Quality Improvement Strategy

Transcription

1 / Colchester Hospital University NHS Foundation Trust Quality Improvement Strategy Including our four Quality goals Strategy Author Angela Tillett, Medical Director Version 1 Date of Issue - 27th August 2015 Review Date August Colchester Hospital University NHS Foundation Trust Quality Strategy

2 Foreword Delivering quality care is an aspiration of all healthcare staff. As a Trust we have a duty to ensure our patients receive safe and personal care at all times- and empower our staff to deliver this. Our Vision is reflected in our values and the diagram on the front page (known as a Wordle) summarises how we would like our patients to experience care in our Trust. With this strategy along with our Trust objectives will set the direction for continued improvement in the quality of care over the next 3 years. Introduction At Colchester Hospital University NHS Trust we are committed to providing the highest quality care for our patients, their families and the community. Quality care can be defined in three parts: 1. Patient Experience 2. Patient Safety and 3. Clinical Effectiveness 1 Colchester Hospital University NHS Foundation Trust Quality Strategy

3 Closely linked to caring is being responsive to patient s needs and indeed all of these components require good leadership - hence we have included all these key components in our Quality Strategy. At the centre of this strategy is seeing each of our patients as a person, listening to them, involving them in their care and being responsive to their individual needs and values: No decision about me without me Equity and Excellence: Liberating the NHS DOH 2010). This strategy includes the urgent quality priorities we have committed to in our annual Quality Report for 2015** and provides an opportunity for us to clearly set out our priorities for quality improvement over the next 3 years. By its nature- this will need to be a living document that continues to develop as we achieve some of the early milestones whilst ensuring we keep focused on the more challenging goals to ensure we deliver the care we would wish for our patients and their families. Context We have considered the national context of The NHS outcomes framework which describes 5 domains for improvement in health care, we have also considered our history the Trust has been through several challenging years of external and regulatory measures in relation to poor quality of care in certain areas and particularly the lack of consistency in delivery of high quality care. The Keogh review in 2013 identified several key quality areas for improvement in addition to the need to strengthen leadership and governance. The CQC inspection in May 2014 rated the Trust as requiring improvement and then subsequently in December 2014 following an inspection focused on emergency care the Trust was rated as inadequate. We have since developed an Improvement Plan with our partners and regulators such that the overarching goals and actions highlighted in the plan will be reflected in this strategy which in turn will be underpinned by a detailed plan for delivery. The Wordle below shows the compliments received by our services over the past 12 months to April 2015 with word height proportional to frequency: this reflects the feedback we would aspire to receive from all of our patients. 2 Colchester Hospital University NHS Foundation Trust Quality Strategy

4 Our Goals Goal 1 Person-centred care Caring for our patients as people- with kindness, dignity, respect and compassion is fundamental to providing quality care. Involving our patients in all aspects of care from development of services to feedback Improving our responsiveness to patients needs by reducing waiting for appointments, discharges and response to complaints when things to not go well Improving accessibility for patients with disabilities Measures 1. Every patient to have an individual care plan reflecting their needs and values. 2. Achieve results in upper quartile for friends and family test across all services 3. Establish trust-wide process for real time feedback from cancer patients** 4. Reduction in complaints by 50% - increase compliance with response time by 20%** 5. >95% patients receive information about their condition on discharge ** 6. Support patients and carers with disabilities including dementia car 7. Reduce average waiting for first appointment to average of 6 weeks Goal 2 Keep patients safe from infection and harm Strengthen infection control culture Improve medication safety Trust-wide Improve consistency of care by incorporating best practice into care bundles Reduce harm by acting on near misses and eliminate never events Improve consistency of care with 7 day week emergency services 3 Colchester Hospital University NHS Foundation Trust Quality Strategy

5 Measures 1. Healthcare related infections ** no cases of Methicillin Resistant Staphylococcus Aureus bacteraemia (MRSA) no more than 18 cases for Clostridium Difficile per annum 2. Reduction in missed doses of medication for non-clinical reasons by 50%** 3. Implementation of care bundles and achievement of upper quartile performance for: Sepsis 6 Febrile neutropenia Hip fracture COPD NEWS tool in Escalation of the deteriorating patient 4. Incident reporting in upper quartile nationally with serious incidents in lowest quartile 5. Compliance with WHO checklist trust-wide with zero never events** 6. Patient review 7 days/week with consultant led handover Goal 3 Provide Effective care to patients The risk-adjusted mortality rate is a key measure of quality care- we aim to reduce this by: Reviewing all deaths to focus on any required improvements in the care pathway and documentation Improving resuscitation (DNACPR) discussions and decisions Implementation of evidence based guidance Measures 1. Reduce HSMR to below Mortality case review of all deaths by clinical teams 3. Reduction in inappropriate cardiac arrest calls by 25% 4. Stroke outcomes: in top decile nationally 5. VTE assessment: above 95% compliance 6. Quarterly review of readmissions by each speciality 4 Colchester Hospital University NHS Foundation Trust Quality Strategy

6 Goal 4 Enhance Leadership and improve culture The At Our Best programme, which commenced in April 2015, has focused on engaging staff in what they see the vision of good care to be and empowering them to speak up and take forward ideas for improvement. This change in culture is paramount to the success of the delivery of all our safety goals and is highly dependent on leadership at all levels within the Trust: Measures 1. Improved staff survey results to third quartile or above 2. Education and training of staff including mandatory, clinical skills and leadership skills mandatory training compliance of >95% 3. Appraisal and development of staff : appraisal rate of >95% 4. Engagement with Ward to Board governance processes in all Divisions: 100% compliance with monthly meetings ** 5. Development of Information Technology to capture data and measure components of improvement goals Strategy Governance and delivery Key to the delivery of this quality improvement strategy is the Governance system within the Trust which is led by the Board. Delivery of this strategy will be supported by the Trust Improvement Plan and overseen by the Quality and Patient Safety committee (QPS) supported by the clinical governance committee where divisional and Trust-wide quality and safety issues are reviewed and discussed. The QPS committee will discuss and approve a timeline for initiation and continuation of projects referenced in this strategy. The key performance measures will be available in the Quality Dashboard which will be reviewed at Board. The QPS committee will also: Ensure required standards are achieved Investigate and take action on sub-standard performance Plan and manage continuous improvement Identify and manage risk We will publish our performance of these quality goals in our Annual Quality Account in addition to any actions we plan to take in forthcoming years and prioritisation of these actions. This strategy will link with and be integral to- Trust strategies for clinical services, education and training, research and innovation, estates and Information Technology. 5 Colchester Hospital University NHS Foundation Trust Quality Strategy

7 Conclusion This strategy aims to set the direction of travel for quality improvement in the Trust over the next 3 years and most importantly aims to create the infrastructure for a culture of continuous learning and improvement. Dr Angela Tillett Medical Director July 2015 ** Refers to CHUFT s annual Quality Report for Colchester Hospital University NHS Foundation Trust Quality Strategy

8 Appendix 1:Feedback from staff and stakeholders Caring : what does quality look like? Person- centred care vs patient care Listening, Communicating clearly and avoiding jargon, written patient information Not walking by- doing what we say- at our best all the time Individual care plan for each patient good discharge information Excellent Patient reported outcomes and Friends and family test Fewer compalints and speedy response Plaudits and national awards Team work- whole team shared team ethic - MDT working Good trainee feedback- trainees want to train here Staff appraisal to support teams and exit interivews to learn why staff leave Doing the right thing first time Safe: what does quality look like? Attention to cleanliness Good consent processes Staffing levels and skill mix- accredited staff Safe environment with access for hearing impaired patients, counselling area Low HSMR and SHMI High scores in Safety scorecard measures : VTE, HAI, no Never Events Learning from incidents with feedback to wider teams Policies and guidelines available for key issues Technology support for safety eg electronic prescribing Good Cross locality working- continuity of care Clinical records clear and kept safely Responsive: what does quality look like? Patients contribute to committees, user groups, service development Improved accessibility: Twitter, Facebook, Spiritual care and access to counselling No patients wait > 4 weeks for first OPD, or >12 weeks for operation, No patients lost to follow-up All patients welcomed and seen on arrival Extended hours of working to improve flexibility Increased frequency of patient surveys to gauge responsiveness 7 Colchester Hospital University NHS Foundation Trust Quality Strategy

9 Effective : what does effecitve care look like? Staff follow best practice and NICE guidance, high quality audit Outcome measures reported and acted upon Good compliance with safety thermometer Improved IT systems to provide better data Leadership: what does excellent look like? All staff empowered and valued Clear Trust vision, values and objectives Good Communication at all levels between all staff Stable and visible leadership team who role model good behaviours All staff feel able to challenge poor behaviour Good clinical governance Job plans match business needs Staff conflict manged well Mandatory training up to date Leadership development support available 8 Colchester Hospital University NHS Foundation Trust Quality Strategy