Healthcare Improvement Scotland. NHS Tayside

Transcription

1 Faculty Site Visit Report Healthcare Improvement Scotland NHS Tayside 8 th June 2011 FINAL VERSION 19 July 2011

2 CONTENTS 1. Key Contacts... 2 NHS Tayside... 2 Site Visit Team SPSP Programme Key Aims... 3 Mortality Reduction and Rescue Strategies... 4 Adverse Events Workstream Specific Discussions... 5 Leadership... 5 Critical Care... 5 General Ward... 6 Medicines Management... 6 Peri-operative Other Ongoing Patient Safety Programmes Summary of Observations and... 9 Page 1 of 11

3 1. Key Contacts NHS Tayside Diane Campbell, (ext 71167) Wendy Sayan, (ext 71169) Site visit team Dr Brian Robson, (Team Leader), Medical Director, Healthcare Improvement Scotland Dr Andy Longmate, Consultant in Anaesthesia and Critical Care, NHS Forth Valley Dr Ken McKinley, Consultant Anaesthetist, Golden Jubilee National Hospital Jane Ross, SPSP National Facilitator, Healthcare Improvement Scotland Page 2 of 11

4 2. SPSP Programme Key Aims Mortality Reduction and Rescue Strategies Reduction in HSMR noted and organisational systematic approach to mortality reduction in operation. Active engagement in review of medical deaths underway. Active work on review of SEWS and response algorithms. Code Scene Investigation (CSI) within 48 hours offers a super example of an approach which goes beyond the individual and considers human factors and their impact sending a clear message to staff that system issues are critical. To synergise the energy and learning around medical case note review, CSI and rescue systems and further evaluate and improve key processes to drive and support improvements in outcomes the cardiac arrest and crash call charts. Ensure close linkages between CSI and Mortality Reviews and linking learning from the above to effective organisational change. Wider sharing, out with NHS Tayside, on SEWS and medical mortality reviews, for example consider sharing of the medical mortality reviews and linkages with improvement at LS 8. Linkage with Paul Fish (Durham) on CSI. Overall High profile of mortality reduction and impressive, structured approach to mortality reduction programme. We believe that your work in this area is leading in the field. Tools to share with the community Adapted SEWS Medical mortality review process and outcome feedback (? at LS 8) Page 3 of 11

5 Adverse Events Work in primary care Primary Care Trigger Tool, multiple ramped PDSAs etc well received in practice. Educational exercises with undergraduates in incident reporting and incident reviews with GTT. Learning in trigger tool use in General and Paediatrics and evolution of thinking and tools. Know more about how you are feeding back the learning from the trigger tool reviews in to the improvement cycles. Overall Culture of testing and learning from adverse event reviews and tool is evident. Tools to share with the community We would ask you to consider sharing your trigger tools and what you have learned with the wider Scottish safety community. Page 4 of 11

6 3. Workstream Specific Discussions Leadership There was excellent Board, Executive, Senior Management and Clinical Leadership engagement throughout visit exemplary. Positioning of safety and improvement in agenda for the Board, the Executive Team and in the new Governance and Hub developments. Patient stories and staff stories at Board Strong CEO leadership and ET support for leadership Walkrounds Investment is being made to ensure this work is further improved and sustained. Investment in Non Executive Directors and ET in quality improvement and safety is impressive and reflects an evolution of a longstanding NHS Tayside commitment to this agenda. ET reporting mechanism against the SPSP Driver Diagram is very effective approach- definitely worth sharing. It would be very helpful for NHS Tayside to consider and share their progress since the Boards on Board event. Continue to develop all Board members in their roles in relation to quality of care and improvement. Share their approach to reporting on Executive Team SPSP driver diagram at LS8. Overall Impressive, committed and sustained leadership in the field. Critical Care Although not specifically covered in detail, expressly stated their ongoing commitment to monitoring data on process and outcomes. Extensive spread on interventions (CLI, PVC bundle etc) and measures beyond pilot sites and, indeed, beyond SPSP workstreams. Continue with improvement weeks and ensure frequent, formal review of all extranet measures to ensure levels of reliability of process and outcomes are maintained. Page 5 of 11

7 General Ward General ward / Renal: - excellent use of data and dashboards to inform and support routine clinical practice - Clinical ward staff have real ownership over data and using it real-time across sites. - Roll up data to connect in Board s objectives was a stimulus to staff on front line - High and low tech visual data displays Hospital at Night : - Excellent work on briefings and communications in H@N with a focus on behaviours and ensuring cross organisational awareness of key issues. Staff have a real appetite for further development of the dashboards we are aware of the plans for staged development and would urge early progress to further enhance user satisfaction and enable linkages across various improvement programmes. Consider again the role of ehealth and track and trigger tools to supplement your mature rapid response arrangements (NHS Fife testing with efews using Patient Trak solution). Consider broadening H@N briefing team to include bed management and facilities in keeping with acclaimed Cincinnati Children s hospital briefing. Consider data and reporting on attendance at briefings to encourage attendance and assess impact of improvement interventions. Medicines Management Mental Health - The passion and commitment of staff in this field was notable. - Creative use of improvement methodologies and tools in advancing improvement - Patient involvement and engagement - safety brief for patients was innovative - Med rec on discharge at 100% was heavily pharmacist dependant and, although impressive, is not likely to be sustainable. - Great use of run charts and Pareto. Med rec pharmacist dependant consider and develop medical engagement model Page 6 of 11

8 Use of 5 why s or appreciative inquiry consider Highland star chart and named data to encourage doctor engagement in the med rec process at all levels. Consider Tayside COE support in medical staff engagement Peri-operative Vigilance around data and data collection is paying off with your electronic systems and staff dedicated to data entry and quality. Senior engagement and support e.g. regular Executive Sponsor meetings with peri-op team leads. Continued investment in data collection and review. Page 7 of 11

9 4. Other Ongoing Patient Safety Programmes Women & Child Health Maternity & Paediatrics Paediatric and Maternal Health - The Maternity Collaborative is demonstrating a significant investment in this important area and demonstrates adaption and adoption of a range of effective SPSP interventions. Staff support and enthusiasm is impressive as is the spread of improvement tools and techniques including the WHO safety checklist. - Excellent staff engagement at all levels. - Culture survey excellent. - Patient survey is an innovative and engaging approach. - Interesting work around maternal health and sepsis. - Waste identification and reduction associated with Cystic Fibrosis medication reconciliation. What are the altered care plan / bundle to intervene in high sepsis risk patients? Share weekly paediatric, on-site simulation plans and rational for investment locally and raise awareness externally. Consider support for simulation video and Sim-Baby. Student Education Medical students involved in review of medication prescribing error are a stimulating and innovative development demonstrating a systematic approach to safety teaching and learning. Nursing and medical u/g educational trigger tools. Huge emphasis on improvement rather than traditional audit. Acknowledge extensive work by Peter Davey and Vicki Tulley advanced practicum and international relationships in the field. We recommend sharing widely the work of Professor Davey and Vicki Tulley. Overall Excellent partnership working across teaching, research and practice. Page 8 of 11

10 Primary Care and Mental Health Great testing and learning across primary care, mental and the and interface. Well documented and use of data and PDSAs excellent presentation of the multiple PDSAs. Strong GP leadership by Dr Martin and the team, yet again demonstrating NHS Tayside s UK and international reputation for innovation and improvement. Share medication reconciliation work between primary care / PRI could inform national med rec work. Caution re spreading too early. We encourage NHS Tayside to fully explore the role that ehealth might play in accelerating these interventions and supporting spread. Overall Innovative development of trigger tool, safety climate surveys and recognition of the context of change and improvement in primary care. Page 9 of 11

11 5. Summary of Observations and We would like to thank you all for taking the time to share your work with us. NHS Tayside has clearly demonstrated a significant breadth and depth of quality improvement approaches across your organisation and your systematic planning and committed leadership and engagement at all levels is commendable. The commitment to transparency at NHS board level and throughout the organisation, including the use of medical mortality review case studies, is world class. Your investment in staff and QI support programmes is recognised as essential by your leadership as you organise for quality and build a reliable system of safety and improvement. We discussed the challenges facing NHS Tayside and NHSScotland in achieving the bold goals set out by SPSP and encourage you to continue your drive and enthusiasm and relentless review to accelerate your progress. We hope that our comments and recommendations offer a balance of commendation for the excellent work and also offer stimulation to further improve. The students engaged in safety and quality improvement reported that they really believe they can make a difference and this could be a strap line for NHS Tayside. We wish you well in making that difference and sharing the learning widely. Page 10 of 11