Bwrdd Iechyd Prifysgol Betsi Cadwaladr University Health Board

Transcription

1 Thursday 25 th November 2010 Liberty Stadium / Optic Technium Bwrdd Iechyd Prifysgol Betsi Cadwaladr University Health Board

2 Betsi Cadwaladr University Health Board Ysbyty Glan Clwyd Ysbyty Gwynedd Ysbyty Maelor Betsi Cadwaladr University Health Board

3 Organisational Aim To reduce Harm within the area covered by Betsi Cadwaladr University Health Board as measured by mortality and adverse event rates. Betsi Cadwaladr University Health Board

4 Betsi Cadwaladr University Health Board Driver Diagram OUTCOME PRIMARY DRIVER SECONDARY DRIVERS INTERVENTIONS PLANNED P Lives implementation and spread Leadership and a culture of safety Consolidate and spread Normalization through CPGs & workstreams The New - Stroke, Hospital acquired thrombosis, and Pressure Ulcers Develop the measures and use clinical data Make care safer for patients As evidenced by reductions in RAMI and Adverse Event Rate P2. Target the top causes of Death in BCU P3. to identify and prioritise the causes of harm Amenable Mortality? Amenable Harm? R&D process The evidence base for what is efficacious The methodology for Improvement - Spread Collaborate- National Campaigns, SPN,etc. Notes Reviews, Global Trigger Tool, IR1, Complaints & Litigation, Serious Incident Reviews, External Notification BCU Governance, Stakeholder Groups etc. Involve patients and families in safety improvement P4. Validate and standardise the data Clinical engagement- challenge through use Dash-Boards for Safety

5 Integration and.. Normalisation.

6 All the way to the Board Quality & Safety Risk Management Sub Committee Clinical Effectiveness Improving Service User Experience Sub Committee Patient Safety Steering Group Betsi Cadwaladr University Health Board

7 Leading the way to Quality & Safety Improvement Progress since April 2010 Board Development Executive Accountability Visible Leadership (Walkrounds) Strategy agreed July Patient Safety- the next steps Quality &Safety agree September Item Zero and regularised review of Patient Safety topics at each meeting.. Changing the culture Betsi Cadwaladr University Health Board

8 Leading the way to Quality & Safety Improvement Progress since April Cont. Patient safety dashboard RAMI by month Complications Adverse Event Rate Top 10 causes of death and RAMI ( amenable mortality) Infection control data Hospital Acquired Thrombosis rate Etc. Quarterly to Board of Directors Betsi Cadwaladr University Health Board

9 Executive WalkRounds TM Betsi Cadwaladr University Health Board

10 Executive Walkrounds TM WalkRounds recommenced across BCU HB from September 2010 Each WalkRound to include: Independent Member Executive Scribe Betsi Cadwaladr University Health Board

11 Executive Walkrounds TM An open and honest discussion about Patient Safety Martin Jones, Executive Director of Workforce & Organisational Development & Independent Member Jenny Dean meet with members of Hergest Ward, Ysbyty Gwynedd Betsi Cadwaladr University Health Board

12 Executive Walkrounds TM Taking them forward. Capacity to cover all areas including secondary, primary and community care Robust process for monitoring actions Feedback to areas on progress Rounding to Influence intervention focused WalkRounds Betsi Cadwaladr University Health Board

13 Adverse Events Rate Adverse Event Rate BCU HB Combined Acute Secondary Care Units Adverse Event Rate per 1000 Beddays Period October 2007 to March 2010 From September 2009 includes Ysbyty Gwynedd Acute Secondary Units Data Data collection commenced SPI Glan Clwyd Hospital SPI Wrexham Maelor Hospital GTT 2008 North West Wales Mar/10 Feb/10 Jan/10 Dec/09 Nov/09 Oct/09 Sep/09 Aug/09 Jul/09 Jun/09 May/09 Apr/09 Mar/09 Feb/09 Jan/09 Dec/08 Nov/08 Oct/08 Sep/08 Aug/08 Jul/08 Jun/08 May/08 Apr/08 Mar/08 Feb/08 Jan/08 Dec/07 Nov/07 Oct/07 Betsi Cadwaladr University Health Board

14 Risk Adjusted Mortality Index (2010 Model) Risk Adjusted Mortality Index (RAMI) BCU HB Combined Secondary Care Units Rolling 12 Monthly Risk Adjusted Mortality Index (RAMI 2010 Model) Period March 2008 to June Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Feb-09 Jan-09 Dec-08 Nov-08 Oct-08 Sep-08 Aug-08 Jul-08 Jun-08 May-08 Apr-08 Mar-08 BCU HB RAMI RAMI National Average BCU HB Median Betsi Cadwaladr University Health Board

15 Mortality Casenote Review (Nov 10) YGC All Health Boards in Wales were requested by CMO to undertake Mortality Reviews of all deceased patients in acute hospitals during launch of 1000 Lives Plus in May All consultants within Glan Clwyd Hospital were invited to take part in the weekly review process there is presently a consistent team of 6 consultants attending regularly with 3 experienced nurse reviewers. Testing of Mortality Review process began in Glan Clwyd, September 2010 using a modified mortality review template and global Trigger Tool in order to determine Adverse Event Rate. The tool has been refined and team is now using version 5. Learning from this review will be two-fold: Thematic analysis of the overall results and feedback within the organisation. These issues will steer patient safety improvement work. Referral of individual cases to Consultant/Nursing/Infection Control Team as appropriate when event are identified whereby learning could potentially take place.. Betsi Cadwaladr University Health Board

16 Mortality Casenote Review Glan Clwyd Hospital Early Results (Nov 10) The weekly review has been ongoing for 5 weeks. 84 of the 92 deceased patient casenotes have been reviewed. 39 adverse events have been recorded. 9 cases have been referred back to the Consultant (responsible the patients episode of care). 5 cases have been referred to nursing. 4 cases have been referred to Infection Control team for RCA Betsi Cadwaladr University Health Board

17 Betsi Cadwaladr University Health Board

18 Mortality Review Identified Actions & Plans for Spread Outcomes of Consultant/Nursing & Infection Control team reviews are awaited. Monthly recurring agenda item within Grand Round and Nursing Meetings to be requested. Reporting/dissemination mechanisms to be agreed. Ethical issues to be agreed eg adverse events identified during the reviews & being open GP to be invited to join the team. Process guidance to be produced. Plans for Spread Leads have now been nominated within both Gwynedd and Wrexham Maelor. Implementation will be supported by Quality Improvement Manager. Betsi Cadwaladr University Health Board

19 Primary Care Trigger Tool S: The Annual Operating Framework includes the use of the Primary Care Trigger Tool (PCTT) in one in twenty practices. B: There are about 250 million consultations between patients and GPs in the UK every year. Yet there is limited evidence about error and harm inherent within the system, no systematic studies undertaken and the levels difficult to estimate. Betsi Cadwaladr University Health Board

20 Primary Care Trigger Tool A: There are expressions of interest from practices to undertake the PCTT, however further testing is taking place in BCU of electronic searching methods to reduce manual and time consuming process of identifying notes to review. R: The production of a revised how to guide to be complete by December 2010 and full recruitment of practices to begin in January For further information please contact:- Andrea.hobbs@wales.nhs.uk Debbie.Doig-Evans@wales.nhs.uk Betsi Cadwaladr University Health Board

21 Chronic Heart Failure In BCU I adrodd yr hanes.the Northern Story So Far Natriuretic Peptide testing roll out from Gwynedd and Anglesey to include Conwy GPs 2 new community echo clinics opened (Deeside and Llandudno) Intensive work with individual practices in Wrexham and Gwynedd area improves medication treatment measures software support improving Medication chart stickers improve medication treatment measures in in patients Coding and communication hospital community remain a challenge but EPoC helps LEAD CONTACT: Graham Thomas, Consultant Cardiologist (Ysbyty Gwynedd) Graham.Thomas@wales.nhs.uk

22 Methiant Galon Llwyddianau a herion Successes & Challenges Achievements Natriuretic peptide testing and echo access for GPs Validating and improving GP registers In patient treatment sheet sticker prompts Work with clinical coding to identify highest risk in-patients Access to cardiac rehab. Traffic light advise sheet getting out to all patients now and, Regular coffee afternoons for patients to meet and share experiences now rolling programme (Wrexham area) Challenges Experienced Awaiting decision from Board CPG for lab funding Communicating echo reports and medication from hospitals Engaging inpatient pharmacists and nurses Communicating clinical team needs and admin support Robust data collection and data accuracy remains a problem - CCAD is a much bigger problem than we thought (Wrexham area). LEAD CONTACT: Graham Thomas, Consultant Cardiologist (Ysbyty Gwynedd) Graham.Thomas@wales.nhs.uk

23 Methiant Galon Y camau nesaf next steps In relation to: Reliability, improving electronic communications and data collection Sustainability funding of core team and laboratory testing Organisational spread filling in the gaps across different localities LEAD CONTACT: Graham Thomas, Consultant Cardiologist (Ysbyty Gwynedd) Graham.Thomas@wales.nhs.uk

24 06/07 07/08 08/09 09/10 Percentage Heart Failure prevalence and treatment in primary care is falling across most of Wales due to under detection of cases: NP testing and access to echo for GPs reverses this trend at population level (QOF data). Anglesey Prevalence Insert Outcome measures (i.e. run charts / data table) here (if applicable) HF01 HF02 HF03 HF04 Year LEAD CONTACT: Graham Thomas, Consultant Cardiologist (Ysbyty Gwynedd) Graham.Thomas@wales.nhs.uk

25 Number of tests Natriuretic peptide testing finds and risk stratifies cases cheaply and easily NT pro BNP test results No of test results 1000 & over No of test results between 301 & 999 No of test results 300 or below 0 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Month LEAD CONTACT: Graham Thomas, Consultant Cardiologist (Ysbyty Gwynedd) Graham.Thomas@wales.nhs.uk

26 Medicines Management The Story So Far Amiodarone project in Anglesey identifying patients not reviewed. 47% of patients reviewed annually by cardiology 63% of patients had LFTs checked at least 6monthly 54% of patients had thyroid function tests checked at least 6 monthly The majority of patients (72%) had normal results for LFT s & TFT s Actions identified to be completed by March 2011 Conwy targeted 2 main areas INRs for patients on warfarin Completing all measures and investigating why patients fall out of range ECHOs for patients on heart failure register Ensuring all patients on HF register have proper diagnosis Denbighshire targeted: INRs for patients on warfarin Completing all measures and investigating why patients fall out of range Focus on why patients are under dosed Still a wide inter-practice variation Lithium shared care agreed Ongoing work on medication-related admissions in Wrexham SBAR introduced to pharmacies at Ysbyty Glan Clwyd & Wrexham Maelor Hospital 17 SBARs in first week of using for dispensary handover in Wrexham LEAD CONTACT: Pippa Rogers, Principal Pharmacist - pippa.rogers@wales.nhs.uk

27 Medicines Management Successes & Challenges Achievements Engagement of all GP practices within Conwy Repatriation of patients on warfarin monitored within 2 nd care Support of GPwSI in Heart Failure to support GP practice staff Challenges Experienced Information at discharge (fax) for patients commenced on warfarin still problematic Information on admission of patients on warfarin to hospital Bringing together many organisations into one LEAD CONTACT: Pippa Rogers, Principal Pharmacist - pippa.rogers@wales.nhs.uk

28 Medicines Management Next Steps Need to link up teams from different legacy organisations Identified need to standardise warfarin labelling across 3 hospitals Creation of an INR Newsletter in Conwy Individual to each GP practice Shows comparison of practice and area data Identifies learning outcomes or next steps for practice Other areas to encompass Amiodarone Audit ensuring patients have correct monitoring and review by doctor Discharge Trigger Tool link in with Global Trigger Tool patients from 2 nd care to review medicines reconciliation (Conwy) LEAD CONTACT: Pippa Rogers, Principal Pharmacist - pippa.rogers@wales.nhs.uk

29 Result Medicines Management Outcome Measure 40% INRs in Denbighshire Data collected by multiple legacy organisations but not yet merged into one (examples shown) Hospital data collection as part of AOF: 35% 30% 25% 20% 15% Patients NO INR in last 12 weeks Patients INR 8+ Patients INR 5+ Patients INR<2 Patients INR<1.8 INRs >5 & >8 10% 5% Medicines Reconciliation on hospital admission 0% Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Date Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Hospital data LEAD CONTACT: Pippa Rogers, Principal Pharmacist - pippa.rogers@wales.nhs.uk

30 Transforming Care The Story So Far Our three pilot wards continue to make steady progress & links made with previous TCAB and RTTC wards. Health Board in collaboration with HEI developed Transforming HealthCare module for ward leaders to attain academic credit as an integral part of Transforming Care. Education & Clinical Leadership the vehicle for spread & sustainability of Transforming Care across the Health Board. First PDSA with cohort commenced 1 st October LEAD CONTACT: Diane.Read@wales.nhs.uk Direct Tel:

31 Transforming Care Successes & Challenges Achievements Team engagement during challenging times. Waiting list for ward teams to undertake Transforming Care. Module development. Incident free days of ward acquired pressure ulcers over 150 days. Engagement with the Independent sector. Challenges Experienced Uncertainty during restructuring. Keeping teams motivated. Staff role redesign. LEAD CONTACT: Direct Tel:

32 Transforming Care Module Cohort One LEAD CONTACT: Direct Tel:

33 Transforming Care Next Steps Celebration event to mark successes. Commencement of cohort two, three in Transforming Care network within BCU HB to help with sustainability. Independent sector involvement. LEAD CONTACT: Direct Tel:

34 Transforming Care Outcome Measures Ward Outcome Measure Paediatric Ward MRSA rate - Ward acquired Enfys Ward (Cancer) Clwyd Ward (Rehab) Ward Acquired Pressure Ulcer Ward Acquired Pressure Ulcer Current Data 365 days 157 days 130 days LEAD CONTACT: Diane.Read@wales.nhs.uk Direct Tel:

35 Reducing harm from falls Successes & Challenges Achievements ENTHUSIASM! Making connections Weaving together all falls related programmes Mapping of services Approach that is multi disciplinary, professional agency Challenges Experienced Geography Variation: Services Criteria Documentation Falls services have evolved organically Data gathering to report on BCU basis Betsi Cadwaladr University Health Board

36 Reducing harm from falls: Next Steps Infrastructure is developed and starts functioning Sub-groups focusing on Awareness Assessment Action Getting Operational Groups to test ideas of component parts of BCU strategy Betsi Cadwaladr University Health Board

37 Acute Stroke Care The Story So Far Improving the reliability of acute stroke care: First Hours rapid recognition of symptoms and diagnosis First Day emergency treatment First 3 days early mobilisation First 7 days patient centred and goal orientated specialist care LEAD CONTACT: Lynne Hughes, Stroke Coordinator Lynne.Hughes2@wales.nhs.uk

38 Improving the reliability of Acute Stroke Care Successes Achievements - Dedicated Stroke Unit with 6 acute assessment beds and 15 rehabilitation beds - Introduction of rapid stroke screening tool into ED - Direct admission to stroke unit from MAU - Development of a stroke thrombolysis service - Implementation of an Early Supported Discharge Team for Stroke - Weekend Imaging for routine CT scans - Roll out of care bundle tool to guide staff to complete bundle interventions - Development of Orthoptic service for stroke patients - Stroke specific information available - Education and awareness training for all staff - Development of core goals for patients during the first week after stroke LEAD CONTACT: Lynne Hughes, Stroke Coordinator Lynne.Hughes2@wales.nhs.uk

39 Improving the reliability of Acute Stroke Care Challenges Integration of acute care into a rehabilitation ward (culture shiftadapting to increased pace, e.g. therapies) Streamlining of systems Excellent engagement of ED overcame any issues Implementation of new thrombolysis service with no additional resource Capacity/demand concerns re Weekend CT scanning Overcome by review of activity data showing 60% of stroke CTs done as adhoc requests already Release of clinical staff for education and training Cross-CPG working LEAD CONTACT: Lynne Hughes, Stroke Coordinator Lynne.Hughes2@wales.nhs.uk

40 Acute Stroke Care Next Steps 1. Monthly Local Stroke Team meetings on the Stroke Unit 2. Working through each bundle intervention systematically and addressing gaps in processes 3. Engagement of all disciplines 4. Quarterly regional Stroke Forum, involving Clinical Leads Stroke Co-ordinators, CPG Management. 5. Monthly review of bundle compliance and performance issues by CPG management, review and sign off of monthly performance at Executive level. LEAD CONTACT: Lynne Hughes, Stroke Coordinator

41 Acute Stroke Care: Outcome Measure % compliance with First Hours bundle BCUHB - Wrexham Maelor Stroke patients from Jan 2010 to Nov 2010 % compliance with First Days bundle BCUHB - Wrexham Maelor Stroke patients from Jan 2010 to Nov Jan 2010 Feb 2010 Mar 2010 Apr 2010 May Jun Months Jul 2010 Aug 2010 Sep 2010 Oct Jan 2010 Feb 2010 Mar 2010 Apr 2010 May Jun Months Jul 2010 Aug 2010 Sep 2010 Oct 2010 % compliance with First 3 Days bundle BCUHB - Wrexham Maelor Stroke patients from Jan 2010 to Nov 2010 % compliance with First 7 Days bundle BCUHB - Wrexham Maelor Stroke patients from Jan 2010 to Nov Jan 2010 Feb 2010 Mar 2010 Apr 2010 May Jun Months Jul 2010 Aug 2010 Sep 2010 Oct Jan 2010 Feb 2010 Mar 2010 Apr 2010 May Jun Months Jul 2010 Aug 2010 Sep 2010 Oct 2010 LEAD CONTACT: Lynne Hughes, Stroke Coordinator Lynne.Hughes2@wales.nhs.uk

42 Critical Care The Story So Far Sustained compliance with ventilator care bundle Inclusion of theatres and A&E in CVC insertion bundle Implementation of sepsis management bundle Integration of 1000 Lives plus quality measures into critical care dashboard Betsi Cadwaladr University Health Board

43 Critical Care Challenges Data collection! Supporting the spread of CVC bundle outside the Critical Care area Next steps: Engaging with areas outside of Critical Care to improve communication of sepsis pathway Betsi Cadwaladr University Health Board

44 Critical Care BCU HB % compliance with sepsis management bundle 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Compliance Goal Betsi Cadwaladr University Health Board

45 Enhanced Recovery at BCULHB - The Story So Far Continued with the development and roll-out of Enhanced Recovery Orthopaedics (Hips and Knees) and Colo-Rectal Surgery. Development of Enhanced Recovery Urology Programme Development of Enhanced Recovery Implementation Board LEAD CONTACT: Mr Neil Windsor, Performance Improvement Facilitator Neil.Windsor@wales.nhs.uk

46 Orthopaedic Rapid Recovery Successes & Challenges Achievements Halved length of stay Halved readmission rates All patients mobilised in recovery and full weight bearing 2 hours post-op Virtually eradicated post-operative nausea and vomiting Prince of Wales ward opened as a Rapid Recovery Centre of Excellence by the Health Minister Wrexham Maelor the Orthopaedic Case-Study in the DoH English ERAS How to guide Significant patient satisfaction and the collection of true quality of life PROMS outcome data Significantly changed organisational culture, particularly at ward level Founder member of English National Rapid Recovery Board Challenges Experienced Programme implemented without any financial resources to support it Changing culture to change practice Collecting audit data Rolling-out project from just clinical champions LEAD CONTACT: Mr Neil Windsor, Performance Improvement Facilitator Neil.Windsor@wales.nhs.uk

47 Orthopaedic Rapid Recovery: Next Steps Embed Rapid Recovery as the norm for all knee replacements across BCULHB Pilot Rapid Recovery Daycase & 23/59 pathway for hip replacements Investigate potential for Enhanced Recovery #NOF, shoulders, hips LEAD CONTACT: Mr Neil Windsor, Performance Improvement Facilitator

48 Length of Stay (days) Percentage Orthopaedic Rapid Recovery: Outcome Measures Length of Stay Rapid Recovery Best Practice Mr Smith English Peer BCULHB Length of Stay Distribution Distribution Of Patients According to Length of Stay Length of Stay (days) Pre Rapid Recovery Rapid Recovery Pain hours 12 hours 18 hours 24 hours Post-Op Nausea & Vomiting 2.5 Length of Stay halved, and in line with Rapid Recovery best practice. Relatively small numbers of patients with high pain scores (due to LIA and management of expectations at Joint School). PONV virtually eradicated due to the elimination of Opioids and PCA s from the pathway hours 12 hours 18 hours 24 hours LEAD CONTACT: Mr Neil Windsor, Performance Improvement Facilitator Neil.Windsor@wales.nhs.uk

49 WHO surgical safety checklist The Story So Far Since April 2010 the WHO checklist has been spread to all main, day case and ENT theatres in Wrexham Maelor hospital. This has helped improve compliance with antibiotic prophylaxis and sustain compliance with normothermia and appropriate hair removal. Test of change of adapted WHO checklist completed in vasectomy clinic in Deeside Community hospital and now implemented. LEAD CONTACT: Tracey Radcliffe, Practice Development Nurse

50 WHO surgical safety checklist Successes & Challenges Achievements The spread and compliance with the WHO checklist including primary care Valuing of the safety brief concept by Theatre staff Communication between all members of the theatre team Challenges Experienced Change in culture to current ways of working Difficulties in engaging some staff Management of time to complete safety brief LEAD CONTACT: Tracey Radcliffe, Practice Development Nurse

51 WHO surgical safety checklist Next Steps The WHO checklist is being incorporated into our theatres care pathway documentation and test of change planned. An ophthalmology WHO checklist is currently in development to introduce into eye theatre. Further spread to minor surgery units and community hospitals LEAD CONTACT: Tracey Radcliffe, Practice Development Nurse

52 WHO Surgical Safety Checklist Outcome Measure LEAD CONTACT: Tracey Radcliffe, Practice Development Nurse

53 Rapid Response to Acute Illness Clinical Developments BCU have 5 wards that are progressing with RRAI Admission, Recognition and Response bundle are being used, moving onto the sepsis six. Managerial Developments Now working together as one BCU team and have a workshop on the 6 th of December Clinical leads identified and ward staff keen to progress LEAD CONTACT: Anwen Crawford (YG) Cath Roberts (YGC) Julie Ward-Jones (WMH)

54 Rapid Response to Acute Illness Successes & Challenges Achievements Increased critical illness score compliance Having a BCU team approach to RRAI Use of the 2 min safety brief Maintenance of drive to succeed Challenges Experienced Engagement to progress at the pace required Identifying relevant measures Different compliance forms on 3 sites Assumed complexity of collaborative by staff LEAD CONTACT: Anwen Crawford (YG) Cath Roberts (YGC) Julie Ward-Jones (WMH)

55 Rapid Response to Acute Illness. Next Steps Strengthen engagement in the collaborative on the 6 th of December workshop. Engage more clinical staff Identify consultant leads from each site Standardise compliance forms / measures Improve reliability Support wards to measure compliance and outcomes LEAD CONTACT: Anwen Crawford (YG) Cath Roberts (YGC) Julie Ward-Jones (WMH)

56 Compliance Percentage Compliance Percentage Rapid Recovery to Acute Illness Outcome Measure BCU HB Ysbyty Maelor Acute Secondary Care Unit - MAU Weekly Compliance with RRAILs Admission Bundle w/e 14/10/10 w/e 21/10/10 w/e 28/10/10 w/e 04/11/10 w/e 11/11/10 Compliance with Admission Bundle Target 95% BCU HB Ysbyty Maelor Acute Secondary Care Unit - MAU Weekly Compliance with RRAILs Recognition Bundle w/e 14/10/10 w/e 21/10/10 w/e 28/10/10 w/e 04/11/10 w/e 11/11/10 Compliance With Recognition Bundle Target 95% LEAD CONTACT: Anwen Crawford (YG) Cath Roberts (YGC) Julie Ward-Jones (WMH)

57 Hospital Acquired Thrombosis rate for Glan Clwyd developed How to guide developed Data does not exclude any of the adult specialities so gives incidences for all areas Retrospective data gathered and compliance reviewed also Hospital Acquired Thrombosis (HAT) Betsi Cadwaladr University Health Board (Glan Clwyd Hospital Data)

58 Hospital Acquired Thrombosis (HAT) Betsi Cadwaladr University Health Board (Glan Clwyd Hospital Data)

59 (HCAI) The Story So Far Progress and developments since 1000Lives+ launch in April 2010 Agreed to ensure that we achieved a greater than 20% reduction in Clostridium difficile. Ensure 95% compliance with data collection for Orthopaedics and Caesarean Section surgical procedures. Reduce the incidences of C. Section infections. Develop systems to reduce adverse incidences related to Peripheral Vascular Catheter. Develop systems to reduce adverse Urinary Tract Infections. LEAD CONTACT: David Casey, Infection Control & Prevention David.Casey@wales.nhs.uk

60 (HCAI) Successes & Challenges Achievements 1. Achieved the targets for reducing the incidences of C. difficile. 2. Reduced the incidence of C. Section infections. 3. Achieved a greater than 95% compliance with SSI data sets. Challenges Experienced 1. Financial imperative to make cost savings within the CPG's. 2. Challenging other surgical specialities to accept the SSI processes utilised for Orthopaedic and C. Section. LEAD CONTACT: David Casey, Infection Control & Prevention David.Casey@wales.nhs.uk

61 (HCAI) Next Steps Reliable processes for C. difficile and SSI which need to be spread into the PVC and UTI work streams. C. difficile and SSI are part of the AOF the organisational responsibilities and must be sustained. All current projects have been spread across the organisation. The next steps are to spread the PVC and UTI work from the project areas across the CPG's. LEAD CONTACT: David Casey, Infection Control & Prevention

62 Betsi Cadwaladr University Health Board progress against Clostridium difficile AOF minimum 20% reduction target 01/10/ /10/2010 Insert Outcome measures (i.e. run charts / data table) here (if applicable) LEAD CONTACT: David Casey, Infection Control & Prevention David.Casey@wales.nhs.uk

63 Communication The Improvement Cycle 10 th September Our 1000Lives+ Team seized the opportunity to share successes and improvement work with Patients and the Public across the three sites when four of the NLIAH team cycled the length of Wales raising over 1500 for selected charities. Members of the team were on hand to answer questions and highlight the BCU HB s commitment to improving patient safety Wrexham Maelor Glan Clwyd Ysbyty Gwynedd LEAD CONTACT: Sylvia Hughes, 1000 Lives+ Communications Lead Sylvia.Hughes2@wales.nhs.uk

64 Communication Do you have a good news/success story to share? A template for sharing your story across BCUHB and possibly in the local media is available from Sylvia.Hughes2@wales.nhs.uk Please help to Spread the learning and celebrate the successes LEAD CONTACT: Sylvia Hughes, 1000 Lives+ Communications Lead Sylvia.Hughes2@wales.nhs.uk