ENCLOSURE: J. Date of Trust Board 29 February Pressure Ulcer Clinical Improvement Programme. Purpose of Report

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1 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 the Midlands and East SHA ambition for 100% elimination of all grade 2, 3, and 4 Pressure Ulcers across all settings and NCH&C s planned approach. An emergent strategy has been created upon which the organisation will build as more details are released regarding this ambition and any associated tools we will be required to implement. A coordinated and cohesive approach has been developed in the form of a clinical improvement programme. This will ensure a robust accountability structure that will enable monitoring, accountability and governance for the delivery of the strategy. The fundamental aim of this programme will be to identify, communicate and implement the necessary clinical improvements necessary to ensure all avoidable pressure ulcers are eliminated. Our clinical staff and managers engagement in this clinical improvement programme is absolutely vital. As an organisation we must ensure they are supported and encouraged to implement the relevant tools and clinical interventions to meet this demanding ambition. Training and clinical competency will be the central focus required to improve pressure ulcer care, to achieve this at the necessary pace, it is essential that clinical staff are released to attend any necessary training and then supported to cascade this across their teams. Risks and benefits of proposed action 1. The significant risk associated with 100% elimination of grade 2, 3, 4 Pressure Ulcers, is within our Community nursing and Therapy teams. Many patients in their own home do not comply with the clinical guidance given or utilise the pressure relieving equipment provided, and a large proportion of pressure ulcers occur within care home settings. The clinical improvement task and finish group will work closely with the patient engagement task and finish group to develop enhanced ways and information to help patients and carers understand the risks and actions necessary to prevent a pressure ulcers. 2. Releasing clinical staff to undertake clinical training relating to Pressure Ulcer care and use of associated tools will also present a risk in relation to the impact on caseload activity. Every effort will be made by the clinical improvement programme team to ensure training can be delivered to staff as efficiently and effectively as possible e-learning and cascade methodologies will be applied where ever possible to minimise this risk. It is expected that under the SHA ambition training for Pressure Ulcer care will be mandated for all Trusts. 3. An increase in the number of reported Pressure Ulcers will occur over the first three months, once the Pressure Ulcer tools are launched alongside awareness training sessions. The Pressure Ulcer clinical Improvement steering group will monitor this change in reporting and implement any necessary actions to ensure the required decrease in avoidable Pressure Ulcers is achieved. A new baseline and trajectory will 1

2 be defined to replace our current QIPP KPI trajectory, once clarification has been provided from NHSN&W. Recommendation The board are requested to note the development of an emerging strategy to work towards the ambition to eliminate all avoidable pressure ulcers. Presented by Previous consideration by Board Committee or EDT Appendices Anna Morgan Director of Operations Quality and Risk Assurance Committee Appendix 1 Pressure Ulcer Grading definitions Appendix 2 Pressure Ulcer unavoidable NHS Midlands and East (SHA) Definition Appendix 3 NHS Norfolk QIPP KPI 30% reduction trajectory Appendix 4 Pressure Ulcer Clinical Improvement Programme Steering group and Task and Finish groups. In completing this report, I confirm the following matters have been considered: a) Implications for the NHS Constitution b) Implications for CQC registration c) Equalities Impact d) Environmental impact Any material considerations arising from the above are reported below. 2

3 1. Introduction Pressure Ulcer Progress Report 1.1 This paper provides a short summary of the NHS Midlands & East of England SHA Ambition for Pressure Ulcers which will be formally launched on the 28 th February 2012, along with a brief overview of NCH&C s progress to date and planned next steps for the Pressure ulcer clinical improvement programme. 2. Background 2.1 Pressure Ulcer prevention, management and eradication is currently a high profile issue for all Provider Services across the NHS. This is our top priority clinical improvement programme over the next year and beyond. It will need both clinical and managerial engagement at every level of the organisation to achieve the goals we aspire to. 2.2 Pressure ulcers are a significant burden to the NHS and have a detrimental effect on patients health and well-being. Original figures in 2009 based on 10.2% prevalence of pressure ulcers in hospital patients, estimated the following: 29,800 acquired in hospital, 20,700 acquired in the community with subsequent admission to hospital 2,838 cost of hospital care and 2,286 cost of follow-on community care per patient (total 5,124) These figures suggest a potential annual saving of 154 million The majority of cases are avoidable if patient solutions are put in place 2.3 Pressure ulcers are a recognisable proxy measure for the quality and safety of care patients receive. The QIPP Safe Care (Safety Express) programme which commenced across the SHA Cluster in January 2011 sought to reduce hospital acquired pressure ulcers by 80% and community-acquired pressure ulcers by 30% by December 2012 with the potential national annual savings of 154m. 2.4 The aim of NHS Midlands & East of England SHA Ambitions programme is to use the elimination of all avoidable Grade 2, 3 and 4 pressure ulcers as an outcome measure for nursing care which includes; hydration, nutrition, pressure area care, medication management and individualised care. Pressure ulcers are more likely to occur in patients who are malnourished, elderly, obese and also have underlying medical conditions, and therefore it is important that the fundamental aspects of high quality nursing care are in place. 2.5 Definition of a pressure ulcer 2.6 A pressure ulcer is a localised injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are associated with pressure ulcers; the significance of these is yet to be elucidated. Source: EPUAP and NPUAP (2009) 2.7 There are four categories of pressure ulcers from Grade 1 to 4 (see Appendix 1 for grading definitions). For the purposes of the Ambition, NHS Midlands and East SHA have agreed to concentrate on elimination of Grade 2, 3 and 4 avoidable pressure ulcers. Nationally the Department of Health have mandated that all NHS trusts across England will monitor reduction via the NHS Safety Thermometer data collection tool and triangulate this with Serious Incident Reporting. 2.8 An emergent strategy has been created by NCH&C to ambitiously strive for the elimination of all avoidable pressure ulcers. This strategy is in development due to the evolving requirements from the SHA and NHS Norfolk, in terms of the actual specification relating to

4 Trusts, for achievement of this ambition. It is anticipated Trusts will receive greater clarity regarding the ambition by March 2012 along with a set of clinical tools to support the elimination of all grade 2,3,4 pressure Ulcers. 2.9 Achievement of this SHA ambition will be demonstrated by continuing to build on the progress made by the clinical improvement group under the existing QIPP KPI 30% reduction of all grade 3 and 4 for Pressure Ulcers. Clarification has been requested from NHS Norfolk regarding this QIPP KPI which currently runs until December The Pressure Ulcers Clinical Improvement Programme 3.1 A coordinated and cohesive approach has been developed in the form of a clinical improvement programme. This will ensure a robust accountability structure that will enable monitoring, accountability and governance for the delivery of the strategy. The fundamental aim of this programme will be to identify, communicate and implement the necessary clinical improvements necessary to ensure all avoidable pressure ulcers are eliminated. 3.2 This programme will ensure the most efficient use of clinical and managerial resources is possible to identify improvements in clinical interventions systems and process. To achieve effective co-production in this improvement programme it is essential to have good clinical and managerial engagement from both children s and adult business units across the Trust. This has been possible by identifying clinical leaders from recent workshops and through clinicians already participating in the QIPP KPI group, who will now be invited to engage in the various improvement programme task and finish groups. 3.3 As part of the clinical improvement programme a steering group has been formed to oversee the delivery of the strategy. This group have identified required streams of work and highlighted the expected deliverables from nominated task groups. The steering group will have executive leadership and strategic focus along with representation from Children s and Adults services plus the four task and finish group leads. 3.4 A baseline and trajectory for the reduction in grade 3 and 4 pressure ulcers has been developed, however this will be updated shortly to reflect the new SHA Ambition to include all grade 2, 3 and 4 avoidable Pressure Ulcers. (See appendix 3). Underpinning the Steering group are four specific task and finish groups. These task groups have responsibility to determine the specific measureable outcomes and associated activity to meet the required 100% elimination of all avoidable grade 2, 3, 4 pressure ulcers by December Again, this is in recognition that this strategy is dependent on the current work being undertaken by the SHA and PCT. They will provide regular feedback and reports to the steering group. The task and finish groups are as follows; (see appendix 4 for details of each group s role): Clinical Improvement and Outcomes Task & Finish Group (plus a subgroup for Equipment and another for clinical standards and protocols) Performance and Improvement Task & Finish Group Education, Competencies and Clinical Skills Training Task & Finish Group Partnership Working and Patient Engagement Task & Finish group 3.5 Integrated working across trust work streams and business units 3.6 To ensure the Preventing Pressure Ulcers (PPU) programme is fully aligned and synergised across existing corporate functions e.g. training, performance, business planning etc, a number of groups with corporate representation have been identified within the programme structure that will either influence the progress of the programme or require regular information and updates from the PPU steering group to deliver other key activities.

5 3.7 NHSN&W warmly received our proposed approach for pressure ulcer care and recognised the significant challenge the 100% elimination target presents to community services. Acknowledgement was also given to the progress achieved to date which will inform the clinical improvement programme delivery against the following areas: Membership of the SHA expert pressure ulcer group, and associated pressure ulcer networks QIPP Clinical engagement group / pressure ulcer action group Pressure ulcer policy (appendix 9) Documentation Waterlow assessment, Malnutrition universal screening tool (MUST) discharge, assessment tools E-learning tools for staff Initial review of SystmOne tools Pressure ulcer grading system Reporting processes review Review of RCA forms Identified themes from SUI / RCA 3.8 NHSN&W have also expressed a keenness to work with the Pressure Ulcer clinical improvement programme partnership and patient engagement task and finish group, to create a Norfolk wide approach building on this initiative. A scoping paper will presented by NCH&C in collaboration with NHSN&W via the Norfolk Directors of Nursing group by the Pressure Ulcer Programme lead. 4. Conclusion 4.1 Our clinical staff and managers engagement in this clinical improvement programme is absolutely vital. As an organisation we must ensure they are supported and encouraged to implement the relevant tools and clinical interventions to meet this demanding ambition. 4.2 Training and clinical competency will be the central focus required to improve pressure ulcer care, to achieve this at the necessary pace. It is essential that clinical staff are released to attend any necessary training and then supported to cascade this across their teams. The progress against targets will be monitored both internally through corporate performance structures and externally through safety thermometer and incident reporting. 5. Recommendations 5.1 The board are asked to acknowledge and champion this important clinical Improvement programme and to note the development of an emerging strategy to work towards the ambition to eliminate all avoidable pressure ulcers..

6 Appendix 1 Grading Definitions

7 Appendix 2

8 Appendix 3 QIPP Target - to reduce Grade 3 and 4 PUs by 30% by Dec Q3 Q4 Q1 Q2 Q3 Oct 11 - Dec 11 Jan 12 - Mar 12 Apr 12 - Jun 12 Jul 12 - Sep 12 Oct 12 - Dec 12 Grade 3 & Actual Planned even reduction 30% reduction compared to same quarter last year

9 Appendix 4 The role of the Preventing Pressure Ulcer (PPU) Steering Group In view of the importance of this programme, this group will be chaired by the Chief Executive, together with the Deputy Director of Service Pathways, and the support of the Assistant Director of Service Development. The steering group will ensure that the Pressure Ulcer programme aligns and integrates with the SHA proposed targets, NHS Norfolk QIPP KPIs, Transforming Community Services, CQUIN and NCH&Cs Integrated Business Plan. They will ensure that this informs the organisation s workforce planning process. The group will monitor the performance and SIRI data, which will inform the direction of the strategy and ensure sustainability for the future. The steering group will receive regular updates from the associated task and finish groups ensuring the Pressure Ulcer risk register is maintained and actioned appropriately. Representation will also be sought from Learning disabilities and Children s directorates. The steering group will provide strategic direction and leadership to the associated groups and clinicians across the Trust as appropriate. The role of the Preventing Pressure Ulcer (PPU) Task & Finish Groups Four key task groups have been identified to provide wider expertise, engagement and involvement from key clinicians and individuals to facilitate the delivery of key operational tasks/objectives to support the overall goal & aim of the project. The membership of these task groups will vary depending on work streams but a representative group of clinicians and staff from both In-patient and community teams across the organisation is required. Each task group requires an identified lead. These leads will have expertise and knowledge of project aims and coordinate activity within each task group. They will also regularly attend; provide feedback and linkage to the steering group. The task groups identified are as follows: The role of the Clinical Improvement and Outcomes Task & Finish Group This group will develop protocols and standard operating procedures (SOPs) for specific clinical groups and develop a set of clinical competences and standards for NCH&C. This group will inform key performance indicators against clinical outcomes. They will present to the PU steering group with any concerns for agreement, and following approval at the PU Steering, all protocols and SOPs will be taken to the clinical polices steering group for ratification. Once this work is complete, the group will cease but reconvene when review of protocols standards and competencies is required and new conditions have been identified. *Supporting this task group will be two subgroups one for: Equipment and another for the development of clinical standards and protocols The role of the Performance and Improvement Task & Finish Group This group will identify what performance data is required which will meet the QIPP KPI and any other associated targets for 2011/12. The task group will review the results from the internal pressure ulcer audit and outcomes from SIRI reports and will use the baseline evidence to forecast the direction of roll out for Pressure Ulcers across Norfolk. Monthly performance reports will be presented to the steering group for information and review. A dashboard will also be used to demonstrate month on month progress against any agree trajectory for the agreed % reduction across inpatient and community team settings. The role of the Education, Competencies and Clinical Skills Training Task & Finish Group This task group will develop robust clinical competencies, training and education programmes for the organisation. The group will be responsible for the identification, design and

10 implementation of training packages, learning events. They will present to the PU steering group with any concerns for agreement before implementation. The role of the Partnership Working and Patient Engagement Task & Finish group This task group will develop/design patient information and to capture current patient and staff experiences of pressure ulcers, develop an engagement network for service users and carers. They will also work closely with the Clinical Protocols Task Group to share outcomes and testing of protocols with service users. report will be presented to the steering group on a monthly basis. The group will identify potential and known partners from acute hospitals and other patient settings where our clinical staff have involvement, and establish opportunities to improve clinical care and joint working to reduce and prevent pressure ulcers. Public and Patient Engagement group This group is already in existence within NCH&C s corporate structure and will play a fundamental role informing the Pressure Ulcer steering group and task and finish groups in the following areas: Identify key partnerships by working across provider organisations i.e. acute hospitals and residential homes Work with other providers to develop a system wide approach to Pressure Ulcer prevention and care for patients across Norfolk Involve patients and carers in the development/design of patient information and education process to prevent and manage effectively Pressure Ulcers particularly for patients in their own home i.e. establish a focus group Identify measurable targets that can demonstrate how we are Improving patient experience, delivering safe, seamless holistic care for patients with long term conditions and thus preventing avoidable Pressure Ulcers Workforce and Organisational Development A representative from the workforce/organisational development team will be an active member of the steering group. They will give guidance on the workforce /OD requirements for education and training. This will link with the strategy for leadership and development within NCH&C.