Clinical Programme Groups Quality & Safety (Q&S) Monitoring Report

Transcription

1 Clinical Programme Groups Quality & Safety (Q&S) Monitoring Report Name of CPG: Surgery & Dental CPG Name and role of individual responsible for this report: Meinir Williams, Associate Chief of Staff (Nursing) Date of report: August 2011 Summary of progress made on establishing CPG Q&S structures, roles and scrutiny arrangements: CPG Structure: The CPG tier 4 structure has been approved and is part way through the OCP process. It is envisaged that the first posts within the structure will be in place by November Job descriptions are now being finalised for new and emerging roles such as Matron and Quality and Safety Lead Nurse, with a clear focus on leadership, accountability, dignity and patient centred care. A dedicated Governance team has been created within the CPG structure with the responsibility to monitor and deliver compliance with existing and future quality standards; manage risk (including health and safety), complaints and compliments; policy management; drive forward service improvement initiatives and to work as part of the CPG team in delivering the strategic agenda in collaboration with other CPGs. HR support is intrinsic to the Governance team to support processes such as complaints, clinical incident reviews, staff misconduct/disciplinary and investigations, all of which will provide the foundation for the CPGs delivery of the NHS Redress policy. The new team structure discourages vertical (site specific) working as far as is possible, and is focused on horizontal (service specific) delivery which supports the CPGs vision for integration of its services across BCUHB. Recent learning from complaints and patient experience feedback has demonstrated that the CPG has much to learn in terms of understanding the impact of implementing service change and improvement through PDSA cycles and a single site approach, in particular around variation of specialist outreach and community based services which are fundamental to supporting early discharge. 1

2 Quality Assurance: Monitoring and quality assurance of services delivered across the CPG are reported through: Key Performance Indicator (KPI) tool, based on the Executive Director of Nursing s assurance framework. These have recently been reviewed to incorporate performance reporting against 1000 lives + and AQF initiatives and targets. Concerns and compliment reports (in conjunction with the corporate concerns team) Infection control and cleanliness champion reports (in conjunction with the corporate infection control team) Performance reports (through F&P) Fundamentals of Care audits (through senior nursing group) Ward walk around Sickness and absence reports (through Workforce and OD subcommittee) Incidents and serious events (through H&S and lead nurses) Monitoring of action plans for service improvement and efficiency drives The integrated Quality & Safety and the Finance & Performance CPG committee has now been established and reports to the CPG Board through a balanced scorecard approach. The committee meets monthly immediately prior to CPG Board to ensure that the Board information is current and meaningful as is currently the main vehicle for quality assurance within the CPG. Reporting & Accountability The attached accountability and reporting chart depicts the flow of information through the CPG to the Health Board. An area currently being formalised to improve the CPGs quality assurance framework, is the links with the medical Clinical Governance groups which meet quarterly across the CPG. Once established these will better inform clinical effectiveness and drive the clinical audit integrated CPG plans. Key Q&S priorities to be addressed over the next 6 months: Establish formal reporting links from CPG Clinical Governance to the Q,S,F&P committee Appoint into the CPG structure, securing strong leaders and role models to key posts A continued focus on dementia care, dignity and respect through embedding leadership and accountability at ward level Implement actions following Ombudsman report Develop the Orthopaedic/orthogeriatrician service at YGC in line with YG and YM 2

3 Implement bed reconfigurations in a safe and timely manner at YG and YGC Enhance day surgery services focusing on the key areas for improvement i.e. ENT and Breast Orthopaedic and Colorectal Enhanced Recovery Programme to be rolled out across all sites Introduce Enhanced Recovery into Urology. Deliver the Productive Theatres programme to support safety and productivity across all three sites Progress with Infection Control and Cleanliness priorities through the work of the Clean Wards Champion across the CPG Continue to develop nurse leaders through Transforming Care initiatives Policy and written control documents review and management Risk register management Implementation of Saving 1000 lives + CPG action plan Transfer of endoscopy service to medicine CPG at YM Review of HSDU services across North Wales Any other issues to highlight for the Q&S Committee: CPG capacity to manage concerns, investigations, serious incidents and poor performance Maintaining safe staffing levels on all wards and theatres Addressing variation in service structures and clinical practice Supporting service reviews and implementing any agreed service changes. Services currently under review include: o Orthopaedics o Emergency Surgery o Urology Cancer o Ophthalmology o ENT o Vascular Ongoing decontamination issues in YM relating to estates Continuing operational challenges associated with the YGC theatre work Necessary speedy, smooth transition of beds at YG and YGC Delivery of additional orthopaedic capacity and manage the delivery of orthopaedic service for ASA3/4 patients at YGC Transfer of ophthalmology services from HMS to ABH Transfer of orthopaedic services from ABH to YGC CPGQ&SReport.doc v2 August

4 Emergency Surgical and Dental Clinical Programme Group 1000 lives Plus Action Plan ( / Central / ) May

5 NHS staff save lives every day 1000 Lives Plus will help save more 1000 Lives Plus is a national programme which seeks to improve the quality of patient care and reduce avoidable harm across NHS Wales. It is aligned with eleven other national programmes in a five year framework to deliver transformational change in the delivery of health services in Wales. Every health board and trust in Wales is involved in 1000 Lives Plus, which is introducing new ways of working to improve care by reducing harm, waste and variation. It is also committed to accelerating the pace of change to ensure good practice is spread from ward to ward, practice to practice and organisation to organisation. Progress: The aim of the 1000 Lives Campaign is to save an additional 1000 lives and prevent 50,000 episodes of harm in Welsh healthcare between April 2008 and April Every Health Board and NHS Trust in Wales is taking part and has been implementing agreed interventions, monitoring their impact and reporting on progress. A national HSMR (Hospital Standardised Mortality Ratio) is being used to measure the mortality and a methodology using case note reviews will measure harm on a Wales-wide level. 2

6 1000 lives plus campaign: 1000 lives campaign commenced April 2008 and has now ended. In its place the 1000 lives plus campaign has been launched in May The campaign has 17 key areas:- 1. Leading the way to Safety and Quality Improvement. 2. Reducing Healthcare Associated Infections. 3. Improving Critical Care. 4. Reducing Surgical Complications. 5. Preventing Hospital Acquired Thrombosis. 6. Rapid Response to Acute illness (RRAI). 7. Improving Medicines Management. 8. Transforming Care. 9. Reducing harm from Falls. 10. Stroke Improving the reliability of Acute Stroke Care. 11. Stroke Improving Early Rehabilitation. 12. Stroke Improving reliability of TIA Services. 13. Improving Care for Chronic Heart Failure Patients. 14. Identifying Depression in Hospital Setting. 15. Improving Dementia Care. 16. Enhanced Recovery after Surgery. 17. Transforming Maternity Services lives plus - New areas of work: 1000 Lives Plus also incorporates several new areas of work which will minimise waste, harm and variation. In total, there are over twenty programme areas which are being phased in over the next twelve months. These include: 1. Prevent Fall in Community Care 2. Enhanced Recovery after Surgery (Number 16) 3. Improving Maternity Services (Number 17) 4. Offering better treatment to those suffering from Depression (Number 14) 5. Improving Quality of Life and care for those with Dementia (Number 15) 6. Reducing patient identification Errors (Number 7) Mini Collaboratives: 3

7 To support organisations in implementing new areas of work introduced as part of the five year programme, 1000 Lives Plus will deliver a mini-collaborative per programme area. There will also be mini-collaboratives to support some of the mandatory interventions. Programme Areas: Mental Health Acute Coronary Syndrome Patient Identifiers Reducing Falls in the Community Enhanced Recovery after Surgery Transforming Maternity Services Aim: To improve treatment for depression, patients with dementia, first episode psychosis (FEP), and eating disorders by ensuring consistent measurement and appropriate treatment for individuals. To support clinical teams in the timely management and treatment of acute chest pain to reduce patient morbidity and mortality. To provide assist clinicians, health records and information staff to consolidate their patient information across multiple clinical systems, allowing health care professionals to make decisions based on all the relevant facts. To reduce mortality and harm in adults who have fallen and are at risk of further falls, by providing a structure around which community based services can be aligned and developed. To improve the care for patients after gastrointestinal surgery through investment in equipment and key staffing which will reduce the length of stay, post-operative complications and cancelled operations. Improving outcomes for mums to be, with a particular emphasis on by tackling sepsis, and venous thrombo-embolism. Local Targets for Mortality and Harm To support Medical Directors in achieving their local targets for the reduction of harm and hospital mortality. The events will address tools including the primary care trigger tool, the Global Trigger Tool and Mortality Reviews. Improving Care for Chronic Heart Failure Patients Reducing Healthcare Associated Infections Transforming Care To build on the work and progress across Wales to deliver reliable, evidence based care for patients with chronic heart failure. To reduce the overall burden of Healthcare Associated Infections (HCAIs) across the NHS in Wales. Reducing waste and improving quality, safety and patient focus. Rapid Response to Acute To support clinical teams in the reduction of harm and mortality associated with the acutely 4

8 Illness Improving Medicines Management Early Rehabilitation Following Stroke Transient Ischaemic Attack (TIA) deteriorating patient. To support clinical teams with the overarching actions to reduce harm from all high risk medicines and actions to reduce harm in six groups of high alert-medications. To support clinicians and healthcare professionals to make improvements in the reliability of integrated early rehabilitation for patients and carers following stroke. To support local teams of healthcare professionals to make improvements in the reliability of integrated care for the management of individuals who present with a TIA. 5

9 Emergency Specialist Surgical and Dental Clinical Programme Group Proposed Nursing Management Structure ACoS (Nursing) 8D Deputy ACoS & CLN () 8C Deputy ACoS & CLN () 8C Theatre Managers x3 (, Centre & W t) 8B Matron () 8A Head of HSDU 7 Ophthalmology Matron 8A Matron () 8A Deputy Theatre Manager x3 7 *Unit Managers x6 () 7 HSDU Managers x2 6 Ophthalmology Unit Managers x3 (, Central, W t) ***Unit Managers x6 () 7 Theatre Team Leaders x31 7 Matron (Centre) 8A 8A Quality & Safety Lead Nurse 8A **Unit Managers x7 7 (Inc. ABH & LLGH) Health, Safety, Risk & Governance Lead x3 (, C t W t) 7 Quality & Service Improvement Lead 7 Training Lead 7 HR Support 4 6

10 Senior Nursing Structure: 1. Associate Chief of Staff Nursing - Mrs Meinir Williams 2. Deputy Associate Chief of Staff Nursing (Awaiting permanent appointment) Interim Mrs Llinos Thomas 3. Deputy Associate Chief of Staff Nursing (Awaiting permanent appointment) Interim Mr Andrew Davies 4. Matron (Senior Nurse) - (Awaiting permanent appointment) - 5. Matron (Senior Nurse) Central - (Awaiting permanent appointment) - 6. Matron (Senior Nurse) - (Awaiting permanent appointment) - 7. Theatre Lead - 8. Theatre Lead Central - 9. Theatre Lead 10. Ophthalmology Lead Nurse Quality and Service Lead Nurse - Quality and Safety Reporting structure to the CPG:- ESSD CPG Quality and Safety Performance Group (Steering Group), now set up to join the CPG Finance and Performance group. In order to maintain the momentum for delivery of 1000 lives plus there needs to be constant sharing of information - Monthly Site Specific Quality and Safety Group for / Central / (Members - Clinical Director, ACoS Nursing / Deputy, Quality and Safety lead Nurse, Quality and Service Improvement Lead, Health/Safety/Risk/ Lead, Matron, Theatre Lead. - Key objectives for Site Specific Matrons to delivery 1000 lives plus This group would review site specific 1000 live plus update, objectives, progress and corrective action 7

11 Review of current ESSD CPG 1000 lives plus: 1000 Lives Plus Campaign: 1000 Lives Key Driver: 1000 lives Key Interventions: CPG Overall Performance Status: CPG Site Status Areas of Good Practice / 1. Leading the way to Safety and Quality Improvement. 2. Reducing Healthcare Associated Infections. Will Ideas Execution Prevention of Transmission Prevention and effective treatment of infection Patient Engagement a. Demonstrate visible leadership. b. Hear patient stories. c. Share best practice. d. Focus on learning and development. e. Establish organisational accountability. f. Share and seek new evidence of best practise. a. Hand hygiene. b. Decontamination of the environment. c. Isolation precautions. d. Use of Antimicrobials. e. Management of medical devices. f. Patient information and education. g. Patient awareness of risk. h. Patient empowerment and involvement of care. Amber Amber - Amber Central - Amber - Amber - Amber Central - Amber - Amber Need to launch the CAUTI bundles / pathways BCUHB Catheter Insertion Care Bundle Urinary Catheter Nursing Care Pathway Hand Hygiene Report April 2011.doc Betsi Cadwaladr Orth SSI April 10 - March 1 3. Improving Reduce a. Implement severe 1000 Lives PERIPERHAL CANNUL 8

12 Critical Care. NB: Work in progress within Anaesthetic CPG Mortality and harm from severe sepsis Reduce mortality and harm from mechanical ventilation Reduce complications from central venous catheters (CVC s) Reduce transmission of infection in critical care Improve communication and create a safety culture in critical care Provide patient and family driven care sepsis pathway or sepsis bundles. b. Implement ventilator bundle c. Implement oral hygiene d. Implement subglottic suction e. Implement CVC insertion bundle f. Implement CVC maintenance bundle g. Implement hand washing surveillance h. Implement safety briefings to ensure communication i. Ensure staff have knowledge and expertise in improvement work j. Appropriate infrastructure k. Inclusion of patient / public representation of local critical care improvement team l. Integrate patient / family into improvement work m. Promote open communication among family and team. - Central A review into HOBS (High Observations beds in Surgery - Managing the Acutely Ill patient (Steering Board established, with representation from ESSD Working towards a National TPR chart ABC NEWS.doc Agenda Acutely Ill Patient.doc... BCU CVC Maintenance.doc CVC BUNDLE ELEMENTS.doc 9

13 4. Reducing Surgical Complications. Preventing surgical site infections Creating a team culture attuned to detecting and rectifying intra-operative errors Patient Involvement a. Administer prophylactic antimicrobials appropriately. b. Use of recommended hair removal methods. c. Maintain glycaemic control for known diabetics. d. Maintain perioperative normothermia. e. Use team briefings at the beginning of the theatre list. f. Use WHO surgical safety checklist for each patients. g. Patient education. h. Patient awareness of risks. i. Patient involvement in care. Amber (Theatres) - Amber Central (Theatres) - Amber (Theatres) - Amber Prevention of surgical site infections WHO Checklist March 2011.doc ( Preventing Hospital Acquired Thrombosis. Assessment of Risk Prophylactic Treatment Patient Involvement a. Document risk assessment on admission b. Document action required c. Reassessment of risk every 48 hours / Change in condition d. Mechanical methods e. Pharmacological methods f. Early mobilisation g. Patient Education h. Patient awareness of risk and i. symptoms of HAT j. Patient involvement in care. Amber - Amber Central - Amber - Amber 10

14 6. Rapid Response to Acute illness (RRAI). Admission Bundles Recognition Bundles Response Bundles Sepsis Six Bundles Ensure Competence in monitoring, measurement, Interpretation and response a. Full set of observations. b. Clear monitoring plan specifying how often vitals signs should be recorded. c. Communication this information to the clinical team d. Monitor physiological observations at least every 12 hours according to plan. e. Record track and trigger system score. f. Perform risk assessment g. Consider severe sepsis if patient is at risk. h. Inform appropriate staff using SBAR. i. Change frequency of observations. j. Additional patient monitoring if appropriate. k. timely assessment and initiation of response l. Initiate Sepsis Six Bundle if appropriate. m. Oxygen. n. Blood Cultures. 0. IV Antibiotics. p. Fluid Resuscitation. q. Serum Lactate and HB. r. Hourly urine output monitoring. s. Regular and frequent multidisciplinary reviews Amber - Amber Central - RED - Amber All three sites are completing RRAI s at various levels/. Also commencing Trial of Managing the Acutely Ill patient and review of the NEWS early warning score in the CPG in conjunction with the Anaesthetic CPG. ABC NEWS.doc Response and Sepsix Six Bundle New form. Agenda Acutely Ill Patient.doc... ViEWS for Wales - Background.doc 6. ViEWS for Wales - Timeline.doc 7. ViEWS for Wales - Evaluation.doc 11

15 of circumstances surrounding patient deterioration. t. MD Training in recognition and response to acute illness. observation charts 2010.pdf Sepsis screening tool for wards A5.doc KPI report front Summary report April 7. Improving Medicines Management. Reliable medicines management of high risk medicines Prevent Identify Mitigate Co-ordination of care Patient and family involvement a. Use standardised protocols, scales and recovery protocols for high risk medicines: guided algorithms. b. Routine and reliable laboratory monitoring Identify high risk areas using FMEA. c. Pharmacy consultation service. d. Accuracy of medicine at the interface, verification, validation, medicines reconciliation. e. Education and training f. Reliable in hospital handoffs. g. One-stop delivery service. h. Communication between primary and secondary care / community pharmacy. Red - Red / Amber Central - Red / Amber - Red / Amber Audit BCU Inpatient Areas 3 11.doc Undertaking medication management self assessment at present across all three sites 12

16 8. Transforming Care. Transforming Care at the bedside Transforming Theatres Transformation al Leadership Value-Added Care Safety and Reliability Patient Centred Care Teamwork and Vitality a. Establish, oversee and communicate system levels aims for improvement. b. Align measure, strategy, projects and leadership learning system. c. Channel leadership attention to quality improvement and safety d. Build the right team. e. Align quality projects to finance. f. Engage Physicians in improving care at all levels. g. Increase the percentage of time spent in direct / value added care to 70% by - Eliminating waste - Improve work flow processes - Improving working environment through physical space redesign - Enhancing efficiency - Reducing duplication and time spent in documentation. h. Reduce the adverse event rate in pilot wards. i. Prevent falls by implementing the falls bundle. j. Prevent pressure ulcers by Amber Amber Wards - Amber Wards Central - Amber Wards - Amber Theatre - Amber / Green Theatre Central - Amber / Green Theatre - Amber Baseline Audit Skin Bundle v2.doc Prevention of surgical site infections 13

17 implementing skin bundles. k. Support and involve patients and families. l. Ensure patient physical comfort. m. Ensure patients rights to privacy and dignity. n. Empower ward managers to create care teams with the authority to act and transform care 0. Build capability of front line staff and mid level managers in innovation and improvement. 9. Reducing harm from Falls. Trigger bundle Assessment bundle Intervention bundle Monitoring bundle a. Complete the initial screening using an agreed trigger tool of the falls on the register. b. Notification of the fall as per locally agreed pathway, copy to GP. c. Take falls history d. Complete a basic falls assessment using an agreed risk assessment tool. e. Provide written and verbal information about falls prevention. f. Make appropriate referrals for specialist assessment and intervention based on the outcome of the risk Amber - Red / Amber Central - Red / Amber - Red / Amber Development of new Patient pathways to reduce incident of patient falls BCUHB Falls Risk Assessment V BCUHB Risk of Falls Protocol Essential Care after In patient Fall & Risk o 14

18 assessment Initiate a bespoke plan of care, dependant on need. g. Review compliance of the plan. h. Agree timescales and review. i. Copy of plan to be sent to the patients GP. j. Evaluate efficiency of the plan in terms of further falls or injury k. Update of close the plan as appropriate and update the falls register Labels for Neuro chart 2011.doc 15

19 14. Identifying Depression in Hospital Setting. Trigger point of contact case identification Appropriate intervention for mild / moderate depression Appropriate intervention for moderate / severe depression a. Use two questions for target high risk groups in general hospital settings. b. High risk groups are those with co-existing cancer, heart disease, respiratory disorders, neurological disorders and diabetes. c. Administer the PHQ-9 for patients who score yes to the two questions. Refer patients for further assessments if they score above threshold on PHQ-9. D. Watchful waiting for 2 weeks. e. Use of info prescriptions available f. Psychological treatment for 6-8 sessions over weeks. g. Refer to psychiatric liaison service. h. Referral to CMHT I. Treatment in hospital with medication. Red - Red Central - Red - Red 15. Improving Dementia Care. To improve memory assessment a. First point of contact reduce time between onset of symptoms and diagnosis being communicated. b. Rapid referral form 16

20 services To improve care on general hospital wards To improve community care To increase support for carers To improve quality care in NHS Dementia inpatient units. primary care to memory assessment service. c. Multi-disciplinary care bundle. d. Feedback, intervention and signposting care bundle. e. Indentify on admission. f. Follow dementia pathway when identified. Improve care planning. g. Reduce inappropriate use of anti-psychotic medications in accordance with NICE / SCIE guidelines. Carers involved in care planning h. Education and therapeutic interventions and training for care givers. i. Better admission procedures. j. Involve families k. Use appropriate interventions. Red - Red Central - Red - Red 17

21 16. Enhanced Recovery after Surgery. Assessment care bundle Immediate care bundle Intra-operative bundle Post-operative bundle Patient centred and goal orientated specialist care after surgery Discharge and follow up bundle a. Nutritional screening Optimisation of nutritional status. b. Management and optimisation of preexisting co-morbidities. c. Physiotherapy assessment. d. MDT assessment / referrals. e. MDT ERAS care pathway commenced Patient education. f. Anaesthetic assessment g. Nausea and vomiting prophylaxis. h. Optimal analgesia an anaesthetic(limit use of opioids) i. Goal directed fluids therapy. j. Avoid bowel preparation Optimal fluid balance k. Encourage postoperative nutrition. l. Mobilisation within 6 hours post operatively if practical. m. Early enteral or oral nutrition within 12 hours of surgery. Amber Red / Amber (Orthopae dics enhanced recovery) Central Red / Amber (Colorectal Enhanced recovery) - Amber Orthopaedi cs / day of Surgery colorectal Enhanced recovery a. Orthopaedic Enhanced Recovery b. Colorectal Enhanced Recovery c. Urology Enhanced Recovery d. Upper Gastroenterology Enhanced Recovery Elective Orthopaedic ward (Prince of Wales ward) Recognised as a Rapid Recovery Unit and nominated for a NHS Award

22 The baseline assessment of the 1000 lives plus work above is taken from the monthly site specific key performance indicators as well as data submitted by the key Senior Nurses / Safety leads in the CPG. At present we have had key objectives set out in the 1000 lives plus campaign since May 2010 and following our internal review within the CPG we can only demonstrate significant evidence based actions at Amber level, with no clear fully endorsed / embedded processes at present The key action for the CPG will be to assign key Senior Leads to drive the process forward:- 1. Leading the way to Safety and Quality Improvements. Key CPG Leads (Meinir / Andrew / Llinos) 2. Reducing Healthcare Associated Infections. Key CPG Leads (Wendy Williams / Tracey Radcliffe) 4. Reducing Surgical Complications. Key CPG Leads (Dafydd Pleming / Tracey Radcliffe) 5. Preventing Hospital Acquired Thrombosis. Key CPG Leads (Jan McCabe / Cheryl Froom) 6. Rapid Response to Acute illness (RRAI). Key CPG Leads (Andrew Davies / Sandra Robinson Clarke) 7. Improving Medicines Management. Key CPG Leads (Andrew Davies / Jan Garnet) 8. Transforming Care. - Transforming Care at the bedside (Andrew Davies / Wendy Williams) - Transforming Theatres (Llinos Thomas / Dave Bevan) 9. Reducing harm from Falls. Key CPG Leads ( Helen Juckes-Hughes / Sandra Robinson Clarke) 14. Identifying Depression in Hospital Setting. Key CPG Leads (??) 15. Improving Dementia Care. Key CPG Leads (Llinos Thomas / Jan Garnett) 16. Enhanced Recovery after Surgery. Key CPG Leads (Modernisation Lead / Three Site Specific Matrons) Mr Andrew Davies Clinical Nurse Manager () Interim Deputy ACoS Nursing 4 th of June

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28 Emergency, Specialist Surgery and Dental CPG Clinical Effectiveness Accountability and Reporting Structure BCUHB Board BCUHB Quality & Safety Committee BCUHB Clinical Effectiveness Sub Committee ESSD CPG Board ESSD Quality, Safety, Finance & Performance Committee Work streams via work stream leads Ward/Unit Managers via Monthly KPI reports

29 Emergency, Specialist Surgery & Dental CPG Clinical Effectiveness Work Streams Work Stream Lead Driver FOC Andrew Davies FOC # NoF Driver Diagram Llinos Thomas 1000 lives + Aenaeus O'Kelly Urology Cancer Centralisation Jan Ellis Cancer standards Alan De Bolla Kevin Thomas ERAS - orthopaedic Tony Smith 1000 lives + Neil Windsor CRES ERAS - colorectal Jan Garnett 1000 lives + Andrew Maw CRES ERAS - urology Kevin Thomas 1001 lives + CRES Transforming Care Andrew Davies 1000 lives + Transforming Theatres Llinos Thomas 1000 lives + Infection Control - C.Diff Wendy Williams AQF Infection Control - Clean wards Wendy Williams FOC Your Skin Matters Jan Garnett High Impact 1000 lives + Falls prevention Cheryl Froom High Impact Steve Philips? 1000 lives + Orthopaedic Review Dylan Williams Glyn Andrew Emergency Surgical Review Robin Wiggs Royal College paper???? Sub specialisation HSDU Review Llinos Thomas Graham Yarlett Ophthalmology Review Jai Sanker Royal College paper Nia Jones ENT Review David Snow Infection Control Andrew Davies AQF; 1000 lives + Care bundles Sandra R- Clark 1000 lives +; Transforming Care Concerns & Compliments Chris Lloyd Meinir Williams Clinical Audit Meinir Williams Lloyd Jenkinson Workforce & OD Barry Williams Lloyd Jenkinson Meinir H&S / Risk Williams

30 Emergency, Specialist Surgery and Dental CPG Clinical Structure (exc.dental) Chief of Staff Clinical Lead - Urology Urology Clinical Site Leads x2 Clinical Director YG Clinical Lead - ENT ENT Clinical Site Leads x2 Clinical Director YGC Clinical Lead - Max/Fax Max/Fax Clinical Site Lead x1 Clinical Lead - Ophthalmology Clinical Director YWM Ophthalmology Clinical Site Leads x3 Clinical Lead -T&O T&O Clinical Site Leads x3 Clinical Lead - General Surgery General Surgery Clinical Site Leads x3 Clinical Lead - Vascular Vascular Clinical Site Leads x2 Clinical Lead - Breast Breast Clinical Site Leads x2

31 Betsi Cadwaladr University Health Board TERMS OF REFERENCE Surgical and Dental Finance and Performance Group Accountability To the Surgical and Dental CPG Remit To undertake a detailed review of the CPG s financial and performance management position and forecasts, to consider significant financial issues and performance issues and to make decisions on these matters on behalf of the CPG as identified in the Board s Scheme of Delegation and Standing Financial Instructions. Chair Associate Chief of staff (Managerial) Core Membership Associate Chief of Staff (Nursing) Finance Lead CDs x 4 Improvement lead Planning lead Management leads Administrative Support Attendance Quorum To be provided by the CPG Board Secretary Any clinician or manager who is not a core member of the Group may be asked to attend to discuss specific agenda items within their area of responsibility A minimum of four members must be in attendance Frequency & Venue The Finance Group will meet monthly and report back to the CPG Board monthly. Proposed Start Date March Feb

32 Authority The Group is authorised to make financial decisions on operational matters together with set strategic direction in line with agreed CPG and corporate objectives. Functions The duties of the Committee will be:- 1. Budgetary Control To examine the Financial Planning process and to advise the CPG on progress with cost improvement programmes; To monitor financial performance against revenue budgets and statutory financial duties; Based on forecast income, to review proposed revenue budgets; To seek explanations of budget expenditure variance and decide upon necessary remedial action; To consider submissions to be made in respect of revenue or capital funding and the service implications of such changes; 2. Performance Management To approve the LDPs; To monitor performance against Welsh Assembly Government targets including access times, efficiency measures and other performance indicators including NSF implementation; To explore the relationship between activity and cost and ensure adequate monitoring return systems are in place; To monitor activity performance against baseline activity targets; 3. Capital Expenditure and Working Capital To approve and monitor progress of the CPG s capital programme; Based on forecast resources available, to monitor the proposed capital programme and progress against this programme; To review cash management, budgetary controls and forecasts; To review the CPG s financial procedures and ensure they are in accordance with set standards; Reporting The Chair may raise specific matters at the meeting for information, discussion or approval. All members may submit items for discussion Communication The membership reflects the relevant operational staff pertinent to managing the service delivery. Each member has a role that involves the responsibility for communicating and disseminating information back through CPG and organisational structures. 9 Feb

33 Betsi Cadwaladr University Health Board TERMS OF REFERENCE Surgical and Dental CPG Safety and Governance Group Accountability To the Surgical and Dental CPG Remit The purpose of the Safety and Governance Group is to provide: evidence based and timely advice to the CPG Board to assist it in discharging its functions and meeting its responsibilities with regard to the quality and safety of healthcare; assurance to the CPG Board in relation to the BCUHB s arrangements for safeguarding and improving the quality and safety of patient/service user centred healthcare in accordance with its stated objectives and the requirements and standards determined for the NHS in Wales; scrutiny of the Healthcare Standards in relation to improvement in clinical practice and the patient/service user experience Chair Associate Chief of Staff (Nursing) Core Membership Associate Chief of Staff (Nursing) Associate Chief of Staff (Operations) Risk Management CDs x 4 Improvement lead Planning lead Management leads Public and Patient Involvement Representative Staff Side CHC rep Administrative Support Attendance To be provided by the CPG Board Secretary Any clinician or manager who is not a core member of the Group may be 23 Feb

34 asked to attend to discuss specific agenda items within their area of responsibility Quorum A minimum of four members must be in attendance Frequency & Venue The Safety and Governance Group will meet monthly and report back to the CPG Board monthly. Proposed Start Date March 2010 Authority The Committee is authorised by the Board to investigate or have investigated any activity within its terms of reference. In doing so, the Committee shall have the right to inspect any books, records or documents of the LHB. It may seek any relevant information from any employee and all employees are directed to cooperate with any reasonable request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers it necessary, in accordance with the Board s procurement, budgetary and other requirements. The Group is authorised to make Safety and Governance decisions on operational matters together with set strategic direction in line with agreed CPG and corporate objectives. Functions The duties of the Group will be:- oversee the initial development of the CPG s strategies and plans for the development and delivery of quality and patient safety, consistent with the Health Board s overall strategic direction and any requirements and standards set for NHS bodies in Wales; 23 Feb consider the implications for quality and patient safety arising from the development of the BCUHB s corporate strategies and plans or those of its stakeholders and partners; consider the implications for the CPG s quality and patient/service user safety arrangements following review reports and actions arising from the work of external reviewers. The Group will, in respect of its assurance role, seek assurances that governance (including risk management) arrangements are appropriately designed and operating effectively to ensure the provision of high quality, safe healthcare across the whole of the CPG s activities. To achieve this, the Group s programme of work will be designed to ensure that, in relation to all aspects of quality and patient/service user safety: there is clear, consistent strategic direction, strong leadership and transparent lines of accountability; the CPG has a citizen centred approach, putting patients/service users, patient/service user safety and safeguarding above all other

35 considerations; the provision of care across the CPG is consistently applied, based on sound evidence, clinically effective and meeting agreed standards; the CPG has the right systems and processes in place to deliver, from a patient/service user perspective - efficient, effective, timely and safe services delivered by caring and competent staff ; the workforce is appropriately selected, trained and responsive to the needs of the service, ensuring that professional standards, registration/revalidation/indemnity requirements and safeguarding arrangements are maintained; there is an ethos of continual quality improvement and regular methods of updating the workforce in the skills and competencies needed to demonstrate quality improvement throughout the organisation; there is good team working, collaboration and partnership working to provide the best possible outcomes for its citizens; risks are actively identified and robustly managed and mitigated at all levels of the organisation; decisions are based upon valid, accurate, complete and timely data and information; there is demonstrable continuous improvement in the standard of quality and patient/service user safety across the whole organisation continuously monitored through the development and scrutiny of performance against Healthcare Standards for Wales; all reasonable steps are taken to prevent, detect and rectify irregularities or deficiencies in the quality and safety of care provided, and in particular that: Sources of internal assurance are reliable, eg. internal audit and clinical audit teams have the capacity and capability to deliver; Recommendations made by internal and external reviewers are considered and acted upon on a timely basis; and Lessons are learned from patient/service user safety incidents, complaints and claims. The Group will advise the CPG on the adoption of a set of key indicators of quality of care against which the CPG performance will be regularly assessed and reported on to the BCUHB and subsequently through Annual Reports. Reporting The Chair may raise specific matters at the meeting for information, discussion or approval. All members may submit items for discussion Communication The membership reflects the relevant operational staff pertinent to managing the service delivery. Each member has a role that involves the responsibility for communicating and disseminating information back through CPG and organisational structures. 23 Feb

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37 ESSD CPG KPI Report June 2011 Preventing Hospital Aquired Infection Safety Initiatives (1000 lives + baseline assessment & action plan) Risk management Safeguarding User Experience Central BCU Target Total Total Total Overall Total Compliance with Clean Your Hands Campaign(%) 95% 86% 74% 90% 83% Incidents of C.Diff (total) Incidents of SSI (Orthopaedic) See report Compliance with CAUTI insertion bundle (%) 0% 0% 0% 0% Compliance with CAUTI Maintainance bundle (%) 0% 0% 0% 0% Incidence of CAUTI (%) 0% 0% 0% 0% RRAILS - Compliance with admission bundle (%) 20% 79% 0% 33% RRAILS - Compliance with recognition bundle (%) 20% 80% 0% 33% RRAILS - Compliance with Response bundle (%) 0% 67% 0% 22% RRAILS - Compliance with Sepsis Six (%) No pts 50% No pts 50% THEATRES ONLY Compliance with WHO checklist (%) Compliance with Preventing Hospital Aquired Thrombosis bundle (%) 0% 50% 0% 17% ERAS - Compliance with Assessment Care Bundle (%) 0% 50% 0% 17% ERAS - Compliance with Immediate Care Bundle (%) 0% 50% 0% 17% ERAS - Compliance with Intra-Operative Bundle (%) 0% 50% 0% 17% ERAS - Compliance with Post-Op Bundle (%) 0% 50% 0% 17% ERAS - Compliance with Discharge & follow-up Bundle (%) 0% 0% 0% 0% Compliance with MUST tool 20% 77% 0% 32% CAIR's completed (total) RIDDOR reportable incidents (total) Serious adverse events investigations (total) Incidents of Sub optimal staffing (total Entries onto risk register (total) Incidents of POVA (total) Incidents relating to mental capacity(total) Incidents relating to deprivation of liberty(total) Compliance with skin Bundle (%) 17% 0% 67&% 28% Incidence of new pressure ulcers (total) See Concerns received on ward/unit report Compliments received on ward/unit

38 ESSD CPG KPI Report June 2011 Staff Pool usage (hrs) Additional shifts/overtime worked (hrs) Shifts unused (hrs) Vacancy control(total) HR Policy Breaches NMC Lapses (total)

39 Prevention of Surgical Site Infections Situation Compliance data for Surgical Site Infections (SSI) contributes to the Health Board s performance against the Healthcare Associated Infection surveillance AQF target of reducing harm and variation. Background Surgical Site infection surveillance of hip and knee procedures is a mandatory requirement of the Welsh Healthcare Associated Infections Programme (WHAIP) Lives+ defines four interventions to reduce the number of infections after surgery Administer prophylactic antimicrobials appropriately Use of recommended hair removal methods Maintain peri-operative normothermia Maintain glycaemic control for known diabetics. Assessment It is important to track both process and outcome measures as effective processes are key determinants of the outcome. Ultimately, the goal is to improve the outcome. Process measures Progress Issues 95 % antimicrobials administered on time (The percentage of elective patients receiving on-time prophylactic antimicrobials administration.) Compliance for May 2011 is as follows: Colorectal 85% Gynae 81% Hysterectomy 73% TURP 100% Orthopaedic 96% Total patients in main and day case theatres 252/285= 88% TJR

40 95% surgery with appropriate hair removal (The percentage of inpatient elective surgical patients with hair removal by an approved method.) Central Main theatres = 86% Abergele Hospital = 88% Llandudno theatres 100% Day surgery 100% Theatre 2 93% Theatre 3 100% Theatre 4 83% Theatre 5 100% Theatre 6 100% Theatre 7 100% Theatre 10 99% Theatre % Total patients in main and day case theatres = 98% BCUHB Overall compliance 91% Compliance for May 2011 is as follows: 100% compliance within theatre. Central No longer collect data as all razors removed from theatre 98% compliance within theatre BCUHB (excluding Central) Overall compliance 99% Razors still available in theatre when they have been removed from the other two sites. TJR

41 95% with perioperative normothermia (The percentage of appropriate elective surgical patients with a body temperature of greater than 36.0 degrees Centigrade immediately following surgery.) 95% diabetic patients with good glucose control (The percentage of known diabetic elective surgical patients with controlled serum glucose (5-10 mmol/l) immediately post operatively. Compliance for May 2011 is as follows: Main theatres 97% Maternity theatre 94% Day case theatre 98% Central Main theatres and Abergele combined 98% No data available BCUHB (excluding ) Overall compliance 97% Compliance for May 2011 is as follows: No data available. Central Main theatres 74% No data available BCUHB (excluding and ) Overall compliance 74% Measurement of preoperative temperature only being recorded 78% > 36.0 C BCUHB Insulin sliding scale regimes are different across the 3 sites. Manual collection of this data has proven problematic. To identify if there is an issue with perioperative glycaemic control, notes of diabetic patients are being reviewed to look at the diabetic management throughout their inpatient stay. The data on s SharePoint does not reflect the 1000 Lives measure. This has TJR

42 been discussed with Dafydd Pleming and Simon Burnell who are unable to explain the information. Bill Hildyard (IT) has been contacted and will look into it. Outcome measures Reduce % of surgical patients with SSI Primary hip WHAIP mandatory surveillance Primary knee WHAIP mandatory surveillance Breast Colorectal Progress No further report received from WHAIP Breast and colorectal data being collected for local improvement only using crude methodology of positive wound swab. Breast SSI for April was 1 out of 23 = 4.3% Colorectal SSI for April was 0 out of 45 = 0%. Central No further report received from WHAIP Work ongoing with Breast data collection. No further report received from WHAIP Issues Andrew Davies has attended a meeting with the orthopaedic outpatients nursing staff to discuss the SSI audit and will be attending the orthopaedic consultants meeting in August. It has been identified that the orthopaedic secretary has sent some forms to WHAIP without them being checked and when the photocopies have been looked at, there are incomplete forms. These forms have been requested back and as discussed previously all future forms will be checked either by Tracey Radcliffe or Andrew Davies prior to them being sent to WHAIP. TJR

43 Graphs BCULHB 95 % antimicrobials administered on time Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Central Target TJR

44 BCULHB 95% surgery with appropriate hair removal Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Central Target TJR

45 BCULHB 95% with perioperative normothermia Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Central Target TJR

46 BCULHB 95% diabetic patients with good glucose control Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Central Target TJR

47 Recommendations Surgeons must undertake the WHO checklist at Sign in and Time out to ensure that the need for antimicrobials is identified and appropriate administration is confirmed. This facilitates the communication of the intervention to the whole team including the member of staff who is recording the data on the electronic system. Tracey Radcliffe/ Andrew Davies to check the Orthopaedic SSI forms in before they are sent to WHAIP. Andrew Davies to attend Orthopaedic consultants meeting to formally discuss the issues around completion of the Orthopaedic SSI form. Standardisation of what is being measured across BCUHB and identification of the key people involved in the process. Creation of a SharePoint for the above measures to be recorded across BCUHB. Possible use of s SharePoint BCUHB wide. Sustain practice in theatre where compliance is above 95% and address areas of non compliance. Explore the possibility of removing razors from theatres in the. Root cause analysis of infections to include compliance with reducing surgical complications drivers. TJR