CQC Quality Improvement Plan

Transcription

1 CQC Quality Improvement Plan Date of Submission: 21/03/2018 Chief Executive: Lance McCarthy Chair Alan Burns

2 Navigation Our Patients Our People Our Performance Our Places Key The table below identifies the 2018/19 KPI target, current performance and then sets a trajectory for the year. The different coloured boxes indicate the individual month's trajectory and in which month the target will be met as follows: RED: Starting point AMBER: Moving towards meeting the target GREEN: The month when the trust is expected to meet the target IPR = Integrated Performance Report (the trust wide dashboard) Patients Executive LEAD MUST / SHOULD 2018 / 19 Target Compliance Data Source Current performance (Feb 18) June 18 July 18 Aug 18 Sept 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 March 19 Review DNARCPR forms to ensure completed fully in line Audit of with Trust Guidelines and National Policy Nancy Fontaine MUST 95% DNARCPR forms 82% Dec 17 84% 86% 88% 90% 90% 90% 90% 90% 90% 90% 90% 90% Audit of medical Review MCA & DOLS and how this is documented within patient notes Nancy Fontaine MUST records every 2 90% months 80% 85% 85% 90% 90% 90% Fridge temperatures are regularly checked and Ward if temperatures are outside the normal range Nancy Fontaine MUST 98% Accreditation Audit 95% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% (Urgent Care) Medical records contain a complete and contemporaneous record in respect of each patient and that appropriate risk assessments are completed and documented Nancy Fontaine MUST 90% ED Documentation audit Implement new ED NA documentation Embed ED documention Embed ED documention 90% 90% 90% 90% 90% 90% 90% 90% 90% (Paeds) Improve transition arrangements for adolescent patients Nancy Fontaine MUST Transition arrangements in Transition audit / place & embedded Patient Survey Limited Transition arrangements in Transition Policy Policy place approved Transition Policy Transition Policy embedded Transition Policy embedded Transition Lead in post Transition policy fully embedded Transition policy fully embedded Transition policy Transition policy Transition policy fully embedded fully embedded fully embedded The Trust must continue to ensure that bottles of liquid medications are dated, signed on opening and do not exceed the expiry date Nancy Fontaine SHOULD 90% Pharmacy Audit & Clinical Wednesday Audit 71% 80% 82% 84% 86% 88% 90% 90% 90% 90% 90% 90% 90% Audit (Urgent Care) Conduct regular Care Rounds Nancy Fontaine SHOULD 95% documentation NA Weekly audit in (Urgent Care) Conduct Emergency Care Safety Checklists Nancy Fontaine SHOULD 90% ED Implement new ED documentation Embed ED documention Embed ED documention 90% 90% 90% 90% 90% 90% 90% 90% 90% Evidence of disposable bowls (Critical Care) Introduce disposable washing bowls for patients Nancy Fontaine SHOULD in use in Critical 100% Care None 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Documentation & (Paeds) Consent should be consistently documented Nancy Fontaine SHOULD 90% notes audit Align with GDPR Align with Not audited process GDPR process 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% (Paeds) Enhance communication with patients to ensure they have all the information they need Nancy Fontaine SHOULD 100% leaflets reviewed NA Review in progress 79% 80% 85% 90% 100% 100% 100% 100% 100% 100% 100% 100% (Paeds) Ensure records are complete and comprehensive, in particular the documentation of conversations with parents Nancy Fontaine SHOULD 90% Documentation & notes audit ED ED document documentation being revised revised Me First work Me First work shops for staff shops for staff Me First work shops for staff Me First work shops for staff 90% 90% 90% 90% 90% 90% 90% People Appraisals Raj Bhamber MUST 90% Appraisal records 86% 87% 88% 89% 90% 90% 90% 90% 90% 90% 90% 90% 90% Stat/Man Training (inc: safeguarding, Fire, Infection Control, Hospital Life Support) Raj Bhamber MUST 90% Training recoreds 84% 85% 86% 87% 88% 89% 90% 90% 90% 90% 90% 90% 90% Paediatric Life Support Training Compliance Raj Bhamber MUST 90% Training recoreds 80% 85% 87% 89% 90% 90% 90% 90% 90% 90% 90% 90% 90% Adult Life Support Training (level 2) Raj Bhamber MUST 90% Training recoreds 77% 70% 74% 78% 82% 86% 90% 90% 90% 90% 90% 90% 90% Adult Safeguarding Training (Levels 1 & 2) Raj Bhamber MUST 90% Training recoreds Paediatric Safeguarding Training (levels 1, 2 & 3) Raj Bhamber MUST 90% Training recoreds L2-78% L2-78% L2-85% fl2-87% L3-62% L3-70% L2-80% L2-88% L3-74% L2-82% L3-78% L2-84% L3-82% L2-86% L3-85% L3-88%

3 Key The table below identifies the 2018/19 KPI target, current performance and then sets a trajectory for the year. The different coloured boxes indicate the individual month's trajectory and in which month the target will be met as follows: RED: Starting point AMBER: Moving towards meeting the target GREEN: The month when the trust is expected to meet the target IPR = Integrated Performance Report (the trust wide dashboard) Executive LEAD MUST / SHOULD 2018 / 19 Target Compliance Data Source (Urgent Care) Staff are competent including: Fire, Safeguarding & Infection Control Raj Bhamber MUST 90% Training recoreds Current performance (Feb 18) June 18 July 18 Aug 18 Sept 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 March 19 81% (medical HCG) 85% 86% 87% 88% 89% 90% 90% 90% 90% 90% 90% 90% (Surgery) There must be a Paediatric trained nurse in theatres at all times Raj Bhamber MUST 100% Staff Roster 0% 0% 0% 0% 50% 50% 50% 50% 50% 50% 100% 100% 100% Staff Roster / (Paeds) Recruit Registered Paediatric Nurses to ensure compliance with RCN standards regarding staffing & competences on Dolphin Ward Raj Bhamber MUST Shelford Acuity Model & Safer 14% Staffing 22.9% 22% 22% 18% 18% 18% 15% 15% 15% 15% 15% 15% 14% Recruit Registered Nurses (RNs) to ensure adequate numbers of RN's in line with national guidance Raj Bhamber SHOULD 18% Vacancy Data 24.0% 22% 21.5% 21% 20.5% 20% 20.0% 19.5% 19.5% 19% 19% 18.5% 18%

4 Key The table below identifies the 2018/19 KPI target, current performance and then sets a trajectory for the year. The different coloured boxes indicate the individual month's trajectory and in which month the target will be met as follows: RED: Starting point AMBER: Moving towards meeting the target GREEN: The month when the trust is expected to meet the target IPR = Integrated Performance Report (the trust wide dashboard) Executive LEAD MUST / SHOULD 2018 / 19 Target Compliance Data Source Current performance (Feb 18) Performance (HDU) Reduce the number of mixed sex breaches Steph Lawton MUST Zero IPR Ambulance patients are appropriately assessed & triaged in a timely manner in accordance with RCEM guidelines Steph Lawton MUST <30mins - 80% 30-60mins - 20% IPR <30mins - 66% <30-65% 30-60mins - 26% % >60mins - 8% >60-3.5% <30-68% % >60-3% <30-70% % >60-2.5% <30-74% % >60-2% <30-77% % >60-1.5% June 18 July 18 Aug 18 Sept 18 Oct 18 Nov 18 Dec 18 Jan 19 Feb 19 March 19 Reduce the number of late discharges ( hrs) Steph Lawton SHOULD Zero IPR 3.0% 4.0% 4.0% 3.5% 3.5% 3.0% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0% Reduce the number of bed moves between ( hrs) Steph Lawton SHOULD Zero IPR 3.0% 4.0% 4.0% 3.5% 3.5% 3.0% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0% Reduce the number of delayed discharges from HDU to the wards Steph Lawton SHOULD 4-24hrs=12 >24hrs = 2 IPR 4-24hrs= hrs=23 >25hrs=12 >24hr= hrs=22 >2hr4= hrs =21 >24hr= hrs=20 >24hr= hrs=19 >24hr= hrs=18 >24hr= hrs=17 >24hr= hrs=16 >24hr= hrs=15 >24hr=8 4-24hrs=14 >24hr=6 4-24hrs=13 >24hr=4 4-24hrs=12 >24hr=2 (Surgery) Reduce the use of for inappropriate patients (DSU etc.) late at Night Steph Lawton SHOULD Extend DSU opening hours to 22.00hrs / Zero IPR DSU closes at Recruit 18.00hrs additional staff Recruit Recruit additional staff additional staff to 22.00hrs. The Trust needs to monitor trends in delayed discharges to identify trends / areas for improvement Steph Lawton SHOULD monitored & Audit data not not monitored monitored monitored and Places (HDU) When refurbishing, consider the position of the sink area in HDU, moving it so that staff do not have to pass through a bed area to wash their hands Marc Davis SHOULD Review space & identify a new design. Submit business case. NA NA Review space Review space Submit business case for approval If approved go out to tender If approved go out to tender Start building work Complete building work New HDU New HDU New HDU New HDU New HDU (HDU) When refurbishing, consider the space required to provide safe movement around bed spaces Marc Davis SHOULD Review space & identify a new design. Submit business case. NA NA Review space Review space Submit business case for approval If approved go out to tender If approved go out to tender Start building work Complete building work New HDU New HDU New HDU New HDU New HDU (CCCS) Ensure there is a planned preventative maintenance programme in place for all the equipment in the Mortuary Marc Davis SHOULD 100% NA Improved documentation of maintenance commenced Feb % 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

5 Navigation Five P trajectory Our People Our Performance Our Places Our Patients CQC MUST actions Issues Review DNARCPR forms to ensure completed fully in line with Trust Guidelines and National Policy Actions *Revise Trust DNACPR form to incorporate MCA / Best Interest & to comply with national recommendations *Revise Trust DNACPR policy to comply with national recommendations (appendix will be altered by to incorporate MCA etc.) * Conduct a monthly audit, focusing on supporting individuals who don't complete the form in line with trust policy, presenting the results at Patient, Safety & Quality Committee * Strengthen the nursing quality review process & audit monthly to assess compliance * If compliance does not improve, consider implementing a DNACPR Guardian to check all forms are completed *Introduce an interactive DNACPR e-learning process *Revise the MCA/TEP form to align with the DNACPR form *Explore the possiblity of making the DNACPR form digital and integrate it into the Cosmic electronic patient record system Completion Date December 17 September 18 September 18 November 18 July 18 CQC MUST actions CQC MUST actions CQC MUST actions CQC MUST action Review MCA & DOLS and how this is documented within patient notes Fridge temperatures are regularly checked and if temperatures are outside the normal range Medical records contain a complete and contemporaneous record in respect of each patient and that appropriate risk assessments are completed and documented (Urgent Care) (Paeds) Improve transition arrangements for adolescent patients * Safeguarding policy to be reviewed and submitted to Policy Review Group * Audit to be conducted every two months to monitor compliance against the revised policy * Actions taken as appropriate following audit results * * Undertake a baseline nursing documentation audit * Implement a revised nursing documentation booklet in ED, which incorporates the Bristol Safety Checklist * Monitor record keeping compliance * Implement e-obs into ED & evaluate * Develop a plan which seeks to address those children under the care of a Paediatrician who need to be transition to adult services * Develop a plan which seeks to address those young people in the age group who are not chronically unwell but who are admitted for a specific surgical procedure or who are otherwise unwell * Seek funding for a Transition Lead * Develop a Transition Policy and implement March 218 On-going Monthly March 2018 Quarterly September 18 s The Trust must continue to ensure that bottles of liquid medications are dated, signed on opening and do not exceed the expiry date * Date Opened & Expiry stickers issued by Pharmacy to all wards & departments * Internal safety bulletin issued to all wards and departments, informing them of the need to write the date opened and expiry date on all liquid medications and to inform them that additional stickie labels are available from Pharmacy * Compliance will be audited 2 monthly December 2017 December 2017 March 2018

6 Our People Issues Actions Completion Date Appraisal Compliance July 2018 Statutory / Mandatory Training Compliance Paediatric Life Support training compliance * Non-compliant staff to receive a letter from the CNO/CMO * Creation of additional sessions for staff out of hours January 2017 July 2018 Adult Life Support training compliance (Level 2) * Non-compliant staff to receive a letter from the CNO/CMO Adult Safeguarding Training compliance (Levels, 1 & 2) Paediatric Safeguarding Training compliance (Levels, 1, 2 & 3) October 2018 (Urgent Care) Staff are competent (including: fire, safeguarding & infection control)

7 Navigation Five P trajectory Our Patients Our People Our Places Our Performance Issues Actions Completion Date CQC MUST action (HDU) Reduce the number of mixed sex breaches * Reduce the number of delayed discharges from HDU to the wards as a result of improved flow March 2019 CQC MUST action * Implemented streaming process for all patients attending ED Ambulance patients are * Implemented Rapid Assessment & Treatment Process (RAT) appropriately assessed & triaged in * Consistent use of internal and external escalation process a timely manner in accordance with * Use of real time data for dynamic movement of staff to meet clinical acuity RCEM guidelines * Introduction of substantive paramedic role to support safe skilled staffing levels * Opening of assessment and Urgent Treatment Centre to support achievement of 95% target which will improve ambulance & triage times September 2017 October 2017 August 2018 Reduce the number of late discharges ( hrs) * Full implementation of Fleming Ward as an assessment unit * Ensure patients are placed in the right ward at the right time * Implement Saunders Ward as a short-stay ward (<48 hours) * Continue to embed SAFER & Red 2 Green * Increase the number of 'Golden' patients the day before discharge and then discharge the following day before 10.00hrs * Implement the Real Time Patient Flow module on COSMIC * Re-align patient flow: opening of Surgical Assessment Unit, Assessment Unit, Short-stay unit, Clinical Decision Unit and the Urgent Treatment Centre On-going July 2018 Reduce the number of bed moves between ( hrs) * Full implementation of Fleming Ward as an assessment unit * Ensure patients are placed in the right ward at the right time * Implement Saunders Ward as a short-stay ward (<48 hours) * Continue to embed SAFER & Red 2 Green * Increase the number of 'Golden' patients the day before discharge and then discharge the following day before 10.00hrs * Implement the Real Time Patient Flow module on COSMIC * Re-align patient flow: opening of the Surgical Assessment Unit, Assessment Unit, Short-stay unit, Clinical Decision Unit and the Urgent Care Centre On-going July 2018 Reduce the number of delayed discharges from HDU to the wards * Early identification of patients suitable for ward transfer * Introduce an SLA for 'step downs' and monitor compliance March 2018

8 Navigation Five P trajectory Our Patients Our People Our Performance Our Places Issues Actions Completion Date (HDU) When refurbishing, consider the position of the sink area in HDU, moving it so that staff do not have to pass through a bed area to wash their hands * Look at reviewing the whole space that both ITU & HDU occupy and consider if changes could be made to enhance the facilities provided for HDU patients without compromising ITU facilities * If a better solution can be found, draw up a business case for capital monies *Submit the business case and seek approval for funding * Implement the changes June 2018 November 2018 (HDU) When refurbishing, consider the space required to provide safe movement around bed spaces * Look at reviewing the whole space that both ITU & HDU occupy and consider if changes could be made to enhance the facilities provided for HDU patients without compromising ITU facilities * If a better solution can be found, draw up a business case for capital monies *Submit the business case and seek approval for funding * Implement the changes June 2018 November 2018