Nursing and Midwifery Ambitions Evaluation

Transcription

1 Nursing and Midwifery Ambitions Evaluation Nursing and Midwifery Ambitions Evaluation

2 Contents Page No. 1 Contents 2 Executive summary 3 Introduction Progress towards the Ambitions: To improve patient safety To improve patient experience To improve communication To enhance professionalism and leadership 21 5 To enhance staffing and satisfaction 22 Priorities for and Conclusion Appendix 1: Key Milestones Action Plan Nursing and Midwifery Ambitions Evaluation Page 1

3 Executive Summary I am pleased to deliver this evaluation report that details the significant progress made in the third and final year of this Nursing and Midwifery strategy. I am proud of the nursing and midwifery workforce for being able to take forward the ambitions of during a time of tremendous change throughout the Trust with the delivery of the Our Changing Hospital programme. The report provides evidence of meeting key milestones, and a record of the continuous delivery of initiatives to improve patient safety and experience key achievements include: A continued reduction in falls and pressure ulcers Robust reporting and monitoring of nursing and midwifery staffing levels Development of a Nutrition Strategy Widening learning Disability Awareness Supporting teams through Our changing Hospitals Friends and Family Test results Angela Thompson Director of Nursing and Patient Experience Nursing and Midwifery Ambitions Evaluation Page 2

4 Introduction East and North Hertfordshire NHS Trust (ENHT) has as its vision to be amongst the best performing NHS Trusts in the country, with high quality care and excellent patient experience very much incorporated within the Trust values that underpin the vision: The Trust s five key ambitions for nursing and midwifery are:- Ambition 1 To improve patient safety Ambition 2 To improve patient experience Ambition 3 To improve communication Ambition 4 To enhance professionalism and leadership Ambition 5 To enhance staffing and satisfaction This year has seen the culmination of Our Changing Hospitals programme; a 150million investment programme that has taken several years to complete. This has taken a tremendous amount of hard work from staff and volunteers. We need to continue the good work that we have started to ensure that our values are embedded in all we do and we really do put our patients first. This is only the start of an exciting future as we move forward in vastly-improved facilities to deliver the very best care to the people in our local community. This report details the outcomes of the milestones and the actions for the coming year as the Nursing and Midwifery Ambitions are concluded. It also celebrates the many other achievements and developments within nursing and midwifery practice which have had a significant effect on patient safety and experience. Nursing and Midwifery Ambitions Evaluation Page 3

5 Progress towards the Ambitions Ambition 1 To improve patient safety Our Aim: To minimise avoidable harm Embed safety walkabouts on all wards: Safety walkabouts are undertaken by the senior nurses and the quality and compliance teams. These are based upon the assessment format of the Care Quality Commission using the key line of enquiries. The walkabouts include discussions with staff and patients; and a review of documentation and the environment. Feedback, both positive and identifying areas for improvement, is shared with the ward team. A programme of 15 Steps Challenge visits is in place throughout the Trust. This is a tool that allows us to see the ward or service as a patient would. Teams go onto wards unannounced to see how they are welcomed, what they can hear, see, smell and touch and feedback is provided to the ward team. Action plans are developed and monitored following these visits. Implement intentional rounding on all wards: All wards use the intentional rounding tool which is a regular check (hourly during the day-time and two-hourly at night-time). The check includes observation of the patient and asking about levels of comfort, i.e. levels of pain, personal, nutrition and hydration needs. Nursing staff monitor documentation of the intentional rounding tool in the patient documentation audits. In ,472 sets of patient notes were audited and the Trust scored 91.6% for completion of the intentional rounding tool. Reduce the number of falls and reduce the instances of serious harm resulting from falls: As a result of a number of initiatives including continuing education and a high level of engagement between clinical teams and the Trusts Falls Prevention Practitioner, a reduction of 55.3% in the number of falls has been achieved over a 5 year period. The Trusts Falls Prevention Strategy focuses on a year-on-year reduction in inpatient falls to ensure that improvements are achieved and sustained. Nursing and Midwifery Ambitions Evaluation Page 4

6 A target to reduce inpatient falls by a further 5% has been set for 2015/16. Monthly audits are conducted in inpatient clinical areas throughout the medical and surgical divisions to measure local adherence to the Trust Falls Prevention Policy and Strategy The falls prevention page on the Knowledge Centre has been developed to include links to educational resources and organisations specialising in falls prevention. Monthly falls reports are now routinely shared with all grades of nursing staff at team meetings and published on the intranet. Real-time reporting of falls incidents is now embedded into clinical practice. The Datix reporting system provides a tool to analyse themes and trends associated with inpatient falls on a daily basis. This allows bespoke speciality falls risk mitigation measures to be introduced at an earlier stage of an individual patient s admission to prevent falls. Falls prevention is now included on Preparation for Practice courses for Clinical Support Workers, patient safety study days and the Safe Care Wednesday programme, education is also delivered at local ward staff meetings. The Trusts Falls Prevention Policy has been reviewed and updated in 2015 to incorporate the latest research and evidence based best practices in falls prevention. To maintain zero hospital acquired avoidable pressure ulcers During the overall number of hospital acquired pressure ulcers reduced slightly with a total of 104 both avoidable and unavoidable pressure ulcers compared to last year s figure of 121. In addition to this on-going reduction in the number of pressure ulcers, the Trust has not recorded an unavoidable grade four the very worst pressure ulcer since October The table below demonstrates the enormous strides the Trust has made towards achieving its goal of zero hospital acquired pressure ulcers for every clinical area in the Trust: Nursing and Midwifery Ambitions Evaluation Page 5

7 Wards are working towards a goal to achieve the maximum number of pressure ulcer free days, which demonstrate how long it has been since a patient developed a hospital acquired, avoidable pressure ulcer. The table below shows the number of wards achieving pressure ulcer free days: Patients to have a Malnutrition Universal Screening Tool (MUST) assessment and relevant patients to have their hydration needs assessed and met: Monthly nutrition documentation audits are completed to ensure compliance with completion of the Malnutrition Universal Screening Tool. Wards are asked to deliver actions plans with robust timescales against the level of compliance. The nutrition steering committee has developed a 4 year plan - Food and Drink strategy with a gap analysis. Nursing and Midwifery Ambitions Evaluation Page 6

8 A rolling programme of nutrition education for nursing and clinical support workers continues to be delivered by dietitians in collaboration with the University of Hertfordshire. Following a patient consultation in September 2014 work has been undertaken by the catering department in collaboration with dietitians to review and revise patient menus with the introduction of a catering services directory at ward level for staff, and a patient menu booklet. Food safety training for staff (certificated by the Chartered Institute of Environmental Health) will be rolled out from October 2015 for all new housekeeping and clinical support staff. A number of mealtime observation audits have been completed at the Lister site. Feedback has been provided at the end of the audit to the ward team. There has been a review of the role of the ward housekeepers over a 7 day period and during mealtimes, considering elements such as helping patients with their meals, and use of the red tray/jug system. Feedback will be provided to the Nutrition Steering Committee with recommendations for service improvement. Nursing and Midwifery Ambitions Evaluation Page 7

9 Nursing Quality Indicators to be included in Ward to Board reports: The Nursing and Midwifery Quality Indicators report was reviewed in 2015 and includes data, broken down by ward, Division and Trust to enable monitoring of:- Number of beds and % bed occupancy E-rostering including % e-roster meeting deadline, net hours position and % annual leave Funded and actual staffing establishment, vacancy rate, planned-v- actual hours worked, sickness, agency/bank usage, staff appraisal, missed breaks, overtime, statutory training, wards triggered red in month and wards stayed red Length of stay and number of delayed discharges Patient safety including falls and those resulting in serious harm, hospital acquired pressure ulcers, % NEWS score completion and evaluation, medication administration errors, unplanned omissions providing patient medication, delay of >30 minutes for pain relief, omission of intentional rounding, number of safety thermometer patients with harm and compliance with hand hygiene. Patient experience including the Friends and Family Test % of patients who would/would not recommend the ward, FFT response rate and patient responses to questions within the inpatient survey: enough nurses on duty, enough emotional support, someone to talk to about worries and fears, know who named nurse is, understandable answers to questions from nurses, pain control, response to call button and help from staff to eat meals. Each Division presents their Nursing Quality Indicators to the Matrons/Sisters meeting on a rotational basis. Achievements in addition: During the 12 months to the end of March 2015, the Trust recorded five hospital-acquired blood infections (bacteraemias) caused by Methicillin-resistant Staphylococcus aureus (MRSA) bacteria strains, four of which were unavoidable along with 14 cases of infections due to the bacteria Clostridium difficile. The targets for these two important causes of hospital-acquired infections were none and 12 cases respectively. The Trust remains amongst the better performing NHS organisations in the country, especially for Clostridium difficile. Nurse Education has launched the Safe Care Wednesday initiative at the Lister site and Target Tuesdays at Mount Vernon Cancer Centre, which provide drop in learning sessions for clinical staff. The sessions are delivered by subject experts (specialist nurses, AHPs, nurse education team) and cover key messages related to patient safety and good practice. The Care Certificate has been embedded successfully in the Apprenticeship Level 2 award for all new Clinical Support Workers. Nursing and Midwifery Ambitions Evaluation Page 8

10 The NHS Safety Thermometer is a national audit designed to measure a snapshot once a month of patient harms from pressure ulcers, falls, urinary infection in patients with catheters and treatment for VTE. The audit does not take account of where the harm occurred, for example a patient arriving in hospital with an old pressure ulcer is counted as a patient harm. The percentage of patients with harm continues to fall from 6.4% ( ), 5.2% ( ) to 4.9% ( ). An Independent Domestic Violence Advisor funded by Victim Support is now based in the Emergency Department. In January 2015, the Trust purchased The National Patient Safety Suite- Diabetes E Learning Programme, an online suite developed to provide access to comprehensive learning on The Safe Use of Insulin: The programme was launched collaboratively by Nurse Education and the Diabetes Outreach Team (DOT) in March 2015 and since its inception, 265 staff members have completed and passed The Safe Use of Insulin module, with 905 modules being passed in total, in the 5 month period. East and North Herts NHS Trust is the first organisation nationally to achieve a Gold Certificate of Achievement. The certificates are based on the number of module completions when measured against the number of clinical staff in the Trust. A staff nurse on Critical Care has won an IPAD in the monthly raffle run by Virtual College for all new registrants. The renal team has been successful in obtaining additional funds from The Nursing Technology Fund to expand the implementation of an electronic observation tool, across the organisation, to all in patient areas. This implementation commenced in June Commissioning at University of Hertfordshire has taken place to provide simulation training for clinical support workers, focusing on the recognition and escalation of the deteriorating patient. The University of Hertfordshire has been commissioned to deliver OCSE (Objective Structured Clinical Examinations) to support the development of registered nurses recruited from the wider EU and internationally. VITAL statutory and mandatory training has been extended to Doctors. The Resuscitation Team have:- Implemented the following competencies: Physiological Observations, Adults and Paediatrics, Pipeline Suction, Checking Cardiac Arrest Trolleys Nursing and Midwifery Ambitions Evaluation Page 9

11 Introduced new technology in teaching and assessing Basic life Support training using QCPR manikins which provide enhanced feedback. Due to the success of these, infant manikins have been purchased and are used for Paediatric basic life support training and new-born resuscitation training. Delivered a project on Do Not Attempt Cardio-Pulmonary Resuscitation including, education, audits and introduction of a new patient leaflet. Developed Operational Policy for Resuscitation at the New QEII Hospital which includes, placement of equipment and maintenance, how to call for help (999), ensuring that sufficient emergency equipment is available and staff are familiar with the contents and location. Implemented resuscitation Information folders on all adult cardiac arrest trolleys have been updated to include equipment lists, documentation and policies. Implemented a system for all new areas opening which includes inspection tour by a Resuscitation Officer, cardiac arrest test call, practice scenario for staff before opening. Developed training sessions for student nurses. Implemented a debriefing service introduced throughout the Trust. Nursing and Midwifery Ambitions Evaluation Page 10

12 Ambition 2 To improve patient experience Our Aim: To ensure a positive experience to all patients under our care Maintain performance for the Friends and Family Test score The Friends and Family Test question is now asked in all hospital services: Date: FFT Introduced in: April 2013: Adult Inpatients and Accident and Emergency October 2013: Maternity Pilot October 2014: Outpatients, Day Case and Children s (reported nationally from April 2015) Patients are asked how likely are you to recommend the ward/department/service to friends and family if they needed similar care or treatment. The question must be asked at or within 48 hours of the patients discharge from hospital. Up to September 2014 responses were reported as a net promoter score. From October 2014 NHS England issued new reporting guidance and the results are now presented as a percentage of patients who would/would not recommend. The table below shows the proportion of inpatients who would/would not recommend the Trust in : Nursing and Midwifery Ambitions Evaluation Page 11

13 The response rate to the Friends and Family Test is closely monitored each month and the Trust achieved the national target response rates for inpatients and Accident and Emergency in In ,141 patients answered the FFT question 8,144 Inpatients, 16,133 A&E, 6,481 Maternity, 20,871 outpatients, 440 children s services and 1,072 day case. Wards and departments to continue to deliver at least the minimum number of patient feedback responses using the Meridian trackers The Trust continually monitors feedback from patients and uses this feedback to make changes and improvements to the services it provides. An electronic patient survey system is in place called Meridian which enables patients to complete relevant surveys by the use of a simple electronic device (i-pad) whilst they are in the hospital; these surveys can also be accessed via the Trust s web-site for completion by patients at home. During ,148 patients completed one of our electronic surveys. Meridian Surveys No. completed Inpatient 5744 Maternity 3022 Outpatients 3133 Accident and Emergency 360 Discharge 2075 Neonatal Unit 132 Renal Dialysis Unit 1374 Critical Care 38 Young Outpatients 196 TOTAL 16,148 In October 2014 the inpatient experience survey on Meridian was reviewed. Two questions relating to patients having a choice of food and cleanliness of toilets and bathrooms were removed as these were scoring consistently well and the following new questions added: Did you get enough help from staff to eat your meals? In your opinion, were there enough nurses on duty to care for you in hospital? Do you feel you got enough emotional support from hospital staff during your stay? Do you know who your named nurse is? Nursing and Midwifery Ambitions Evaluation Page 12

14 The Meridian League Usage Report enables Matrons and Ward Sisters/Charge Nurses to monitor responses made to the Trust s patient experience surveys and the percentage response rate to the inpatient survey is reported in the Trusts Nursing and Midwifery Quality Indicators report (by ward/division/trust). Continue to act on comment card results and communicate changes to visitors and patients All wards have a patient experience poster which is updated monthly with the best/worst performing areas in the patient experience surveys and the You Said We Did actions. The poster also includes the wards Friends and Family Test score which is calculated from responses to the Friends and Family Test question and includes the number of responses to the question for the month. Continue to deal with complaints in the moment and aim to further reduce complaints During the Trust received 1180 formal complaints, an increase of 37% on the previous year. A particular increase was noted in October 2014 around the time when many services were being centralised at the Lister Hospital. The majority of complaints reported to the Trust, however, were of a low or moderate severity and related to delays and communication problems, rather than clinical treatment. Patients and their relatives/carers are encouraged to talk to the ward staff or Matron if they have any concerns or worries. A new Comments, Compliments, Concerns, Complaints leaflets was produced including all feedback options in one leaflet. Posters are displayed encouraging patients to provide feedback about their hospital experience; these include details of how feedback can be provided by completing one of our surveys including the Friends and Family Test survey, using social media, NHS Choices or Patient Opinion. Nursing and Midwifery Ambitions Evaluation Page 13

15 Achievements in addition: Over 1,630 hours of interaction with patients from further education college students and volunteer visits organised by Kissing it Better: Nursing and Midwifery Ambitions Evaluation Page 14

16 Dementia Awareness Day held on 21 May 2015 to encourage working towards providing a seamless service for patients with dementia whilst in hospital and on discharge, ensuring that patients and their families receive all the care and support they need. The Trust has over 70 staff who are Learning Disability Champions and work in liaison with the Learning Disability Nurses to support patients with Learning Disability and their carers or family when they are using hospital services. Learning disability champions are across all Trust services and come from all staff groups. The Day Surgery Unit at the Lister Hospital was awarded the Purple Star accreditation in 2015, which is a standard mark for people with Learning Disability, and shows people with LD that they can expect to receive care appropriate to their needs by this recognised standard mark. The New QEII Hospital and Endoscopy Unit at QEII are now working towards achieving this accreditation. Nursing and Midwifery Ambitions Evaluation Page 15

17 Ambition 3 To improve communication Our Aim: To communicate more efficiently, effectively and courteously to everyone Implement the SBAR method of communication: SBAR (Situation Background Assessment Recommendation) is in place across the Trust. This is a tool that facilitates a structured method for communicating critical information about a patient s condition should it require immediate attention. It can also be used as a tool for handovers between staff. The roll out of this tool has resulted in improved communication and patient safety across multi professional teams. Teams to hold regular team meetings: Wards have regular team time, to communicate information and learning from a number of sources including complaints and incidents. Listening forums for band 5s and clinical support works were instigated during the lead up to consolidation, hosted by the Director or Deputy Director of Nursing. All Nursing Service Mangers meet regularly with the Director and Deputy Director of Nursing and the Nursing and Midwifery Executive Committee meets monthly. The Sisters and Matrons meetings continue to have high attendance with divisions presenting monthly on issues and achievements and their nursing and midwifery quality indicators. The Clinical Nurse Specialists and Research Nurse forums continue to meet bi-monthly, establishing an extremely important network for this group of nurses. Nursing and Midwifery Ambitions Evaluation Page 16

18 To act on feedback in relation to communication as identified in the quarterly staff survey: The Trust s organisational development strategy is supported by a programme called ARC: Accelerate quality, staff training, communication Refocus on our patients, on our staff, on our values, on our partners Consolidate services, patient pathways, our hospitals, our teams The ARC name is underpinned with the strap line it s all about you each and every staff member makes a difference. To improve the level of customer care that the Trust provides to its patients and visitors, a programme of training called Delivering excellence in customer care was launched across the Trust in February 2012 and ran until June Around 2,700 staff have completed this training programme since its launch. The programme is now changing and customer care training will form part of a wider staff engagement programme and will be delivered in a way that best suits the needs of our staff and services. Achievements in addition: A standard Operating Procedure (SOP) for ward handovers has been developed and implemented to ensure the use of bay handover. The aim of the initiative is to ensure a consistent and safe approach to communication across all inpatient wards. Nursing and Midwifery Ambitions Evaluation Page 17

19 Ambition 4 To enhance professionalism and leadership Our Aim: To strengthen Nursing and Midwifery Professionalism and Leadership. Evidence of nursing and midwifery staff participating in local and national research studies: Research nurse competency based training has been supported by workforce development collaboration with ECRN providing the Advanced Research Practitioner course and the research fundamentals course. The Trust are in the process of piloting the NIHR Principle Investigator oversight masterclass. This will be led by senior research nurses to ensure robust and evidence based Good Clinical Practice processes are in place throughout the trial. The outcome of the Research and Development consultation 2015 has supported the MHRA findings of aligning protocols and processes within the Trust. There has been a further increase in research activity in surgery, rheumatology, ENT, cardiology, stroke, renal and diabetes. Successful funding award from the ECRN to appoint a research nurse to the paediatric division. An exciting opportunity to expand research participation for children. The Ok to ask campaign is ongoing within the Trust, encouraging members of the public and patients to ask about research and offering an opportunity to get involved. Research for Patient Benefit (RfPB) submission in progress to apply to the National Institute Health Research looking at tele health for thyroid cancer patients. The research project to improve the experience of people with learning disabilities in hospital RfPB awarded to ENHT and Cambridge University Hospital s Foundation Trust is successfully ongoing. Published article 'Noise at Night in Hospital General Wards' British Journal of Nursing. Successful award of an East of England CLAHRC fellowship. Two applications are in progress for the HEE Clinical Academic Internship Programme Interviews and appraisals to test the understanding and application of the Trust s core values: HR have developed recruitment interview and appraisal packs which test all staff understanding and application of the Trust values. During the selection process candidates are asked to discuss the Trust values. Nursing and Midwifery Ambitions Evaluation Page 18

20 Expectations of professional behaviour to be reminded and challenged where appropriate: The customer care training programme is changing and will form part of a wider staff engagement programme which will be delivered in a way that best suits the needs of our staff and services. Development of a professional and dress code audit. Achievements in addition: The Director of Nursing, Adult Safeguarding Nurse and research nurses are participating in and supporting the HEALeD project (Hospital Experiences of Adults with Learning Disability). This is a joint research project with Cambridge University and Addenbrooke s Hospital funded by a Research for Patient Benefit research grant of 300,000. Leadership development was an ongoing priority for the Trust in 2014 and was provided through: Work based learning University provision through CPD commissioning Health Education East of England initiatives The National Leadership Academy Professional bodies. The table below details numbers of staff who participated in local and regional training programmes- in 2014/15 Core Trust Leadership Development Numbers trained Excellence in Management Programme 16 Recruitment and Selection 20 Core Management Skills programme 49 Appraisals Training 134 Patient Story Training 12 (Board members have been trained in addition) ARC Sessions 836 Challenging Conversations 41 Customer Care Facilitator Training 13 Customer Care Training 260 Trust Development to Support OCH Numbers trained Manager s Preparing for OCH Training sessions 69 Drop in sessions and one to one support provided 90 Effective Interview skills workshops 216 Conducting OCH interview Workshops 17 TPP Interview Workshops 52 Moving Through Change Workshops 47 Building and Developing High Quality Teams 28 Bespoke sessions for teams number of attendances 163 Commissioned Courses at HEIs and Regional Numbers trained Programmes Clinical Leadership Skills 25 Foundations in Leadership 35 Nursing and Midwifery Ambitions Evaluation Page 19

21 Change Leaders and Super series 71 Coaching Course Level 5 2 Change Leaders Fellowship 2 Business Skills for clinicians 1 Health care Leadership Model 2 National Leadership Programme s Numbers trained Edward Jenner on line programme - on line 6 month Unknown * programme Mary Seacole - National Leadership Programmes 12 Elizabeth Garrett Anderson- National Leadership 3 Programmes Nye Bevan - National Leadership Programmes 3 Front line Leaders - National Leadership Programme 12 Senior Operational Leaders 1 * The Edward Jenner on line learning has now been embedded into a number of established Trust programmes, staff can access these independently. Nursing and Midwifery Ambitions Evaluation Page 20

22 Ambition 5 To enhance staffing and satisfaction Our aim: To employ excellent staff who feel valued and empowered and, through living the Trust values, perform to the best of their abilities Good news stories to be shared and celebrated on a regular basis: Good news stories are shared at the beginning of all nursing and midwifery meetings, including The Nursing and Midwifery Executive Committee and Senior Sister and Matrons meetings. A number of our Nursing and Midwifery staff have presented at conferences and had articles published in peer review journals. Several teams within the Trust have been awarded or nominated for awards. International Nurses Day for the first time was a pan Hertfordshire event, with the largest number of nurses in the country meeting in one venue in Welwyn to celebrate the day with national speakers such as Helen Bevan. Within the same week the education team hosted an outdoor event engaging staff, patients and visitors on matters of patient safety and experience. Nursing and midwifery rosters to be managed and published four weeks before they begin: Ward teams continue to increase the quality of e-roster management, with performance monitored monthly. All of the inpatient ward s e-rosters are now interfaced with NHSP, making the data available to manage safe staffing in real time. The Trust was a pilot site for the NICE Safe Staffing Guidance, with members of the senior nursing team being invited to observe the NICE Parliamentary Advisory Group on Safe Staffing. The Trust was asked to deliver a workshop at The NHS East of England Sharing Good Practice Event in relation to the Trusts work in safe staffing. Nursing and midwifery staff participating in the internal staff survey and actions to be put in place to improve satisfaction: A new process to understand and capture the continuing professional development requirements of individuals and departments has resulted in greater engagement and an increase of applications for funding for study. Funding requests were decided on based on individual s development needs, service requirements and national priorities. The Listening Forums for band 5s and CSW s allow staff to share concerns and issues with the senior nursing team. Nursing and Midwifery Ambitions Evaluation Page 21

23 Priorities for An action plan showing progress against our key milestones for achieving the Nursing and Midwifery Ambitions are detailed in Appendix 1. The Trust had identified the following priorities:- A ward accreditation programme to ensure excellence in patient safety and experience. Updating the e-roster software to achieve real time safe staffing monitoring. Working with Human Resources to further develop Talent mapping Increase the number of nurses on Leadership programmes and further development of internal programmes for ward managers. Integration of nursing research into practice Striving to improve patient safety and experience following the consolidation of Our changing Hospitals. Conclusion This report demonstrates that, although we have not been able to fulfil all our ambitions in full, given the challenges presented during this year there are many successes and areas of good practice to be celebrated. We will soon be working with nursing and midwifery staff, patients, carers and public members and staff to develop our Nursing and Midwifery Ambitions for the next four years. This will reflect the recent publication of the Chief Nurse Strategy for Nursing. We will continue to strive to improve the care and treatment that we provide to our patients and look forward to the challenges ahead. Angela Thompson Director of Nursing and Patient Experience Nursing and Midwifery Ambitions Evaluation Page 22

24 Appendix 1 NURSING AND MIDWIFERY AMBITIONS ACTION PLAN TO DELIVER KEY MILESTONES ACTION PLAN: Progress updated September 2015 Lead: Angela Thompson, Director of Nursing and Patient experience Co-leads: Liz Lees and Carolyn Fowler Deputy Directors of Nursing Reporting to RAQC Action has slipped Action is not yet complete but is on track Action has been completed Ambition 2014/15 Action Update September 2015 Responsibility Target date To Improve Patient safety Further reduce the number of falls by 10% To maintain zero hospital acquired avoidable pressure ulcers Target areas of high risk Establish themes in relation to specialising requests Escalation of patients with more than one fall to Falls Prevention Nurse(FPN) Continue to embed intentional round. Establish in ward accreditation programme. Falls continue to be monitored monthly, the FPN works on wards in areas of high risk, Ward accreditation programme in progress, 4 wards have commenced the process. Intentional Rounding and Pressure Ulcer reporting are featured in the accreditation audit framework. Enda Gallagher (FPN) Jacqui Attrill On-going monthly review On-going monthly review Further develop the education programme Pressure Ulcer Prevention and MUST (Malnutrition Universal Scoring Tool) training day developed and being delivered bi-monthly for all nursing and support staff. Intentional Rounding and pressure ulcer prevention remain a large focus of the monthly Patient Care and Safety Day. Safe Care Wednesday launched, featuring aspects of safe care including Pressure Ulcer Prevention and Intentional Rounding. Diane Brett & Nurse Education Team Action Plan Nursing and Midwifery Ambitions C. Fowler/L Lees Final Page 23

25 Further increase the percentage of normal births Nursing Quality Indicators Excellent performance to be maintained and action plans in place to address any areas of underachievement Early risk detection, appropriate allocation of staff to labouring women Implementation of revised nursing Quality Indicators in light of NICE guidance on red flag reporting Normal births remain static at 61% The inclusion criteria and transfer document have been reviewed to considering increasing the number fo births in The Midwife lead Unit. New Nursing and Midwifery Quality Indicators mapped against new NICE safe staffing guidance in place. Monthly reports produced discussed at Divisional meetings, senior nursing committees and Risk and Quality Committee. Further developments The Ward accreditation programme Framework and processes developed. Sub group formed with regular meetings. 4 wards currently undertaking the programme and roll out planned for remainder of Trust. To Improve Patient experience Maintain performance for the net promoter score Wards and departments to continue to deliver at least the minimum number of patient feedback responses using the Meridian trackers. Continue to deal with complaints in the moment and aim to further reduce complaints Report on Friends and Family Test survey feedback for all wards, outpatients, day surgery, A&E and maternity. Ward sisters to ensure minimum of 25% of inpatients complete inpatient survey and minimum 40% of inpatients respond to the FFT survey. Training for complaints team Ward teams to proactively manage oral complaints to prevent escalation Wards to have feedback of outcomes from complaints and presentation at NMEC, sisters and matrons and Listening forum. Trust targets agreed for % of patients who would recommend for inpatients/day case, A&E, maternity and outpatients. These are monitored in N&M Quality Indicators and Trust floodlight scorecard. Trust target response rates agreed for Friends and Family Test survey and Meridian inpatient survey. These are monitored in monthly N&M Quality Indicators. Training with complaints team undertaken. Complaints response management has improved through weekly monitoring Rigorous response to patient and carer dissatisfaction is demonstrating a reduction in formal written complaints. This is achieved by supporting teams to manage potential complaints through improved ward manager s quality surveillance of wards, matron input whilst working clinically on rostered shifts and thrice weekly unannounced quality visits. Complaints feedback at monthly ward staff meetings. Helen Altringham Liz Lees Carolyn Fowler Jenny Pennell Jenny Pennell/ Ward/Department managers Jackie Martin Nursing Service Managers (NSM) Review figures Oct 2014 On-going monthly review On-going On going On going Completed On-going Action Plan Nursing and Midwifery Ambitions C. Fowler/L Lees Final Page 24

26 Further developments Development of Tel-health in cancer Pilot of tele-health clinics in Head and Neck Cancer in place. Jackie Jones Pilot in place Introduce improved patient information layout in the ward areas Information displayed to patients and visitors under review and new standardised posters developed for inpatient wards. Jenny Pennell/ NSMs November 2014 Ward welcome leaflets reviewed and updated. How we re doing information posters redesigned to include appropriate information on patient safety eg number of falls/infections etc. Ward visiting and protected mealtimes posters redesigned and distributed to all inpatient wards. To Improve Communication Teams to continue to hold regular team meetings Maintain good practice already embedded. Monitor ward team time post OCH Nurse education to work with HR to develop team building sessions and support team affected by change. Team meetings in place in Medical wards. Notes of meetings available. Template with standing agenda items used in Ward accreditation Carolyn Fowler Wendy Parry Nursing Service Managers December 2014 To act on feedback in relation to communication as identified in the quarterly staff survey Agenda item for all meetings. Ward to review at team meetings Feedback findings monthly, actions detailed in NMEC action plan Nursing Service Managers On-going Further developments Review of customer training with HR HR currently reviewing customer care training provision in the Trust. Carolyn fowler Wendy Parry Dec 2015 Professionalism & Leadership Evidence of publication and presentation from research studies and/or service design Development of a communication skills framework The education team are working to develop with key stakeholders an East of England framework. Noise at night research pilot Sept 2014 Positive feedback from the first round application from the RfPB Steering group Carolyn Fowler Jan 2015 Anita Holmes March 2015 Action Plan Nursing and Midwifery Ambitions C. Fowler/L Lees Final Page 25

27 Networking and shadowing opportunities provided for staff nurses Implementation of Internal skills for clinical leadership Skills for Clinical Leadership programme in collaboration with University of Herts commissioned (aimed at B6 B7 clinical staff). Third cohort in progress, with 4 th planned within the financial year. Jacqui Attrill November 2014 Building Foundations Leadership Joint programme with Anglia Ruskin University, delivered on site, (aimed at B5 B6 clinical staff), Third cohort in progress with 4 th planned within the financial year. Further developments Development of the Care Certificate for Clinical Support workers Care Certificate implemented and embedded into L2 apprenticeship for all new clinical support workers. Carolyn Fowler March 2015 A recruitment and career pathway for clinical staff bands1-4. Pathway in place for clinical staff bands 1-4. L2 apprenticeship progressing to L3 apprenticeship, and then onto a foundation degree, Jacqui Attrill November 2014 Staffing and satisfaction Good news stories to be shared and celebrated on a regular basis Nursing and midwifery rotas to continue to be managed and published four weeks before they begin. Further engagement with the Princes Trust Create a data base of good practice Education newsletter for staff Continue to improve performance in relation to e-rostering. Develop business case for allocate package and clinical post to support implementation. Workforce partnership developing a flexible, 18 month, nursing pathway, to enable foundation degree candidates to gain a BSc in Nursing Traineeships commencing October Work placements offered for candidates. Up and running, capturing all good practice, including publications, awards, and presentations. Nursing took part in the trust poster competition. Poster presentations and examples of good practice have been part of events, such as International nurses day and dementia week. Carolyn fowler (in collaboration with HR) January 2015 Carolyn Fowler June 2014 Business case agreed and implementation in progress. Liz Lees October 2014 Action Plan Nursing and Midwifery Ambitions C. Fowler/L Lees Final Page 26