Achieving High Reliability in Healthcare Hywel Dda Health Board

Transcription

1 National Learning Event 8 th November 2012 Achieving High Reliability in Healthcare Hywel Dda Health Board Insert name of presentation on Master Slide

2 Falls in the Community and Primary Care Setting - Carmarthenshire TEAM Work is being taken forward by the County Falls Prevention and Bone Health group. The group has wide ranging representation including pharmacy, third sector, local Authority Health NLIAH, Home Care Managers, Telecare, Locality Managers and Public Health. Meetings are held every month. Key individuals from the County Group also sit on the Strategic Group. OVERVIEW OF MAIN AREAS OF WORK Initial work involved the implementation of Falls Risk Assessment into A &E. This work is being developed within the community setting. It is important to have an integrated approach although secondary care have a Integrated falls Pathway in place it is recognised that this work needs to be developed further.

3 Primary, Community & Secondary Care Definition of what constitutes a fall agreed. A & E establishment of database active since November 2011 Introduction of Falls Risk Assessment into A & E Invest to save bid for Frailty Nurse posts. Three nurses appointed into posts April 2012 to support the falls and frailty agenda. (1 nurse per locality) Baseline audit undertaken to identify compliance with current Falls Pathway (secondary care) and NPSA alert Essential Care After an Inpatient Fall. NPSA Protocol developed by sub fall group. Circulated to all Adult Wards in Carmarthenshire. Post roll out audit undertaken August 2012 by Quality Improvement Team- awaiting results of audit Datix system reviewed to be updated in order to provide additional information in relation to NPSA guidance Primary Care are working towards establishing a risk register for each locality. This work will be taken forward as part of the virtual ward/ care closer to home concept. Working Group set up for Hywel Dda to review current inpatient falls documentation and risk assessments in place. (1 meeting held to date). Key objectives of group established.

4 Care Homes Trial is currently being undertaken in LA care homes using the FROP- Com screening. Awaiting evaluation. STRENGTHS/ACHIEVEMENTS The level and wide ranging representation on the Carmarthenshire Falls Prevention Group. The integrated work we are taking forward spans Primary, Community and Secondary Care and has helped to take other developments forward for example the frailty clinics. WEAKNESSES IT support and incompatible data transfer systems between Primary, Community and Secondary CURRENT STATUS SCORE: 6

5 IMPLEMENTATION /SPREAD PLAN Secondary care. Audit undertaken by Quality Improvement Team to determine compliance against NPSA Essential Care after an Inpatient Fall. Results to be evaluated, this will inform future work for secondary care. Health Board wide group has been established to look at risk assessment tools for falls used to assess patients on admission and thereafter for reassessment. This group is chaired by Carmarthenshire Lead. This work will dovetail into work being led by NLIAH All Wales Group. Primary / Community- Proposal outline for Rapid Response Frailty Clinic approved. Rapid response frailty clinics to be set up investment in this service aims to demonstrate a prevention of emergency admissions including those who are at risk of falls. Other developments In Carmarthenshire, we have been planning a number of initiatives as part of the Falls Awareness Week as part of the Camu M laen programme. This is a targeted piece of work with Community Pharmacists.

6 NEXT STEPS TO BE TAKEN Frailty Service Clinics to be established initially to held twice weekly in PPH. Commencement date mid September. Service will be evaluated by MDT. Frailty Index score will be used to assess patients. This work supports the delivery of the 5 year plan. WAST falls data has been received. This requires discussion at Strategic Falls Prevention & Bone Health Meeting as it does not fully meet local needs. Group members need to understand the data. Need to confirm how this information will be cascaded and how it will inform future direction.

7 Preventing Falls in the Community - Ceredigion BACKGROUND Work commenced in September 2010 following the first 1000 Lives Plus Mini Collaborative Workshop in Builth Wells. The working group was formally setup in March 2011, with Terms of Reference and work streams being agreed in May The following work streams have been established: WAST Referrals (Trigger Bundle) mini team established in March 2011 Falls in Residential Homes (Assessment Bundle) mini team established in July 2011 Promotional activities mini team established in March 2012 In patient Fallers (Trigger Bundle) mini team established in March 2012 TEAM The Strategic Falls Group is made up of: Aberystwyth University, Age Cymru Ceredigion, Ceredigion Association of Voluntary Organisations, Ceredigion Care and Repair, Ceredigion County Council, Hywel Dda, Community and Secondary Care Services, including the District Nursing Teams, Therapies and Nurses and Public Health Wales

8 OVERVIEW OF MAIN AREAS OF WORK WAST Referrals (Trigger Bundle) On July 25th 2012 we started to receive WAST referrals of those who are not admitted to hospital for recording and an initial screening process. These patients will have already agreed to have their information shared across organizations. Referrals from WAST are sent to a safe haven fax and then circulated to the appropriate District Nursing Team for initial risk of falling. Where the patient is recorded as at a high risk of falling the information is given to their GP. The District nursing teams are keen to undertake the full screening process, however there are currently challenges associated with recording this information. This challenge would be addressed if there was a central fallers register accessible to the collaborative.

9 Falls in Residential Homes (Assessment Bundle) In early 2011 work commenced with all the Ceredigion Social Services run Residential Homes to analyze the falls within those settings. The work concluded that their numbers of falls was no higher than national average with related injuries causing no great concern. Whilst the care homes are very good at recording incidences of falls, their recording is focused very much around the environmental factors and subsequent injury rather than standardized preventative measures for that individual. In March 2011 a trial commenced with one care home to develop the methods used for recording falls to widen the scope of recording. This initial trial informed the new trial which commenced in November 2011 and is based upon the two standardized draft screening tools. This approach is working well and plans are underway to introduce the scheme in the second home with a view for further roll out across other residential homes. An Social Services interim system is being developed for the collection and reporting of information; ideally an integrated system should be created to share information between Social Services and Health; this challenge would be overcome with a central fallers register accessible across the collaborative

10 Promotional activities The strategic group agreed from the outset that an important element of the work was around promotion of preventative interventions associated with falls. This promotional work needed to target the individual, their carer, as well as enabling awareness of peer to peer services across statutory, health and volunteer services. In June 2012 a conference was held with the purpose of: Demonstrating work undertaken by the collaborative Promotion of existing services and how to access those services Raise awareness of preventive issues Help set the direction for future work. The conference was hosted by Aberystwyth University, with Dr Alan Wilson (Director of 1000 Lives Plus) delivering the key note speech. The conference was attended by over 100 delegates, with nineteen participants in the speed networking event presenting how their service impacted upon potential fallers and how to access their service. An interactive play was performed demonstrating the reality of an older person falling at home and being unable to call for help; ideas of interventions from the audience was both informative and enthusiastic! Feedback from the conference was incredibly positive both in the context of learning and from the general experience.

11 In patient Fallers (Trigger Bundle) A trial in one ward in Bronglais Hospital will identify new patients who have a higher risk of falling during their stay and subsequently back in the community. The trial has experienced a number of false starts due to capacity issues associated with nursing staff. It has now been decided that the trigger bundle will be undertaken by Hospital Volunteers, with any concerns being raised with the nurse in charge. A small mini-collaborative has now been formed to take this work forward. In addition to introducing the tools, it is also looking to identify key areas of work which can be taken forward. It is anticipated that a representative from the community hospitals will join the collaborative so that further roll out can be considered from the outset.

12 STRENGTHS/ACHIEVEMENTS The skills and resource of working in a multi disciplinary, multi faceted group are vast and broad; hence the ability to think and act big! WEAKNESSES The Hywel Dda Strategic Falls Prevention and Bone Health Group are in the process of writing a Strategy, which is being led by Public Health Wales; this should be completed in The strategy should give direction and standardize the services which should be delivered across Hywel Dda. The afore mentioned group has already acknowledged a need for a shared accessible falls risk register which would enable a coordinated approach to managing the risk of fallers. Talks are underway with the Hywel Dda Informatics Team; however there are reported issues associated with resource to take the work forward. A centralized fallers register is essential to avoid duplication and to monitor which interventions are having impact. At the HD Falls and Bone Health Strategy meeting (April 2012) it was agreed that the falls register should be linked with frailty information as the two were strongly related. It is acknowledged that access to access to falls clinics is not equitable across Ceredigion. Work to address this will commence once the Hywel Dda Strategic Direction has been set to ensure equality across Hywel Dda. Strength and Balance Classes are currently only available in the North West of Ceredigion. Discussions have commenced with the National Exercise Referral Scheme to see if any resource is available to meet intermediate need and assessment; the challenge is around recruitment of postural stability instructors and the rural nature of the area; currently plans are being drawn up to meet immediate need in the South of the county by September 2012.

13 CURRENT STATUS WAST Referrals (Trigger Bundle) Score:10 - Reliable implementation has been achieved across Ceredigion. However, there is an ongoing concern that the number of referrals into the system is below the number originally envisaged. Confirmation has been requested from WAST that all referrals are being sent, but despite a number of requests this has not been confirmed. Other counties have reported similar lower than anticipated numbers. Falls in Residential Homes (Assessment Bundle) Score: 7 - The pilot has been established in one of the social services run care homes with plans underway to introduce in a second prior to further rollout. Promotional activities Score: 3 - There is a challenge suggesting a score to this element of work, but agreed plans were drawn up and are either in the process of being implemented or have been implemented. In patient Fallers (Trigger Bundle) Score: 3 - The local implementation and data collection for the trial has been agreed and is being implemented.

14 WORK UNDERTAKEN Falls in Residential Homes (Assessment Bundle) Ceredigion Social Services taking the lead to develop a system for collating information to supply the run charts which will be available across all Social Services Care Homes. Promotional activities Successful implementation of the Falls Conference and Networking event in June In patient Fallers (Trigger Bundle) Formulation of implementation plan including the methodology for enabling the hospital volunteers to undertake the initial screening. This approach is currently being trialed. A Hywel Dda wide in-patient falls collaborative has been established under the leadership of Gill Webber (Carms); Ceredigion will have two representatives on this group: Terina Kidby (Bronglais Trauma Nurse) and Jan Walker (Sister in the Community Hospitals).

15 NEXT STEPS TO BE TAKEN WAST Referrals (Trigger Bundle) Continue to seek reassurance from WAST that all appropriate referrals are being sent to the safe haven fax. Falls in Residential Homes (Assessment Bundle) Introduction of the trial into the second care home Promotional activities Launch of the collaborative website which will include video clips of the conference. Promotion of the site and it s contents to GP s, District and Practice Nurses, and Secondary Care colleagues. In patient Fallers (Trigger Bundle) Implementation of the trial of the trigger bundle in one ward of Bronglais hospital. Hywel Dda Falls Prevention and Bones Health Strategy Once the HD Strategy has been agreed, existing services will be checked to ensure that they contribute to the overall strategy as well as identifying any gaps in service provision.

16 Hywel Dda Fallers Register Work continues to develop a HD Fallers Register which meets needs across community and secondary care with links to third sector organizations. Ceredigion Strategic Falls Group This group reconvenes in September 2012 with the objective of reviewing progress to date, determining it s role for the forth coming year and priorities for work. RESULTS Number of calls for 999 ambulances as a result of falls from standing height Total from March 2011 to April 2012 is 641. The full report from the Health Informatics Analytics Team is in appendix 2. The figures to not state if the patient was taken to A & E or if they were assessed and then left at home. Number of hip fractures registered on the National Hip Fracture database April 2011 to March

17 Mortality and Harm - Ceredigion BACKGROUND The Global Trigger Tool audit has been used at Bronglais for over 2 years with 20 sets of notes review each month by a core team of staff. The reviews identify other aspects of patient safety not confined to the trigger and event conversion chart. These are escalated for ongoing review and management for example the WHO checklist was included showing a poor compliance rate, following escalation and the identification of 2 leads the compliance rate from under 50% has now reached a consistent compliance rate of over 95%. The WHO checklist is no longer reviewed as part of the GTT as it owned once again by the theatre team. Currently the team are capturing the lack of pre assessment examination pre surgery when patients are attending the clinic and this improvement/safety work is being taken forward.

18 BACKGROUND continued Mortality notes are reviewed weekly by the Hospital Director for Clinical Care assisted by Consultants working in a rotation. Selected cases are discussed / presented at both medical and surgical M and M meetings Issues identified during the sessions are forwarded to the Medical Director and are progressed via an action plan collated and are progressed via an action plan. The County is working towards setting up a team to assist in a multidiscipline review following the pilot undertaken by the Acute Service Nurse Manager and Quality Improvement Manager. Unfortunately this was not sustainable as a team of two hence the development of a wider team. CURRENT STATUS Score: 10 - Processes are in place for gathering the Adverse Event Rate by means of a multidisciplinary team who meet monthly. Patient safely issues found during note review are taken directly to the Clinicians and or managers for review. RAMI and SHIMI taken from the CHKS live system.

19 RESULTS Ceredigion Outcome Measures

20 Number Number Rate Adverse event rate per 1000 patient days Bronglais Hospital Hywel Dda Health Board Number of triggers Bronglais Hospital Hywel Dda Health Board Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan Values Average (28.0) Number of adverse events Bronglais Hospital Hywel Dda Health Board Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan Values Average (13.5) 0.0 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Values Average (3.5)

21 Monthly Cannula & Catheter Audits July 2012 Methodology Catheter Up to 5 Patients per ward audited for each Hospital PPH GGH WGH BGH PVD Up to 10 Patients per ward audited for each Hospital PPH GGH WGH BGH

22 Wards Taken Part N=42 BGH: Iorwerth, CMU, Meirig, Ceredig, Ystwyth, Rhiannon & Rheidol [N=7] PPH: Ward 1,3,4,5,6 and 9, CDU, CCU [N=8] GGH: Teifi, Cleddau, Derwen, Steffan, CDU, Dewi, Gwenllian, Ceri, Picton, Dinefwr, Merlin, Tysel, Preseli, Towy [N=14] WGH: A&E, ACDU, Medical Day, CSAI, ITU, CCU, Wards 1, 3, 4, 7, 10, 11, and 12 [N=13]

23 Number of Short Term Urinary Catheters insitu Hospital Previous Audit Current Audit PPH 10 8 BGH WGH % Decrease GGH NB 6 more wards audited compared to last month Total 61 65

24 Compliance Rate with Short Term Urinary Catheter Insertion and Maintenance Bundle 100% 94% 100% 75% 71% 75% 75% 75% 75% 75% 75% 71% 69% 71% 71% 69% 71% 71% 71% 71% 63% 63% 63% 50% 50% 44% 25% 22% 19% 19% 19% 19% 19% 19% 19% 19% 25% 11% 13% 0% Care Bundle 0% Sticker Present Catheter Still Needed Drainage bag in Correct Place Gloves & HH Urethral Meatal Hygiene GGH BGH WGH PPH Catheter Circuit in Tact Overnight link system discarded Catheter drainage bag changed

25 Hywel Dda Compliance: Catheter Jan Mar July Aug Sep Oct Nov Dec GGH BGH WGH PPH

26 Number of Peripheral Vascular Cannula Devices insitu Hospital Previous Audit Current Audit PPH % decrease BGH WGH % decrease GGH Total

27 Compliance Rate with PVD 100% 97% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 90% 89% 79% 84% 82% 75% 65% 70% 67% 67% 67% 67% 67% 50% 48% 53% 29% 28% 25% 17% 5% 7% 0% Care Bundles Completed Sticker Present Hand Hygeine Indication for Use VIP Score Less than 2 Dressing Dry & Intact GGH BGH WGH PPH Access Port Dissinfected and Allowed to Dry IV labelled and changed after 72 Hrs Cannula Removed or resited

28 Hywel Dda Compliance: PVD Jan Mar July Aug Sep Oct Nov Dec GGH BGH WGH PPH

29 Next Reinforcement of sticker usage. Appointments made with Senior Drs to assess how best to take this project forward. Complete a prevalence study to assess PVD and CAUTI usage throughout the HB Further HB audit to be completed in November 2012 Begin to develop Exit strategy - Pilot one ward on each Acute site to complete an audit each month and place results on the Nursing Dashboard.

30 Improving Stroke Care: - Acute Stroke care - Ceredigion BACKGROUND Patients presenting with Stoke are admitted to Ystwyth ward which is an 18 bedded ward with 8 beds allocated for stroke care of which 4 acute and 4 rehab beds. The remainder of the ward cares for general medical patients. Before April 2011 BGH had stroke Thrombolysis service that ran between Monday Friday. On April 1st 2011 the service was extended to 24hrs 7 days week. This was achieved by an intensive education programme to ensure appropriate skills were cascaded and by the enthusiastic participation of the medical staff grades and all members of the stroke thrombolysis team. In addition the Health Board has invested in stoke care personnel and locally we have appointed a stroke nurse specialist to drive care standards upwards with a particular focus on the patient experience and integrating secondary and primary aspects of stroke care. TEAM The team is led by Dr P Jones supported by middle grade Dr Omar and Claire West Stroke nurse Specialist and Beth James ward sister. The managerial lead is Rita Stuart, Assistant Hospital Manager, and Unscheduled Care. WORK UNDERTAKEN Acute We have been providing a 24hr thrombolysis service since April For patients meeting the thrombolysis criteria, a unique pathway takes the patient directly to CT suite, bypassing A&E, reducing the in hospital time line to compensate for the increased travel time to hospital due to rurality. Patients are met in CT by the thrombolysis team 24/7, assessed scanned and decision taken and treatment commenced in CT. Once treatment is commenced the patient will be transferred to the ASU. Patients not meeting the criteria for stroke thrombolysis are diverted to A&E for assessment and admission to the Acute Stroke Unit. Key performance measures 95% eligible patients Thrombolysed

31 STRENGTHS/ACHIEVEMENTS Introduction of stroke nurse specialist The introduction of telephone follow up approximately 2 weeks post discharge to identify and action any issues arising Provide secondary prevention advice and signposting to services within the community Set up the education function of the role, for example introduced a Stroke Learning Zone and local stroke thrombolysis scenario training Facilitated an education session with the OOH GP s. Delivered a variety of educational sessions and secondary prevention advice to the public A key part of the audit programme has been implementing the first stroke patient satisfaction questionnaire which received 100% return rate. Results have been acted upon and we now run the questionnaires continuously. Established robust links with local branches of the stroke association. Continue to bridge the gap between secondary and primary care by building on relationships with primary care, community teams and the voluntary sector, representing Ceredigion Stroke services on the Chronic Conditions Management group and providing links with the community resource teams, in particular the neurological conditions rehabilitation teams for short term intervention and long term chronic condition management.

32 WEAKNESSES On site Carotid Doppler not available Very small team No dedicated stroke physician CURRENT STATUS SCORE: 3 - Scoring a 3 at this time as the report must dove tail with the HB Steering Group Plan. NEXT STEPS TO BE TAKEN Spread plan in progress, this report must be inclusive of the HB wide Steering Group plan and process. RESULTS % patients compliant with First Hours bundle % patients compliant with First Days % patients compliant with First 3 days % patients compliant with First 7 days care bundle OUTSTANDING ISSUES/BARRIERS Run charts will be collated by the next meeting as the data collated for DSU is complied differently.

33 Improving Stroke care: Transient Ischemic Attack - Ceredigion TEAM The stroke team is led by Dr P Jones, supported by middle grade Dr Omar and Claire West Clinical Nurse Specialist Stroke Coordinator. The emergency medical team is led by Dr G Boswell supported by Dr L Pandya and their middle grades. The managerial lead is Rita Stuart, Assistant Hospital Manager, and Unscheduled Care. OVERVIEW OF MAIN AREAS OF WORK A local pathway implemented April All referrals must contain an ABCD2 score. Patients with a score of 4 or more (high risk) are immediately referred by telephone, to the emergency medical team and are seen and assessed on the day of referral. Patients attending the emergency service (high risk TIA) are seen and assessed with investigations and treatment commenced that day. Individualised secondary prevention strategy is discussed and agreed with patients and written information is provided. Patients are then reviewed in the next rapid access stroke clinic (within 7 days) and referred for carotid intervention if required. Patients with a score of less than 4 (low risk) are referred immediately by fax to outpatients appointments and the patient is contacted and offered an appointment at the next available rapid access stroke clinic for specialist assessment and commencing of investigations within 7 days of first contact.

34 STRENGTHS/ACHIEVEMENTS Introduction of stroke nurse specialist Provide secondary prevention advice and signposting to services within the community Set up the education function of the role, for example introduced a Stroke Learning Zone and local stroke thrombolysis scenario training Facilitated an education session with the OOH GP s. Established robust links with local branches of the stroke association

35 WEAKNESSES Access to radiology in the required timescale Resources to audit as required by WG No dedicated stroke physician No data available from the secondary care setting for care bundle ongoing secondary prevention and risk management following TIA within 1 month. Some patients will return to clinic but the majority are followed up in primary care. This has been discussed at the Hywel Dda Stroke Steering Group. CURRENT STATUS SCORE: 4 - not able to score a 5 because no demonstrable PDSAs available. NEXT STEPS TO BE TAKEN Spread plan in progress needs to link with HB Steering Group. OUTSTANDING ISSUES/BARRIERS Carotid imaging needs to implement to allow rapid assessment of TIA and Stroke patients. This is a key measure for improving the timely intervention of surgery for patients.

36 % compliant with symptom recognition and referral bundle

37 Transforming Care (Ceredigion and Pembrokeshire) BACKGROUND The Practice Development Team in the Health Board have been facilitating the implementation of the Transforming Care programme across acute care areas since September The organisational objective is to implement the initial phase of the Transforming Care programme to 81 in-patient areas by July 2013 In Ceredigion 12 wards have participated in either the Transforming Care Programme or the Releasing Time to Care Programme to date (10 acute areas, 2 Mental Health). 1 clinical area is currently participating in the programme 3 clinical areas in Ceredigion still need to be nominated for the programme before July 2013 (A&E, Maternity and paediatrics and will be nominated for future cohorts In Pembrokeshire 16 of the areas are in Pembrokeshire (13 acute in-patient areas & 2 Mental Health & 1 Community Hospital). 12 (75%) wards have undertaken either the Transforming Care Programme or the Releasing time To Care (RTTC) Programme to date (9 acute areas and 2 Mental Health wards). 4 in-patient areas in Pembrokeshire still need to be nominated for the programme

38 THE PROGRAMME The delivery of the programme underwent a review in 2011 with the outcome being that the programme has been extended to 18 months and all wards who commenced the programme pre-2012 will continue with the county based embedding and sustaining programme which is currently being planned by the Practice Development Teams in collaboration with the Senior Nursing County Teams. STRENGTHS/ACHIEVEMENTS The programme: Connects with practice and reflects the current local and national agenda e.g lives plus, dignity in care, Quality Strategy, Fundamentals of Care, Provides staff with the tools, techniques and support they need Empowers teams to make sustainable improvements to the quality, safety and fundamentals of care that they provide to patients e.g. transformational leadership, team work, multidisciplinary working. WEAKNESSES Despite the programme being an opportunity for multidisciplinary working, the majority of staff who have attended the workshops have been from the ward nursing team. The review of the programme, and the establishment of the Strategic Transforming Care Steering Group aims to maximise the opportunities for multidisciplinary work based learning and development.

39 CURRENT STATUS Ceredigion SCORE: 9-75% of the wards in Ceredigion have or are currently participating in either the Transforming Care or Releasing Time to Care programme. Pembrokeshire Score: % of the wards in Pembrokeshire have or are currently participating in either the Transforming Care or the previous programme Releasing Time To Care. IMPLEMENTATION/SPREAD PLAN Ceredigion 3 wards/clinical areas in Ceredigion still need to be nominated for the programme). Pembrokeshire 4 (25%) In-Patient areas in Pembrokeshire still need to be nominated for the programme. However advice is currently being sought from the Strategic Senior Nursing Team in relation to future nominations, balancing the need to ensure that existing wards are successfully achieving full implementation of the programme and sustaining the effects in practice and achieving the implementation objective for 2013.

40 RESULTS To increase the % of time for direct patient care to 70% The range of the measurements vary significantly and there is a need to be cautious in making direct comparisons between wards as there are several influencing factors that impact on the % of time spent on direct patient care. These include patient dependency, patient: nurse ratio, ward activity, workload, speciality. Ceredigion The results of the first activity follow indicated an average % of time in direct patient care time for registered nurses in Ceredigion as 41.8% (range 32-55%) The results of the first activity follow for Health Care Support Workers resulted in an average % of 52% (range 37-72%). Pembrokeshire Baseline: of the 12 wards that have completed the Registered Nurse activity follow the results demonstrate that the average % of time spent on direct care for the baseline measurement is 45.89% (range %).

41 Baseline Activity Follow RN's Pembs 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Maternity A&E ACDU Sunderland St Nons St Caradogs Pembrokeshire The average % of time spent on direct care for the two wards who have repeated the activity follow for the Registered Nurse, increased to 69.52%. There is insufficient data to complete a meaningful comparative data chart.

42 Examples of work undertaken to improve both the direct time spent and quality time include: Ceredigion Reviewing nursing handover process. Applying the principles of a Well Organised Ward. Reviewing medication round process to reduce interruptions Reviewing mealtimes in relation to organisation and preparation of meals Repeat activity follows will be part of the embedding and sustaining work. Pembrokeshire Streamlining the nursing handover. Applying the Lean principles from the Well Organised Ward module. Introducing nursing documentation at the bedside. Developing patient centred processes and facilities To reduce locally defined adverse events by 50% % Compliance with Falls Risk Assessment There is currently no standardised mechanism in place to capture this information on a consistent basis. A Health Board multidisciplinary task and finish group has been set up to develop a falls bundle. Pembrokeshire Examples of work being developed by Transforming Care teams include: Introduction of Intentional rounding Monitoring incidence of Falls using safety crosses Incidence and trend mapping using cluster diagrams

43 Incidence of Pressure Ulcers (Ward Acquired) The Care Metrics Module on the All Wales nursing Audit tools site is being used to capture data on Ward acquired pressure ulcers. The graph below shows the TOTAL number of pressure ulcers for ALL inpatient wards in Ceredigion including the 10 Transforming Care/RTTC wards. The source of the data is the All Wales NHS Dashboard. The data prior to December 2011 is not representative of all the wards as 1 ward started to capture data on ward acquired pressure ulcers in April Between July Dec 2011 this was spread to all ward areas in the acute sites and to Community Hospitals in January Ceredigion Since January 2012: Mental Health wards -there have been no reported incidence of ward acquired pressure damage. Community hospitals Tregaron and Cardigan, 5 healthcare acquired pressure ulcers/damage incidence. Pembrokeshire Since January 2012 there have been no reported incidence of ward acquired pressure damage on the Mental Health Wards

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46 % compliance with SKIN bundle (or equivalent) There is currently no standardised mechanism in place to capture this information on a consistent basis. Examples of work undertaken by teams include: Introduction of SKIN bundle Introduction of A &E SKIN bundle Ceredigion Other initiatives using safety calendars; For example a safety cross placed on a medication trolley can measure acceptable standards of organisation of medication and stock levels. A square represents a day on the safety cross and so an acceptable day is a green day and an unacceptable medicine trolley state is a red day. Standard operating procedures can set out the task for each member of staff to ensure the medicine trolley is left at the acceptable standard for the next user. This then minimises the risk of medication errors and increases patient safety with a reliable process. Two areas in Ceredigion have used this for medication. To increase Patient Satisfaction to 95% Ceredigion All areas are using the Fundamentals of Care All Wales audit as the evidence for this objective. The wards first started capturing information via this tool in 2009 with the departments capturing data as of The average patient satisfaction for the 12 wards who have taken part in the Transforming Care /RTTC programmes to date was 87% for The wards are due to repeat this audit between June October Examples of work include: You said, we did notice boards Patient Diary

47 Pembrokeshire Examples of work undertaken by teams include: You said, we did notice boards Use of comments books/suggestion boxes Patient Diary for patients admitted with acute stroke Introduction of memory boxes for patients with dementia Pembrokeshire Patient Satisfaction Fundamentals of Care Audit % % 80.00% 60.00% 40.00% 20.00% 0.00% Maternity A&E ACDU Sunderland St Nons St Caradogs

48 To increase Staff satisfaction to 95% Examples of work undertaken by teams include: Staff involvement in Transforming Care work e.g. applying the principles of Well Organised Ward, empowering small teams to lead on developments and participate in using tools of improvement such as process mapping and PDSA s. Staff suggestion boxes/notice boards Ceredigion A standardised staff satisfaction questionnaire is being used by all the areas as the evidence for this objective. Both quantitative and qualitative data is recorded and analysed. The results are transparent and displayed. The idea is that the whole team are involved in identifying areas for improvement and developing the solutions utilising a PDSA (Plan Do Study Act) cycle of improvement. 10 wards have completed the staff satisfaction questionnaire. The baseline information indicates that they have an average staff satisfaction of 53% (Range 42-73%). Pembrokeshire 3 wards have completed the staff satisfaction questionnaire, there is increased activity to ensure that all participating teams complete this measure as soon as possible. The baseline information indicates that they have an average staff satisfaction of 53.06% (range 40-66%) there is insufficient data to present this in a run chart format. OUTSTANDING ISSUES/BARRIERS Undertaking the activity follow involves someone in the ward team following a Registered Nurse/HCSW for a specified period of time (12 hours for a Registered Nurse and minimum 6 hours for a HCSW) and scanning what activities that member of staff undertakes over that period. This activity provides the team with the % of direct care time each staff group spends with patients. The person undertaking the activity follow needs to be supernumerary for that period of time and this is a significant pressure for ward teams. The difficulties encountered by ward teams are reflected in the number of wards who have managed to timely complete the baseline measure and organising the repeat measure. Another barrier in being able to capture this measure has the availability and reliability of the bar code scanning pens additional pens and improved data analysis programmes have now been purchased which should help to resolve this issue.

49 DELIVERY OF THE TRANSFORMING CARE PROGRAMME Due to the recent operational pressures and the anticipated operational pressures between July September 2012 as well as the current, 3 month, 'vacancy review process' period, it has been necessary to: Minimise/cancel three facilitated 'Embedding and Sustaining programme' sessions Cancel Day 6 of the Transforming Care programme for Cohort 4. This would have been the first day of this cohort s embedding and sustaining programme (2 wards from Ceredigion and 1 ward in Pembrokeshire would have been participating) Cancel Day 3 of the Transforming Care programme for Cohort 5. 1 ward from Ceredigion and 2 wards from Pembrokeshire are participating in this cohort. This cohort is mid way through the introductory phase of the programme and it has been proposed that the final two workshops go ahead on the dates already arranged but with changes to the format: Sept 26th - to be run on a multi site basis as a VC workshop to avoid travel Oct 29th - to be run on a single site due to nature of material to be covered Postpone the commencement of cohort 6, planned for September The Practice Development team will be revisiting how much of the Phase 1 programme (for those areas not yet involved in the programme) and also the Phase 2 'Embedding and Sustaining' programme can be delivered through a county/locality/ward based /individual team model. As part of this review, the impact that this approach will have on the timetable for the HB to achieve the WG directive regarding rollout will need to be recognised.

50 Improving Stroke Care:- Acute Stroke care- Pembrokeshire BACKGROUND In WGH the Acute Stroke Unit (8 beds) and the stroke rehabilitation ward (8 beds) are co-located on ward 11.. The ward hosts a small gym, cognitive therapy room, and MDT room. As well as a Consultant in the Care of the Elderly and members of the MDT, the service is supported by a 1 wte Stroke CNS ( ) and an Associate Specialist 9am -5pm, Mon Friday. 24hr Thrombolysis commenced in WGH in Oct 11. The ward takes parts in all relevant National and Local organizational audits e.g. RCP audit, DSU reviews. Following these reviews local improvement action plans were developed. Currently there is a locality action plan which was formulated in Sept 11 which combined findings from the RCP audit, DSU peer review report and NICE quality standards. The service is monitored monthly via the Intelligent Targets (bundles 1-4). Early rehab bundles have been monitored within HDHB for several months (but not reportable to WAG yet) however their measurement is problematic and work is ongoing with the AHPs/Information dept in order to improve accuracy and consistency of reporting.

51 CURRENT STATUS Score: 8 - Whilst WGH is scoring consistency in the 90% overall, there has been a variation in scores for some of the bundles (First and 3 day bundles). Work need to be done to ensure consistency. IMPLEMENTATION/SPREAD PLAN CNS has present stroke pathway to the medical Directorate meeting. Room identified to facilitate OT assessment Side room decommissioned to improve storage space on the ward (temporary decant to assess if this is a workable option) NEXT STEPS TO BE TAKEN Exception reporting for all missed patients to begin to drill down on reasons for inconsistency

52 RESULTS Outcome Measure (by hospital or county) as a SPC chart % patients surviving 7 days post admission to a hospital with an acute stroke unit. Information not available for this report Process Measures (by hospital or county) as SPC charts (July 12) % patients compliant with First Hours bundle 100% % patients compliant with First Days 92% % patients compliant with First 3 days 100% % patients compliant with First 7 days care bundle 100% OUTSTANDING ISSUES/BARRIERS Some outstanding issues with medical teams being slow to fully confirm Stroke.

53 Rapid Response to Acute Illness Pembrokeshire BACKGROUND Work commenced in Withybush Hospital following the publication of NICE CG50, this resulted in the use of an accumulated scoring system for the tracking of patients observations and triggers for recognition of deterioration. With the 1000 Lives and 1000 Lives Plus collaborative, this initial work has continued to evolve to cover the four Rrails Bundles, including Sepsis screening. It has been demonstrated that the earlier recognition of the deteriorating hospital patient results in improved outcomes for patients and the reduction in inappropriate resuscitation attempts.

54 CURRENT STATUS SCORE: 8 - NEWS is in use throughout the acute hospital site and a trial of NEWS/Sepsis screening is due to commence in South Pembs Hospital imminently and Sepsis screening documentation is available in all clinical areas IMPLEMENTATION/SPREAD PLAN SBAR pads printed, for circulation to wards w/c 27th August, 2012 World sepsis day 13th September, 2012 further promotion of sepsis bundle RESULTS No of Cardiac Arrest Calls 8 Calls for month of July. 2 x prehospital, 3 x accident and emergency department, 3 x ward areas Number of Do Not Attempt Resuscitation (DNAR) orders not available at present

55 Results from August 2012 bundles snapshot audit. 10 charts per ward, total 90 charts Admission Bundle Recognition Bundle 100% 90% 80% 70% 60% 50% 40% 30% 20% Full set of physiological observations recorded 82% Had a clear monitoring plan specifying the observations to be recorded and how often 100% WITHIN 2 HOURS of arrival to the clinical area 99% 100% 90% 80% 70% 60% 50% 40% 30% 20% How many patients had: their physiological observations recorded according to their monitoring plan (at least every 12 hours) 98% How many patients had: A NEWS score calculated and recorded 66% How many patients had: had a clear monitoring plan specifying the observations to be recorded and how often 98% 10% 10% 0% 0%

56 Response Bundle Sepsis Bundle 80% 70% 60% 50% 40% 30% How many of these patients have had an appropriate first response as per the organisational NEWS escalation algorithm, 78% 100% 80% 60% 40% How many of these patients have received all 6 elements of the 'Sepsis Six' bundle w ithin 1 hour of diagnosis? 100% 20% 10% 20% 0% 0%

57 Enhanced Recovery after Surgery: Colo-rectal surgery - Ceredigion BACKGROUND ERAS Group reformed in February 2012 Full MDT including Cons Colo-rectal, Con Anaesth, Ward Sr CNS Nurse, Physiotherapist, OT, Pre-assessment Nurse,Dietician, Scheduled Care Nurse Manager,, Admissions officer, Pharmacy, Clinical Effectiveness manager,. Joint Leads of Colo-rectal nurse specialists. WORK UNDERTAKEN Documentation, pre-assessment, Change of practice in Anaesthetics and Surgery STRENGTHS/ACHIEVEMENTS Very positive team.commenced first patients in February 2012.Bowel prep guideline approved.

58 WEAKNESSES Initial phase commenced cautiously and pts reviewed, further education and MDT meeting to discuss issues and way forward with review in Sept [Pilot stage] CURRENT STATUS SCORE: 4 - Local implementation agreed, Anaesthetist and Colo-rectal Team on board IMPLEMENTATION/SPREAD PLAN Principles of Eras being rolled out to other Consultants within surgery. WORK COMPLETED Review of pilot patients. Next steps to be taken. On going review of patients in September 2012.Update/re-education of ward staff. OUTSTANDING ISSUES/BARRIERS Need to look at HDHB documentation and audit.

59 Enhanced Recovery after Surgery: Colo-rectal surgery - Ceredigion BACKGROUND ERAS Group reformed in February 2012 Full MDT including Cons Colo-rectal, Con Anaesth, Ward Sr CNS Nurse, Physiotherapist, OT, Preassessment Nurse,Dietician, Scheduled Care Nurse Manager,, Admissions officer, Pharmacy, Clinical Effectiveness manager,. Joint Leads of Colo-rectal nurse specialists.

60 WORK UNDERTAKEN Documentation, pre-assessment, Change of practice in Anaesthetics and Surgery Strengths/Achievements Very positive team.commenced first patients in February 2012.Bowel prep guideline approved. Weaknesses Initial phase commenced cautiously and pts reviewed, further education and MDT meeting to discuss issues and way forward with review in Sept [Pilot stage] Review of pilot patients. CURRENT STATUS Score: 4 - Local implementation agreed, Anaesthetist and Colo-rectal Team on board IMPLEMENTATION SPREAD PLAN Principles of Eras being rolled out to other Consultants within surgery. NEXT STEPS TO BE TAKEN On going review of patients in September 2012.Update/re-education of ward staff. OUTSTANDING ISSUES/BARRIERS Need to look at HDHB documentation and audit.

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