Harmfree care * 430 Million. How 2 Guide. A new mindset in patient safety improvement. 4 Harms. 200,000 Patients. Page 16. Page 20. Page 8.

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1 Journal October 2011 Published by the NHS for the NHS Harmfree care * A new mindset in patient safety improvement 4 Harms 200,000 Patients 430 Million How 2 Guide Page 16 Page 8 Page 6 Page 20 5 things every organisation must do * Harm free care as defined by the absence of pressure ulcers, falls, CAxUTI and VTE. Measuring harm free care from the patient s perspective Delivering highly reliable processes of care to reduce harm CASE STUDY Intentional rounding was key to our reduction in the 4 harms

2 2 3 Foreword Over the last year, the QIPP Safe Care coalition and over 100 NHS provider organisations have tested a pilot programme called Safety Express to reduce harm from pressure ulcers, falls, urinary catheters and VTE. The programme is ambitious yet simple. Stop dealing with safety issues in silos, think about complications from the patient s perspective and aim for the absence of all four harms to each and every patient. The lessons we have learned in testing this concept, named by participants as harm free care have been invaluable. Our teams have debated the use of the word harm and understand that, in this context, we are using it to describe only a fraction of possible healthcare complications (or harm), hence you will see it qualified as harm free care from pressure ulcers, falls, urinary catheter infections and VTE. The healthcare issues at the heart of this programme are recognised globally as challenges to every healthcare system. These issues cannot be resolved by isolated secondary care initiatives common harms (some of which may be unavoidable, some of which may not) are often overlooked as less severe and therefore by association, as less of a priority for change. We want you to change that. Our challenge is to redefine the possible for these harms in the way we have with infection. We encourage you to debate with your colleagues where you are on the road to harm free care, and to develop a shared understanding with your patients as you work through this programme. Times are changing and with them the norms of the past. Old ideas like MRSA is unavoidable, you ll never reduce it are replaced by different norms and expectations, with some organisations now going a year without an MRSA bacteraemia. This programme is about challenging ourselves to think and act differently, to be bold and courageous in the face of challenge, to redefine tomorrow s norms. The Safety Express community, which came together for the first time in January 2011, have generously shared their learning with us and without them this guide and website would not be possible. Our materials have been harvested from the skilful patient safety professionals within each Strategic Health Authority and the leaders of the national VTE and Energising for Excellence programme, to whom we would like to offer our personal thanks. We all recognise that harm free care is a journey and that it is one which will require continual work and resilience. We are just beginning. Despite this, a small number of our teams have shown impressive improvement within the lifetime of the pilot, delivering harm free care to over 95% of patients in pilot areas. Our ambition is that their success and learning can be scaled up to all providers rapidly though senior leadership champions. The harm free care website is an evolving resource which can be accessed for support materials and networking. Our shared ambition is to eliminate harm from these conditions in 95% of all NHS patients by We are asking for your commitment to deliver this aim. Go to today. Good luck. Contributors Vicky Aldred (Head of Patient Safety) and Nicola Clark (Patient Safety Manager), NHS London David Charlesworth (Senior Practice Development Nurse) and Judith Connor (Lead Nurse Patient Safety and Practice Development), South Tees Hospitals NHS Foundation Trust Natalie Curvis (Quality Improvement Lead), Salford Royal NHS Foundation Trust Liam Edwards (Senior Nurse Executive Nursing Preceptorship and E4E) and Paula Townsend (Deputy Director of Nursing), Kings College Hospital NHS Foundation Trust Lyn McIntrye (Head of Clinical Quality and Patient Safety and Regional QIPP safe care lead), NHS East of England Lisa Nobes (Head of Nursing Development), West Suffolk Hospital NHS Trust Laurel Simmons (Associate Director of Quality Improvement), Stockport NHS Foundation Trust Kate Cheema (Specialist Information Analyst), Pauline Smith (Programme Manager, Patient Experience and Clinical Development), Clare Stone (Programme Lead, Energising for Excellence in Care), NHS South East Coast Partnerships In this issue At a glance Product Development Steering Group Julie Dawes Portsmouth Hospitals NHS Trust; Kay Fawcett University Hospitals Birmingham NHS Foundation Trust; Katherine Fenton (Chair) University College London Hospitals NHS Foundation Trust; Jenny Leggott Nottingham University Hospitals NHS Trust; Libby McManus York Teaching Hospital NHS Foundation Trust; Suzanne Rankin Ashford and St. Peter s NHS Foundation Trust; Charlie Sheldon Homerton University Hospital NHS Foundation Trust; Lynne Swiatczak Buckinghamshire Healthcare NHS Trust; Sarah Watson-Fisher Plymouth Hospitals NHS Trust. Each of the ten regional Strategic Health Authorities FACT: The direct costs to the NHS associated with harm from pressure ulcers, falls and urinary catheters are estimated at over 430 million per year. 4 Our driving force We set out our overall aim, together with our primary and secondary drivers which will help guide your delivery of harm free care. 10 How to make harm free care happen 10 steps which outline everything you will need to do to in order to plan and mobilise your improvement team. 20 How West Suffolk made a difference Read about how West Suffolk delivered harm free care from Lisa Nobes, the Head of Nursing Development s perspective. Dame Christine Beasley Chief Nursing Officer Professor Sir Bruce Keogh NHS Medical Director Jim Easton National Director for Improvement & Efficiency FACT: Harm from pressure ulcers, falls, urinary catheters and VTE is estimated to affect over 200,000 people each year, more than the number of new strokes. 6 Use the primary drivers to focus your efforts Leadership and safety culture, clinical care 95% reliable and supporting infrastructure are key to your success. 8 How do we measure harm? Think differently and start to measure harm free care from the patients perspective things every organisation must do Discover the top 5 things that every organisation must do in order to effectively deliver harm free care. 18 Top tips Need some fresh impetus? We give you the top tips that will keep driving your organisation forwards big challenge, 2 viewpoints 2 different organisations share their experiences in this at a glance interview.

3 4 5 So where do you start? Our Driving Force One plan to reduce four harms Patients are at the heart of everything we do. They inspire us to change. We are committed to improving their experience of healthcare and protecting them from harm. To effectively deliver harm free care to our patients we need one plan which can be implemented at local level and integrates easily with existing workflow and routines. We recognise the improvement work many of you have already done in these safety areas, so this is not about starting again, it s about building on what you already have in place. We know the challenge is big. But it isn t a path we expect you to walk alone. The diagram below identifies the key drivers which will deliver success. If we focus on these core areas, we will achieve our aim of delivering harm free care. Aim Primary drivers Secondary drivers To deliver harm free care as defined by the absence of pressure ulcers, falls, CA-UTI and VTE by December 2012 Leadership and safety culture Clinical care 95% reliable Local clinical leadership Executive support Walk rounds & rounding Active risk management Continence, skin & moisture Nutrition / hydration To further explain, the driver diagram should be read from right to left. The secondary drivers feed the overall aim. So by working through each of the drivers, you will accomplish our aim of delivering harm free care to our patients. Supporting infrastructure Medication reconciliation Equipment Education & training

4 6 7 Use the primary drivers to focus your efforts TIP: The harm free care website includes useful examples of policy revisions across the four harms, along with training resources and tips to help you develop your improvement plan. At Kings College Hospital NHS Foundation Trust, specialist nurses in tissue viability, falls, infection control and VTE are co-located and work together on making improvements to underlying systems and processes. Co-location means that communication barriers are reduced and inter-specialist working is optimised. At Salford Royal NHS Foundation Trust, clinical specialists, matrons and executives work together to organise regular clinical walk rounds. Each month they agree a focus for their rounding and their learning is shared at a debrief, where themes are identified and prioritised for action. Primary Driver 1 Leadership and Safety Culture Leadership is everyone s responsibility Safety leadership doesn t just rest on the shoulders of one person, it is the role of everyone to drive the plan forwards. Engage clinical and non clinical teams in the work. Learn and move on...it s a journey Failure and resistance are important ingredients in improvement and from them you can learn and innovate, helping you to move forward at an accelerated pace and scale. For more information on learning from testing and overcoming resistance visit Break free from barriers By working together across specialisms, looking at the 4 harms together and not allowing geographical barriers to get in your way, you ll increase the likelihood of harm free care. A Key Intervention INTENTIONAL ROUNDING Intentional rounding is a process in which nurses proactively go round their patients in a structured way at set intervals, usually hourly, asking a series of set questions which aim to make sure that the patient is comfortable, free from pain and has everything they need to hand (e.g. a drink, call bell, assistance with getting to the toilet) Primary Driver 2 Clinical Care 95% Reliable Structure + Process = Outcome It s the improvements you make in a small number of your key processes, delivered in a highly reliable way, which will get you to the outcome of harm free care. Safety science supports the need for improvement The last decade has seen an increase in the application of safety science to healthcare. The findings are fascinating. Reliability levels in basic care processes are in need of improvement in almost all cases. All processes have the same challenges If the process isn t understood and it s not clear what steps need to be taken to achieve the overall outcome, everything falls down. This is true of every single process. A perfect example of this is that despite the compelling research and life saving benefits, a simple aspirin is still only given to 7 out of 10 patients with ischemic stroke. The design of a reliable process has 6 steps apply these steps to risk assessment on admission, catheter checks, skin checks, nutrition assessment, monitoring of hydration and medication reconciliation Bring a poorly understood process to life by identifying key steps using a process map. Identify a failure between the steps and get your team to test a possible solution. Keep studying snapshots of the process until it is working 80% of the time, by repeating steps 1 & 2. Once you achieve 80% success rate, study 100 patients and identify 4 the top three reasons why the remaining 20 patients are left out or not getting the treatment. Fix those top three reasons 5 and you will achieve a 95% success rate. This is then your opportunity 6 to monitor the process, test it under different conditions e.g. at night and spread the change to other areas. Primary Driver 3 Supporting Infrastructure Re-visit the fundamentals of training, education and policy writing All organisations find that they need to re-visit what training, education and policies are in place when they first start on the journey towards delivering harm free care. Connect the disconnect The most successful organisations understand that there is often some disconnect between policy and practice but to deliver the overall aim, improvement in both areas are necessary and can make a big difference. Review your equipment Start the journey to deliver harm free care across your organisation Think differently Ask yourself a primary question does the patient follow the equipment or does the equipment follow the patient? Seek to ensure 95% of patients have all the equipment they need on arrival at a new care setting Ask questions To find out more, visit What do you need? What lives where? What are the systems and processes for accessing equipment in a timely way? Do they work?

5 8 How do we measure harm? The last decade has seen an explosion in the possible ways we can measure harm including: Adverse Events Routine Data Point of Care Audits Case Note Review Each of these approaches has its merits and pitfalls. The big challenge for safety leaders is to understand these different sources of information and what they say about your system. On the website you will find a detailed description of the data sources for pressure ulcers, falls, urinary catheters and VTE. There is also guidance on what this information is telling you about your improvement and how you might use it to create ward to board metrics. You can read about this in more detail at Measuring harm free care from the patient s perspective The quest for harm free care is new and can only be delivered through setting up measurement systems which prompt your frontline teams to think differently measuring harm from the patients perspective and not from the healthcare providers. In all healthcare systems we count the number of pressure ulcers, falls etc and on the diagram below this is like counting downwards in vertical columns, for example, two of five patients had a pressure ulcer (40%). Don t keep me free from pressure ulcers but let me get a urine infection protect me from all these harms and keep me harm free. National Reporting and Learning System Hospital Episode Statistics In harm free care we want to change this and start counting patients protected from harm, in the pressure ulcer example this would be three of five patients (60%) if we count in the usual way. We can raise the bar even further by starting to count across at the level of the individual patient to determine how many patients had none of the 4 harms i.e. were harm free from these conditions ( harm free composite). To explain this further, in the example below, out of five patients, only two, patients three and four (highlighted in red) were protected from all four harms. This measure raises the bar for everyone as it sees harm from the patients perspective. Trigger Tool Audits ADVERSE EVENTS CASE NOTE REVIEW ROUTINE DATA POINT OF CARE AUDITS NHS Safety Thermometer Were patients protected from harm? Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 NO 2/5 (40%) YES Pressure ulcer The NHS Safety Thermometer Fall (with harm) Developed for the NHS by the NHS as a point of care survey instrument, the NHS Safety Thermometer allows teams to measure harm and the proportion of patients that are harm free during their working day, for example at shift handover or during ward rounds. Urine infection (in patients with catheters) VTE (newly acquired) Harm Free composite NO NO YES YES 1/5 (20%) 1/5 (20%) 0/5 (0%) 3/5 (60%) 3/5 (60%) 4/5 (80%) 4/5 (80%) 5/5 (100%) 2/5 (40%) NO The NHS Safety Thermometer provides a temperature check on harm and can be used alongside other measures of harm to measure local and system progress. NHS Safety Thermometer in use on the ward

6 10 11 How to make harm free care happen Your step by step guide STEP 3 Integrate the Plan with Existing Safety Programmes As an organisation you re already making great improvements in safety. To maximise your efforts and ensure you re working as efficiently as possible, look at this plan with your team to work out how it fits in with your existing safety improvement strategy. Put harm free care on the agenda. STEP 1 Select Your Day-to- Day Team Leader STEP 2 Create Your Team STEP 4 Take Your Senior Executive Team with You A good day-to-day Team Leader is critical to making harm free care happen within your organisation. This role is pivotal to ensuring all of the changes proposed in the plan and by your own improvement teams are tested, implemented and all of the data is collected. Team Leader Attributes From a clinical or managerial position with a working knowledge of patient safety. Able to organise and co-ordinate a functioning team that works at an accelerated pace. Able to negotiate with senior leaders and get dedicated time to deliver the plan. Good communication and co-ordination skills to liaise with all of your teams. To accomplish the improvement plan you ll need a multi-functioning team who can work together across your health economy to achieve effective results. Aim to have 10 members with enough time to commit to delivering the plan. The team includes: Day-to-day team leader Medical team member(s) Nursing team member(s) Physiotherapist / Occupational therapist / Dietitian Facilities / equipment loan stores Front-line professionals Patients and/or family members To find out more about the key responsibilities, visit Getting the right support from the outset of the plan is imperative to its success. So make sure you meet with your Senior Executive Team and get their buy-in and full understanding of harm free care. Regular meetings with your Senior Executive Team will give you the opportunity to share updates. We d also recommend asking for time on the agenda at board meetings at the start of the programme and report your progress to the Board at least annually. For those who require them, there is a selection of board papers on the website to help prepare for board meetings. STEP 5 Recruit a Patient to Join the Team Looking at harm free care from a completely different perspective can often help you identify areas for improvement. So we d encourage you to recruit a patient or family member who has experienced care within your health economy first hand. They will have different insights and give you invaluable feedback on how you can make improvements to deliver harm free care.

7 12 13 STEP 6 Use the Breakthrough Series Collaborative to Build Networks and Organise your Improvement The breakthrough series collaborative (BTS) model is a proven way in which teams can learn from one another around a focused set of objectives. Critical success factors include leadership support, patients at the helm, a clear aim, a focus on measurement, an agreed time frame and clinical engagement. To help you get started, we ve taken the most successful aspects of a pilot run by other organisations and plotted out 3 key learning sessions you will need to run in order to get your team mobilised. Full details of how to plan and organise your learning events are available to download on our website. Breakthrough Series Collaborative Model At Learning Session 1 you will need to work through each of the secondary drivers from the diagram on pages 4 and 5 and create your own improvement plan using the event outlines on our website as your guide. The secondary drivers are: Local clinical leadership Continence, skin and moisture Executive support Nutrition / hydration Walk rounds and rounding Medicines reconciliation Active risk management Equipment Education & training Example learning sessions are available to view on our website. To find out more, visit STEP 7 Complete the Base Line Audit Harm free care is not about duplication of improvement work. It s about auditing where you are now and working out the areas where your organisation needs to focus its attention to accelerate the pace of change. To help you plan your improvement work, we have created a Baseline Audit Tool on our website. Simply answer the multiple choice questions to determine which of the secondary drivers it would be most beneficial to focus your improvement team s attention on first. By integrating all of your processes and looking at all 4 harms together instead of in silos, you will be able to move forwards at pace and scale. STEP 8 Develop a Measurement Plan Adopt a plan, do, study, act, change approach Measuring the impact of the changes you make is absolutely paramount to delivering harm free care. A comprehensive measurement supplement is available on our website below you ll find an overview of the actions you will need to complete. Action 1 Review the NHS Safety Thermometer and test it on 10 patients Action 2 Agree operational definitions and method of collection for each item Action 3 Agree the locations from which you are going to measure during the pilot and spread phases Enrol Participants For additional information, please visit the NHS Institute at: improvement_tools/quality_and_service_improvement_ tools/staff_perceptions.html Action 4 Agree the frequency of your measurement Select Topic Recruit Faculty Key LS1 AP P-D-S-A Develop Framework & Changes Learning Session Action Period Plan-Do-Study-Act Prework LS1 A S AP1 P D LS2 A S Supports AP2 P D LS3 Visits Phone Conferences Monthly Team Reports Assessments A S AP3 P D Summative Congresses & Publications Identify your Target Area Prior to Learning Session 1 you will need to identify which ward or caseload you intend to use to trial your plan and undertake your improvement work. For example, a community hospital with 11 wards might choose to work on 1 or 2 of their 11 wards during the initial pilot phase, while a district nursing service might focus on the caseload of 1 or 2 clinicians. By focusing on a pilot area, you can test, change and evaluate results before spreading learning throughout your organisation. You should organise to review progress monthly with teams openly sharing stories of success, tests of change and data on outcomes with each other via monthly conference calls or meetings. Action 5 Agree how many patients you are going to measure at each session Action 6 Train your measurement leads in each location Action 7 Agree who will collate and review the data on a monthly basis Action 8 Agree the process measures you will collect to track progress with your primary driver Reference: Institute for Healthcare Improvement, Boston, MA, USA ( To find out more, visit

8 14 15 STEP 9 Organise Communications and Plan to Spread the Successful Changes from Day 1 To help you get buy in from all members of your organisation and to put the spotlight on what you are trying to achieve, we recommend you create as many channels of engagement as possible. You ll find a detailed engagement section on our website, along with a series of posters and learning materials which you can download and put up around your organisation. 1 Set up regular faculty and team meetings 2 Plan to share the programme design with key stakeholders 3 Put up posters and learning materials around the site 4 Commit a wide group to participation and action 5 Identify cross pollinators those who will travel between locations and share ideas STEP 10 Plan your Weekly Menu As a guide, the recommended time between learning sessions is 90 days. In between these sessions it is important that every member of your improvement team has a clear aim which they need to own and action. To get you started, we ve listed out all of the 9 secondary drivers you will need to work through in order to deliver harm free care. We ve also given you a set of prompts so you can agree your actions and challenge your objectives. Finally, use the communication channels list to agree how you will stay in touch between learning sessions. You can use the handy weekly planner download on our website to keep a track of each person s aims, when they will achieve it by, dates of when you will hold conference calls and details of WebEx sessions. To find out more, visit THE INGREDIENTS OF HARM FREE CARE Choose which order you ll tackle the secondary drivers 1 Local Clinical Leadership Continence, Skin and Moisture Executive Support Nutrition / Hydration Walk Rounds and Rounding Medication Reconciliation Active Risk Management Equipment Education & Training Use the model for improvement AIM Describe your improvement goal using SMART aims PLAN List the tasks needed to set up tests of change Predict what will happen when the tests are carried out Measure to determine if your predictions are true DO Describe what actually happened when you ran the test STUDY Describe the results and how they compare to the predictions what did you learn? ACT Describe what modifications to the plan will be made for the next cycle START AGAIN Agree your communication channels and meetings between learning sessions Agree a traffic light system for s so it s clear what the desired response is e.g. For action (response required to the programme office but no one else). WebEx Select from a list of WebEx sessions to listen to on the website. Conference Calls Plan in regular conference calls to ensure progress is being made and learning shared. Weekly / Monthly Meetings Agree what additional meetings you think you will need in between learning sessions.

9 things every organisation must do YOUR COUNTDOWN TO SUCCESS Leadership 4 Action Good strong leadership is paramount to the success of delivering harm free care across your organisation. You will need a motivated and driven day-to-day team leader who can engage with your senior leadership team and get buy-in from the outset. You will then need to pick your improvement team to drive and implement your plan through the initial testing phase, before helping you cascade the plan throughout your organisation. The team should represent every level of your organisation and be passionate about delivering harm free care. Commit to specific actions i.e. what will you do and when will you do it by? To get started use the Baseline Audit Tool on our website to determine where you are now and what areas you need to focus on first from all the key drivers Local Clinical Leadership, Continence, Skin and Moisture, Executive Support, Nutrition / Hydration, Walk rounds and rounding, Medication Reconciliation, Active Risk Management, Equipment, Education & Training. 3 Measure Stop measuring harm in silos and start measuring harm free care from the patient s perspective. Measurement is your way of celebrating the successes and accomplishments you make as an improvement team. It will also enable you to share information with one another and your wider senior team to drive further improvement work. 2 Learn By measuring all of your actions you will quickly be able to see what is working for your organisation. Some things will be more successful than others, so don t be afraid to acknowledge when things don t work simply move on and try something different. Remember, the improvement plan is not set in stone. It s about giving you the tools so you can create an individual plan that builds on the systems you have in place, so you can focus on areas most in need of improvement. 1 Share Harm free care is a continuous journey and an ongoing commitment to our patients. We want the harm free care website to be an evolving resource tool which every organisation can access. So make sure you send us your case studies that demonstrate how you made harm free care happen. Share your top tips for success and above all, make sure you share your successes throughout your organisation.

10 18 19 Top Tips Over the past year, many of the teams participating in the Safety Express pilot have given us their top tips for harm free care. Here s their selection of the most important, but you can find many more on our website. TOP TIP #1 Local Clinical Leadership Get your clinical specialists in tissue viability, falls, infection control and VTE to meet monthly with one another and frontline teams and set up ward to board reporting of harm free care. TOP TIP #5 Medication Reconciliation Review 10 patients every day to see if they have had their medications reviewed and documented within 2 hours of admission learn from failure and make changes based on trends over a week. TOP TIP #2 Continence, Skin & Moisture Think about catheters in hours and minutes not days and weeks remove them ASAP. TOP TIP #6 Active Risk Management Implement a single risk assessment for 4 harms and agree critical review points where its management will need to change e.g. post surgery, after a change in medication, following deterioration of vital signs. TOP TIP #3 Nutrition / Hydration Get all frontline staff to complete the e-learning modules for nutrition and hydration. TOP TIP #7 Equipment Get ahead have the equipment waiting for the patient not the other way round. TOP TIP #4 Walk rounds and rounding Establish a weekly, daily and hourly routine for reviewing patients discuss what needs including and how to get local clinical ownership. TOP TIP #8 Education & Training Take turns to deliver a two minute teaching tip for the day at handover.

11 20 21 CASE STUDY How West Suffolk made a real difference to patient safety Intentional rounding was the key to our success the process encompasses many very familiar nursing fundamentals, as well introducing measurement of the secondary drivers using the NHS Safety Thermometer, working alongside our existing ward data sets. by Lisa Nobes, Head of Nursing Development West Suffolk Hospital NHS Trust Leadership and teamwork Safety Express was actually handed to my colleague in Governance and Safety, but I caught sight of it and said I want to do this. I saw it as a really exciting opportunity to put into practice some of the things I wanted to work on. It identified the key drivers for safe care whilst providing a framework for implementation. The first activity was forming a strategic team, led by a champion with a real passion for delivering safe care. After that, a ward-led team was created to work through the operational process and implement intentional rounding. I formed a strategic team to support the overall programme and we identified our pilot sites to be our poorest performing wards. I was adamant about that they needed the greatest input and a boost to moral. Strategic team Executive Chief Nurse Deputy Medical Director Governance and Safety Lead Head of Nursing Development Ward-led team Productive Ward Facilitator Matron Ward Manager Band 6 Band 5 Assistant Practitioners Healthcare Assistants Physiotherapist Occupational Therapist Creating and integrating a plan In developing the programme s plan, a number of key themes emerged. The drivers were central to discussions, as an intensive, multi-driver approach was required. The poorest performing wards were identified as pilots because they had minimal recent attention. The pilots were phased one ward at a time and clear objectives were set. I was focusing on reducing the harms as my overall aim, but using the drivers as a means to achieve that. I certainly didn t have a clear idea of how that was going to work at the outset, but the drivers have always been the framework that I ve used. I have always found the drivers to be the most helpful parts because they are the components I really do believe make a difference. For me, they have a real impact. A key aspect of the planning stage was to determine measurement process and a baseline data set of the 4 harms. We also measured the impact on patient experience. The measurement objectives were based on the national aim with realistic staged reductions over the 15 months. Planning key themes to consider: Creating the right environment Ensuring visibility and availability of staff for patients Identifying at risk patients Reducing the risk of harm intentional rounding and checks Measurement criteria and processes SMART Objectives Specific Setting our aim for reduction of harms via implementation of key drivers 80% reduction in pressure ulcers, 50% reduction in harm from falls, 50% CA-UTI, reduce VTE by 50%. Measureable NHS Safety Thermometer Achievable Relevant Doing this in Stages made the reduction in each harm more achievable To increase quality and safety on the wards, linked to patient experience Time bound Over the year to April 2012 Implementing the plan We all learnt together and it was quite an intensive process. Throughout the implementation period the Executives also increased their ward walk arounds and we also worked closely with the ward managers. This was important as each had different ways of doing things and priorities. And some of the rounding tools had to be different. For example, the stroke unit has patients with different needs to those on the rehab unit therefore we adapted the tools for each area as required. At the heart of the plan was the implementation of intentional rounding, encompassing the secondary drivers and measurement processes. During three half-day sessions the ward teams were asked to discuss the current structure of their ward and a typical day. From this shared analysis, a plan for putting in place intentional rounding was agreed. The new day structure and intentional rounding was then shared amongst the wider ward team over a number of sessions.

12 22 23 Implementing the plan continued Implementation Assessment & Diagnosis Why do patients fall? Why do patients develop pressure ulcers? What prevention measures do we currently take? What else could be done? What s happening elsewhere? Implementation Planning What more do you need to do on this ward? Are the changes to practice required? How are you going to implement these changes? Who do you need to involve? How do you plan to communicate this? How will you measure your success? How will you ensure improvement is sustained? Measurement and results If I m completely honest, I wasn t expecting the reduction that we have seen. The first impact shown was the increased morale in staff on the wards the interest shown in their work and improved processes have created a happier ward workforce. The drivers impacted across a whole range of quality indicators including incidence reporting and quality management systems. Initially, NHS Safety Thermometer data was based on a 50% sample and collected by the clinical project lead. Standard data collection continued by ward staff. Aim Primary drivers Secondary drivers Spreading the message The cycle of harm free care is becoming self-fulfilling and sustainable. It is discussed at Matron s meetings and there s an element of internal and peer competition whose ward is at the top of the league? Ward staff are now escalating potential risks to matrons and ward managers, ensuring risk management is proactive and daily, assessing increased risk before an incident occurs. The Trust wants to improve teams have seen and heard the benefits and positive outcomes on pilot wards. A rollout across all units is planned and a low-/-medium risk intentional rounding tool is being developed, in addition to the high risk / vulnerable tool undergoing continuous improvement. Initially we had to sell it; sell it hard, which was time consuming but it is now doing the job itself. It s a slow build, but when you gain expertise, you can see how the programme will sit within the Trust. The facilitators know what they are doing and you start seeing improved performance it starts to escalate, accelerates and takes off with a life of its own. Leadership and safety culture Local clinical leadership Executive support Walk rounds & rounding To deliver harm free care as defined by the absence of pressure ulcers, falls, CA-UTI and VTE by December 2012 Clinical care 95% reliable Active risk management Continence, skin & moisture Nutrition / hydration Medication reconciliation Supporting infrastructure Equipment Education & training The harms have reduced across all pilot wards, especially to higher risk patients, but this was due to our intentional rounding tool being high risk triggered. The medium/low risk patients are now the ones that are falling most frequently we ve identified this from our measurement and we are testing an adapted rounding tool to address this. You can learn more about West Suffolk s results in detail at To read Lisa s top tips, download practical tools, read key elements of our implementation plan, watch videos and hear success stories from the wider West Suffolk team, visit our website at

13 big challenge to reduce harm 2 people tell you how they made a difference We asked two members who ve already participated in the harm free care plan to share their experiences about the most successful outcomes for their individual organisations. What was the overall strategy you put in place to reduce the number of Pressure Ulcers, Falls, CA-UTIs and VTE/PE? Liam Edwards, Senior Nurse, Preceptorship and E4E Trust lead and Paula Townsend, Deputy Director of Nursing, Kings College Hospital NHS Foundation Trust We are working in partnership with our community providers. At the outset we committed to working together to deliver: 5% reduction in urinary catheter utilisation 20% reduction in injurious falls Eradication of category 4 pressure ulcers 50% reduction in category 3 pressure ulcers 90% patients receiving VTE risk assessment and management This was achieved by a teaching programme delivered by the metric leads, close working with the medical team, investment in equipment and innovative new ways of working. Other initiatives included a new risk assessment form, patient information leaflet, publicity events and patient and staff information boards / flyers. Ward managers and link nurses as well as the leads provided a continual source of drive for the programme. David Charlesworth, Senior Practice Development Nurse, and Judith Connor, Lead Nurse for Patient Safety and Practice Development, South Tees Hospitals NHS Foundation Trust Workstream leads were already in existence and improving practice. These were brought together to identify joint initiatives such as rounding that would improve all four outcomes. Key aspects of the strategy were: Board-level and Commissioner commitment to Patient Safety Strategy implementation. Utilising Ward Managers to collect data by completing the NHS Safety Thermometer. A Patient Safety Programme Board and a CPD team with two members of staff who had full time responsibility for patient safety. What would identify as the key success factors? Which of the secondary drivers made the biggest impact? Why was measurement so important throughout the process? Liam Edwards, Senior Nurse, Preceptorship and E4E Trust lead and Paula Townsend, Deputy Director of Nursing, Kings College Hospital NHS Foundation Trust 5 Implementing systematic training across all wards with a huge increase in both knowledge base and competency. 6 Reviewing equipment stocks and sourcing new suppliers as well as investing in new equipment. Introduction of electronic reporting for all 4 metrics. Igniting nurse leadership for hourly walk rounds and monitoring compliance. Publicising the Safety Express programme throughout the Trust, increasing both awareness and interest. Demonstrated success in the decrease in all 4 harms across the Safety Express wards and reigniting passion for preventing harm for all patients. Equipment and education and training. Measuring the harms allowed us to understand what needed to be done and measure whether improvement work was impacting on patient outcomes. We were able to keep enthusiasm for the project at a high throughout the process by having graphical month on month representation of how wards were reducing harm. This was also made public to patients and visitors demonstrating that we were actively looking to reduce harm in all areas. David Charlesworth, Senior Practice Development Nurse, and Judith Connor, Lead Nurse for Patient Safety and Practice Development, South Tees Hospitals NHS Foundation Trust We developed a multi-disciplinary approach, for example with catheter management, along with clear, standard operating procedures and nurse-led training programmes. Partnership working, for example with pressure ulcer equipment that included 6 monthly bed assessment audits for pressure ulcer prevalence carried out by the mattress provider; included checks on bed frames, whether the patient is on a pressure relieving mattress and whether patient has proper seat cushions. Three years ago patients were developing pressure sores whilst sitting out of bed without the appropriate pressure relief and also on heel areas. Now, routinely if a pressure relieving mattress is ordered a seating cushion is also delivered. All 9 secondary drivers have had significant focus. Existing incidence measures were used as retrospective performance data and not as live data. We have had a real focus on measurement using the NHS Safety Thermometer. We have also seen the benefits of using point of care measurement through the NHS Safety Thermometer. For example the NHS Safety Thermometer highlighted a patient with the correct mattress but no pressure-relieving cushion. This was rectified the same day a demonstration of acting timely rather than waiting for a graph to come out a few weeks later.

14 26 Safety Express would like to thank everyone involved in this publication. What s the most significant change you ve seen now you ve spread harm free care throughout your organisation? Liam Edwards, Senior Nurse, Preceptorship and E4E Trust lead and Paula Townsend, Deputy Director of Nursing, Kings College Hospital NHS Foundation Trust We are now using the revised risk assessment. The patient information leaflet is next, to be used across all areas in Kings College hospital. We have raised the profile of the harm indicators significantly across the Trust and implemented intentional rounding. All areas have access to specialised falls equipment, pocket guides for pressure ulcer prevention and treatment is given to all nurses. Electronic reporting is now an accepted norm. David Charlesworth, Senior Practice Development Nurse, and Judith Connor, Lead Nurse for Patient Safety and Practice Development, South Tees Hospitals NHS Foundation Trust There has been a positive response to the concept of harm free care across the organisation. In terms of outcomes, there are early positive changes apparent in the total number of falls due to intentional rounding.

15 This guide has been compiled by the QIPP safe care national work stream. To discover more about harm free care in detail, and to download resources, visit