculoskeletal Triage & Treatment Chronic
More informationClinical Audit for Improvement: HQIP update
Clinical Audit for Improvement: HQIP update Mirek Skrypak @MirekSkr Associate Director for Quality and Development National Clinical Audit and Patient Outcomes Programme Healthcare Quality Improvement
More informationWorking in partnership to improve the identification and treatment of sepsis
Identifying and Tackling Sepsis in Healthcare Tuesday 25 th April 2017 Working in partnership to improve the identification and treatment of sepsis Tracy Broom Associate Director Wessex Patient Safety
More informationIssue 4: October 2014
A trial to evaluate an extended rehabilitation service for stroke patients EXTRAS News Issue 4: October 2014 What has been happening since our last newsletter in March 2014.? 1. New study centres Four
More informationClinical Safety & Effectiveness Cohort # 11
Clinical Safety & Effectiveness Cohort # 11 Implementation of Discharge Planning Rounds on an Inpatient Internal Medicine Service DATE Educating for Quality Improvement & Patient Safety 1 Financial Disclosure
More informationImproving harm from falls as part of the Patient safety initiative
Improving harm from falls as part of the Patient safety initiative The story so far. 1. CONTEXT 1.1. Since January 2011, 2gether NHS Foundation Trust has been involved in the NHS South West Quality and
More informationMental Health Services - Delayed Discharges: Update
NHS Greater Glasgow & Clyde NHS Board Meeting Chief Officer, Glasgow City HSCP and Nurse Director October 20 Paper No: /56 Mental Health Services - Delayed Discharges: Update Recommendation:- The NHS Board
More informationNHS GRAMPIAN. Local Delivery Plan - Mental Health and Learning Disability Services
NHS GRAMPIAN Board Meeting 01.06.17 Open Session Item 8 Local Delivery Plan - Mental Health and Learning Disability Services 1. Actions Recommended The Board is asked to: Note the context regarding the
More informationSTATISTICAL PRESS NOTICE MONTHLY CRITICAL CARE BEDS AND CANCELLED URGENT OPERATIONS DATA, ENGLAND March 2018
STATISTICAL PRESS NOTICE MONTHLY CRITICAL CARE BEDS AND CANCELLED URGENT OPERATIONS DATA, ENGLAND March 2018 Main Findings March 2018: Critical Care Beds There were 4,064 adult critical care beds available
More informationBoard Briefing. Board Briefing of Nursing and Midwifery Staffing Levels. Date of Briefing January 2018 (December 2017 data)
Board Briefing Board Briefing of Nursing and Midwifery Staffing Levels Date of Briefing January 2018 (December 2017 data) This paper is for: Sponsor: Chief Nurse- Dame Eileen Sills (DBE) Decision Author:
More informationQuality and Efficiency Support Team (QuEST) Directorate for Health Workforce and Performance
Quality and Efficiency Support Team (QuEST) Directorate for Health Workforce and Performance A Whole System Approach to Patient Flow for Scotland Our Quality Improvement Approach Jane Murkin Programme
More informationSafety Huddles: Bringing fun to the frontline and reducing harm
Safety Huddles: Bringing fun to the frontline and reducing harm Alison Lovatt Clinical Network Director, Improvement Academy Ali Cracknell Consultant Medicine For Older People, Leeds Teaching Hospitals
More informationApril Clinical Governance Corporate Report Narrative
April 14 - Clinical Governance Corporate Report Narrative ITEM 7B Narrative has been provided where there is something of note in relation to a specific metric; this could be positive improvement, decline
More informationUrgent & Emergency Care Strategy Update
RCCG/GB/17/144 Urgent & Emergency Care Strategy Update 1. Introduction The purpose of this paper is to provide assurance on the effective delivery to date of our urgent and emergency care strategy within
More informationQUALITY REPORT
Humber NHS Foundation Trust Humber Mental Health Teaching NHS Trust Humber NHS Foundation Trust (Foundation Trust status awarded 1st February 2010) QUALITY REPORT 2009-10 Contents Quality Statement 4
More informationBOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013
Borders NHS Board BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013 Aim The aim of this report is to provide the Board with an overview of progress in the areas of: Patient Safety Person Centred Health
More informationFOREWORD Introduction from the Chief Executive 2 BACKGROUND 3 OUR TRUST VALUES 4 OUR AIMS FOR QUALITY 5 HOW WE MEASURE QUALITY 16
Contents FOREWORD Introduction from the Chief Executive 2 BACKGROUND 3 OUR TRUST VALUES 4 OUR AIMS FOR QUALITY 5 - Our achievements so far - Our aims for quality 2017 2020 AIM 1: AIM 2: AIM 3: AIM 4: Reducing
More informationBOARD OF DIRECTORS PAPER COVER SHEET. Meeting date: 31 January 2007 Agenda item: 9.4
BOARD OF DIRECTORS PAPER COVER SHEET Meeting date: 31 January 2007 Agenda item: 9.4 Title: PARLIAMENT & HEALTH SERVICE OMBUDSMAN RECOMMENDATIONS RE: PATIENT COMPLAINT Purpose: To update the Board on the
More informationEnlisted Professional Military Education FY 18 Academic Calendar. Table of Contents COLLEGE OF DISTANCE EDUCATION AND TRAINING (CDET):
Enlisted Professional Military Education FY 18 Academic Calendar Table of Contents STAFF NON-COMMISSIONED OFFICER ACADEMIES: SNCO Academy Quantico SNCO Academy Camp Pendleton SNCO Academy Camp Lejeune
More informationBOROUGH OF ROSELLE PUBLIC NOTICE ANNUAL NOTICE OF CALENDAR YEAR 2018 WORKSHOP SESSIONS, PRE-AGENDA MEETINGS AND REGULAR MEETINGS
BOROUGH OF ROSELLE PUBLIC NOTICE ANNUAL NOTICE OF CALENDAR YEAR 2018 WORKSHOP SESSIONS, PRE-AGENDA MEETINGS AND REGULAR MEETINGS BE IT RESOLVED, by the Mayor and Borough Council of the Borough of Roselle,
More informationPatient safety in the NHS in England and the development of the Healthcare Safety Investigation Branch (HSIB)
Patient safety in the NHS in England and the development of the Healthcare Safety Investigation Branch (HSIB) Dr Mike Durkin NHS National Director of Patient Safety 11 May 2016 The NHS is big! Great potential
More informationHard Truths Public Board 29th September, 2016
Hard Truths Public Board 29th September, 2016 Presented for: Presented by: Author Previous Committees Governance Professor Suzanne Hinchliffe CBE, Chief Nurse/Deputy Chief Executive Heather McClelland
More informationPercent Unadjusted Inpatient Mortality (NHSL Acute Hospitals) Numerator: Total number of in-hospital deaths
Page 1 of 23 Quality Ambition: Safe NHS Lanarkshire aims to be the safest health and care system in Scotland with no avoidable deaths, reduction in avoidable harm, a sustainable infrastructure for patient
More informationColumbus Regional Hospital Pressure Ulcer Prevention
Columbus Regional Hospital Pressure Ulcer Prevention Kathryn Jackson RN, MSN, CRRN Pressure Ulcer Prevention Columbus Regional Hospital, Columbus, IN Objectives & About Us Describe current pressure ulcer
More informationENCLOSURE: J. Date of Trust Board 29 February Pressure Ulcer Clinical Improvement Programme. Purpose of Report
ENCLOSURE: J Date of Trust Board 29 February 2012 Title of Report Purpose of Report Abstract Pressure Ulcer Clinical Improvement Programme This paper provides a progress report on our work in support of
More informationEDS 2. Making sure that everyone counts Initial Self-Assessment
EDS 2 Making sure that everyone counts Initial Self-Assessment Equality Delivery System for the NHS EDS2 Summary Report Implementation of the Equality Delivery System EDS2 is a requirement on both NHS
More informationChange Management at Orbost Regional Health
Change Management at Orbost Regional Health Our change management journey 1 Medication Change System Meds at Beds 2 The slightly exaggerated before process 3 Project Goals The purpose of the Meds at Beds
More informationSafeguarding Strategy
1 Strategy 20-2020 ULHT Strategy 20-2020 October 2016 2 Contents Section Page No. 1 1.1 1.2 2.0 2.1 Introduction Legal Framework for What does cover? Our Duties Statutory Compliance for 3.0 Our Vision
More informationFrom Implementation to Optimization: Moving Beyond Operations
From Implementation to Optimization: Moving Beyond Operations Session 260, March 8, 2018 Scott Aikey, Sr. Director, Core Clinical Applications Children s Hospital of Philadelphia 1 Conflict of Interest
More informationKentucky Sepsis Summit. August 2016
1 Kentucky Sepsis Summit August 2016 St. Elizabeth Healthcare About Us: - 7 facilities & over 1200 licensed beds - Serving the NKY/Cincinnati Region in: - Orthopedic Care - Heart and Vascular Institute
More informationGlasgow City CHP Item No. 6
Glasgow City CHP Item No. 6 CHP Committee Meeting Date: Thursday, 28 th February 2013 Paper No 2013/006 Subject: Presented by: Recommendation(s) Summary/ Background Scottish Patient Safety Programme -
More informationPublic Trust Board Meeting 22 November 2011
Public Trust Board Meeting 22 November 2011 Title Lessons Learned Report Paper Ref 12 PURPOSE (X) Information Strategic Aim Business Plan Objective Approval Decision X 1.2, 3 Assurance X Discussion Purpose
More informationM24: Engaging staff and building a movement for QI
M24: Engaging staff and building a movement for QI @ELFT_QI qi.elft.nhs.uk qi@elft.nhs.uk Monday, December 5, 2016 Introducing the ELFT team Marie Navina Kevin Mason Paul Leigh James Amar 1 Objectives
More informationA must have for any GP surgery. It is like having our own Social Worker, CAB, Mental Health Worker all rolled into one who will chase up patients on
A must have for any GP surgery. It is like having our own Social Worker, CAB, Mental Health Worker all rolled into one who will chase up patients on the phone and even go out to their houses if needed
More informationThe Royal Wolverhampton NHS Trust
The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 24 June 2013 Title: Executive Summary: Action Requested: Report of: Author: Contact Details: Resource Implications: Public or Private:
More informationCreating a Culture of Quality and Safety Gordon C. Hunt, MD, MBA Sr. Vice President & Chief Medical Officer, Sutter Health
Creating a Culture of Quality and Safety Gordon C. Hunt, MD, MBA Sr. Vice President & Chief Medical Officer, Sutter Health M2 This presenter has nothing to disclose December 2012 Blue Ribbon I & II In
More informationNottingham University Hospitals Emergency Department Quality Issues Related to Performance
RCCG/GB/14/123 Nottingham University Hospitals Emergency Department Quality Issues Related to Performance Introduction NUH have failed to meet the 95% 4 hour wait standard for a number of consecutive months.
More informationJANUARY 2018 (21 work days) FEBRUARY 2018 (19 work days)
AND CORRESPONDING DATES FOR JANUARY AND FEBRUARY 2018 JANUARY 2018 ( work days) Deadline* 12-27 12-28 12-29 1-2 1-3 1-4 1-5 1-8 1-9 1-10 Benefit Hold ** 12-28 12-29 1-2 1-3 1-4 1-5 1-8 1-9 1-10 1-11 Mailing
More informationMy Discharge a proactive case management for discharging patients with dementia
Shine 2013 final report Project title My Discharge a proactive case management for discharging patients with dementia Organisation name Royal Free London NHS foundation rust Project completion: March 2014
More informationThe State Hospital Clinical Effectiveness Strategy & Delivery Plan January 2011 December 2013
The State Hospital Strategy & Delivery Plan January 2011 December 2013 NATIONAL STANDARDS NATIONAL GUIDELINES CLINICAL AUDIT CLINICAL EFFECTIVENESS INTEGRATED CARE PATHWAYS MANAGING CHANGE EDUCATION AND
More informationIntegrating Telemedicine into mental Health Care
Integrating Telemedicine into mental Health Care learning from a Care Homes Vanguard Rachel Binks Nurse Consultant Digital & Acute Care Airedale NHS Foundation Trust Chris North Care Home Liaison Team
More informationOverview of a new study to assess the impact of hospice led interventions on acute use. Jonathan Ellis, Director of Policy & Advocacy
Overview of a new study to assess the impact of hospice led interventions on acute use Jonathan Ellis, Director of Policy & Advocacy The problem Almost 600,000 people die each year Half will die in a hospital
More informationKey Steps in Creating & Sustaining Excellence
Key Steps in Creating & Sustaining Excellence 1. Create a context for excellence 2. Enroll others (starting with leaders) in the vision for excellence 3. Create alignment, ownership and transparency to
More informationBETTER REGULATION OF MEDICINES INITIATIVE (BROMI): FIFTH REPORT ON PROGRESS
A2 BETTER REGULATION OF MEDICINES INITIATIVE (BROMI): FIFTH REPORT ON PROGRESS March 2012 A3 BETTER REGULATION OF MEDICINES INITIATIVE (BROMI) FIFTH REPORT ON PROGRESS Chief Executive s foreword In January
More informationThe aim of this report is to provide the Borders NHS Board with an overview of progress in the areas of Safe, Effective and Person Centred Care.
Borders NHS Board CLINICAL GOVERNANCE AND QUALITY REPORT Aim The aim of this report is to provide the Borders NHS Board with an overview of progress in the areas of Safe, Effective and Person Centred Care.
More informationStrategic KPI Report Performance to December 2017
Strategic KPI Report Performance to December 2017 Trust Board 25 th January 2018 Strategic KPI summary SROs: All Directors Objective KPI SRO Target Apr May Jun Jul Aug Sep Oct Nov Success Is Deliver A
More informationQuality Management Report 2017 Q2
Quality Management Report 2017 Q2 Quality Management Program CMS STAR Ratings Member Satisfaction (CAHPS & HOS) HEDIS Risk Adjustment DHS Member Incident Reporting Member Satisfaction Surveys Pay for Performance
More informationIain Patterson. Associate Workforce Director Homerton University Hospital NHS Foundation Trust
Iain Patterson Associate Workforce Director Homerton University Hospital NHS Foundation Trust Who we are? Who we are? North East London Sector 3,800 staff spread across Hackney and beyond c. 3,000 acute
More informationLearning Disability Services Monthly Statistics England Commissioner Census (Assuring Transformation) - December 2016
Learning Disability Services Monthly Statistics England Commissioner Census (Assuring Transformation) - December 2016 Experimental Statistics Published 27 January 2017 Assuring Transformation is a commissioner
More informationTina Nelson, MBA, BSN Lisa Stepp, BSN, RN Rebecca Fyffe, BSN, RN Jessica Coughenour, LPN
Establishing a Conservative Approach to the Prevention of Pressure Ulcers with the Utilization of Data Analytics to Monitor Effectiveness of Quality Efforts and Best Practice Models Tina Nelson, MBA, BSN
More informationThe Duchess Nina Nursing Home Care Home Service
The Duchess Nina Nursing Home Care Home Service 13 Limekilnburn Road Quarter Hamilton ML3 7XA Telephone: 01698 427507 Type of inspection: Unannounced Inspection completed on: 25 January 2018 Service provided
More informationFall Prevention Program. St. Catherine Hospital East Chicago, Indiana Paula Swenson Chief Nursing Officer
Fall Prevention Program St. Catherine Hospital East Chicago, Indiana Paula Swenson Chief Nursing Officer St. Catherine Hospital 189 bed community hospital, located in East Chicago Indiana Member of Community
More informationCriteria Led Discharge Pilot NHS Ayrshire and Arran Lorna Loudon, Linsey Stobo, Fraser Doris Implementing CLD in Scotland
Criteria Led Discharge Pilot NHS Ayrshire and Arran Lorna Loudon, Linsey Stobo, Fraser Doris Implementing CLD in Scotland 18.3.15 Whole System Patient Flow Improvement Programme 1 Background Project Team
More informationFour Steps to Safety. Amanda Pithouse - Deputy Director of Nursing and Quality Katherine Quilty Service User Consultant
Four Steps to Safety Amanda Pithouse - Deputy Director of Nursing and Quality Katherine Quilty Service User Consultant Background Fundamental ethos of service user co-production MDT review team conducted
More informationQu Q a u l a ilt i y t y Ac A c c o c u o n u t n
Quality Account 2010-2011 CONTENTS Statement from the Chief Executive 3 Page Statements from our Service Users 4 Summary of Priorities 6 Summary of Performance 7 Performance Review - Safety 8 Performance
More informationNurse Led End of Life Care. Catherine Malia- St Gemma s Hospice, Leeds Lynne Symonds- St Catherine s Hospice, Scarborough
Nurse Led End of Life Care Catherine Malia- St Gemma s Hospice, Leeds Lynne Symonds- St Catherine s Hospice, Scarborough SETTING THE SCENE Preferences for Place of Death 2014 Home 72% Hospice 10% Care
More informationTell Your Story with a Well- Designed Data Plan. Jackie McFarlin, RN, MPH,MSN, CIC VA North Texas Health Care System
Tell Your Story with a Well- Designed Data Plan Jackie McFarlin, RN, MPH,MSN, CIC VA North Texas Health Care System Purposes of Presentation Describe the elements of a well designed data plan Guidelines
More informationImproving Care, Delivering Quality Reducing mortality & harm in Welsh Ambulance Services NHS Trust
National Learning Session - 10 th June 2011 Improving Care, Delivering Quality Reducing mortality & harm in Insert name of presentation on Master Slide Reducing Mortality & Harm in the Welsh Ambulance
More informationNHS Borders Feedback and Complaints Annual Report
NHS Borders Feedback and Complaints Annual Report 2016-17 1 Introduction NHS Borders Feedback and Complaints Annual Report 2016-17 is a summary of the feedback provided by the complaints, comments, concerns
More informationClinical Governance report prepared for NHS Lanarkshire Board Report title Clinical Governance Corporate Report - October 2015
Page 1 of 22 Print :15/1/215 Page 2 of 22 Print :15/1/215 Quality Ambition: Safe NHS Lanarkshire aims to be the safest health and care system in Scotland with no avoidable deaths, reduction in avoidable
More informationSUBJECT: QUALITY ASSURANCE AND IMPROVEMENT
Meeting of Lanarkshire NHS Board: Lanarkshire NHS Board Kirklands Fallside Road Bothwell G71 8BB Telephone: 01698 855500 www.nhslanarkshire.org.uk SUBJECT: QUALITY ASSURANCE AND IMPROVEMENT 1. PURPOSE
More informationThe Yorkshire & Humber Improvement Academy Clinical Leadership Training Programme
The Yorkshire & Humber Improvement Academy Clinical Leadership Training Programme The Improvement Academy (IA) is one of the leading quality and safety improvement networks in the UK. The IA works across
More informationREPORT SUMMARY SHEET
Quality care for you, with you REPORT SUMMARY SHEET Meeting: Date: Title: Lead Director: Corporate Objective: Purpose: High level context: Trust Board 27 th October 2016 Infection Prevention and Control
More informationLESSONS LEARNED IN LENGTH OF STAY (LOS)
FEBRUARY 2014 LESSONS LEARNED IN LENGTH OF STAY (LOS) USING ANALYTICS & KEY BEST PRACTICES TO DRIVE IMPROVEMENT Overview Healthcare systems will greatly enhance their financial status with a renewed focus
More informationCLOSTRIDIUM DIFFICILE ACTION PLAN
CLOSTRIDIUM DIFFICILE ACTION PLAN Action plan to address the rise in cases of Clostridium difficile (C.diff) at Sheffield Teaching Hospitals NHS Foundation Trust ACTION KEY MILESTONES PERSON RESPONSIBLE
More informationUNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST BOARD OF DIRECTORS. Emergency Department Progress Report
UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST Date of meeting: 27 June Title / Subject: Status Purpose: Report of: Prepared by: BOARD OF DIRECTORS Public To update the Board of actions being
More information13 th March Ruth Pitman- Jones - Val Rhodes -
Report from the North of England Care Homes Falls Summit North of England Care Homes Falls Summit 13 th March 2018 Author Val Rhodes on behalf of the YHAHSN For more information please contact: Ruth Pitman-
More informationDate: 7 October 2015
Item 8.2 Meeting: Trust Board Public Meeting Date: 7 October 2015 Title of Paper: Quarterly Trust Health and Safety Report April to June 2015. Key Issues: Two RIDDOR (Reporting of Injuries, Diseases and
More information