Quality Improvement Plan. Enabling delivery of the Trust Strategy

Item 6.1a Introduction Quality Improvement Plan Enabling delivery of the Trust Strategy 2017-22 Writing the Next Chapter, the Trust s new strategy sets our ambition over the next five years to be an outstanding provider of health services for our population. The measures of success for delivering this ambition are: An Outstanding CQC report; Top 20% for the experience of care, and recommended by 97% of patients; Top 10% for safety, as measured by the summary hospital-level mortality indicator; Improve early detection and treatment for hypertension, atrial fibrillation, COPD and diabetes; Constraining costs from 2017/18 to 2021/22, to support local STP financial recovery; and Top 25% for staff satisfaction and engagement. In five years time we want to be delivering healthcare across our communities and with our partners that will enable people to spend less time in hospital, and more time getting support and treatment at home or in a community setting. Our mantra for patient care will be Home First. In order for us to deliver seamless pathways of care across acute and community services the Trust has embarked on an Alliance with other health and social care partners with an aim to deliver integration, transformation and sustainability. We will be an organisation without walls, working in partnership through long term commitments between Colchester and Ipswich hospitals and through Alliance working with our health and social care partners across North East Essex, East and West Suffolk to ensure joined up care. This document describes our Quality Improvement Plan 2017-22, our vision, ambitions and plans for the development of our organisation from a quality perspective that will enable the successful delivery of the Trust s five year strategy. It highlights four key priorities and considers each in detail. These are to improve Safety Patient and Carer Experience Clinical Effectiveness; And to make sure we have a robust approach to Quality Improvement It is widely recognised that there is a strong link between quality, safety, good patient outcomes, a positive organisational culture and being a learning organisation. What is key is that this plan is read and delivered alongside the Trust strategy, and the IT, People, 1

Organisation & Development, and Estates enabling strategies. Together these will enable us to create an outstanding organisation with an excellent reputation for high quality patient care and for providing an experience for our patients and carers who are proud to recommend the Trust as a place to receive care. Context This plan takes account of the known and anticipated local and national challenges and opportunities that will shape the provision of care over the next five years. These include: Alliance commissioning to deliver community services; Long term partnership with Colchester Hospital Foundation Trust (CHUFT); Five Year Forward View and STP plans; A commitment to increase to seven day working in some services and to improve cover out of hours; and Better Births agenda. As well as our own internal intelligence for where we believe we need to improve from: Patient and service user feedback; Staff confidence in reporting safety issues and confidence in quality improvement; and Investigation outcomes from adverse events. Developing the Quality Improvement Plan As a result of the robust engagement process during development of the Trust Strategy we have found that colleagues and stakeholders already had a clear understanding of the why - the rationale for why we needed to deliver the strategic objectives and had started to frame the what within their Divisions, specialities and professional groups, i.e. what are the quality objectives we need to agree in order to deliver the strategic objectives. This piece of work therefore has been a collation of Divisional business plans, Alliance principles, proposed benefits for long term partnership with CHUFT, the STP plans and professional opinion based on knowledge of national direction and areas which we know we need to improve. We have also incorporated intelligence from feedback following external reviews, learning from adverse events, complaints, and service user and staff feedback. Identifying the priorities- the how and the measures has been through many drafts and consultations and we believe we now have a robust quality improvement plan to support delivery of the strategic objectives 2017-22. This has been through a consultation process with stakeholders and this final draft is the output of that consultative process. We will measure our success in delivering this plan by regular progress reports against key performance indicators to the Quality Committee through reports from Patient Safety Committee, Clinical Effectiveness and Audit Committee and the Patient and Carer Experience Committee. This will mean that we will track the effectiveness of each intervention in terms of its contribution to the required standard of improvement and where necessary we will introduce further actions if the required improvements are not met. The Case for Change The Trust Strategy describes in detail the compelling rationale for change and the changing environment we need to respond to. This plan details the specific quality priorities which will lead us to achievement of the strategic measures. We know that not all of our patients receive the best possible care in a timely fashion whilst under our care. In the latest publication of the SHMI data (July 2015-June 2016), we were 2

within the top 39% of the country; with a mortality rate as expected against the national baseline. However, to sit within our target of the top 10% we need to achieve a mortality rate lower than expected, compared to the national baseline 1. We also know that some of our patients do not receive the right care in the right place and are admitted to our hospital beds because of a lack of service provision in the community that can deliver fast, proactive treatment in patient s own homes. The impact of an admission that could have been prevented for an elderly patient can result in deterioration in their functioning from which they never fully recover. Therefore, despite being driven to do no harm as health care providers, inappropriate time spent in hospital can result in the deconditioning of the health of the patient. Someone who was able to function well before they came to hospital takes longer to regain their preadmission functionality. Prolonged hospital stay, bed rest and associated risks may lead to loss of muscle power, strength and abilities leading to an increased risk of reduced bone mass and muscle strength, reduced mobility, increased dependence, confusion and demotivation. We want to work with the Alliance to make sure the people of Suffolk get the right care when they need it, not when the service can provide it. The feedback we get from our patients, their families and carers is overwhelmingly positive and in fact we have received higher than the national average scores for patient recommendation for the past two years. However, our ambition is to do better and exceed the score we achieved in the last inpatient survey (2015) which saw us in the top 45% with a score of 8.1 out of 10 2. We know from our patients that they sometimes experience a frustrating service where there is a lack of information, poor communication delays, and difficulty understanding our services and what their care will be. We also know from patient feedback that there are variations in their experiences depending on how and when they come into our services and there is a lack of clarity for them in who is in charge of their care. They often report that we are not listening to them and not asking them what matters most to them. We want to improve this experience and give patients more information about their care, more information about our services and improve the ways in which we communicate and add value to the patient journey. Our Quality Improvement Plan Four key priorities In his 2013 paper A promise to learn a commitment to act: improving the safety of patients in England, Don Berwick outlines three key areas for improving quality: 1. Safety: avoiding harm from the care that is intended to help; 2. Effectiveness: aligning care with science and ensuring efficiency; and 3. Patient experience: including patient centredness, timeliness and equity. Within the organisation we have identified a number of key drivers for improving quality: Strengthening clinical leadership and embedding a safety culture which learns from adverse events; Development of a quality management system that supports real time identification of clinical risk; Ensuring that we provide consistent and reliable standards of safe practice; Robust and accessible clinical information; Building capability in our workforce to continually improve quality; 1 Source: SHMI, NHS Digital 2 Source: CQC Adult Inpatient Survey (2015) 3

Improving the information available to patients both about our services and their individual care plans; and Systems and partnership working. Whilst the scope of this plan covers developing and implementing the tools our workforce will need to improve quality in the form of a quality improvement methodology - there is a clear plan to achieve a consistent and substantive workforce set out within the People, Organisation & Development (POD) Strategy. Therefore, it is not repeated in this plan and the POD strategy should be read alongside this document. We have taken the remaining drivers and aligned them to key objectives from our Trust strategy and Don Berwick s recommendations to establish three quality priorities, which this plan addresses. These are: 1. To improve safety To be in the top 10% of hospitals in the UK for safety and to achieve an outstanding Care Quality Commission report; 2. To improve patient and carer experience: To be in the top 20% nationally for patient experience of care, and recommended by 97% of patients; 30% reduction in the proportion of complaints regarding attitude and communication; and 3. Clinical effectiveness To evidence the delivery of care in accordance with best practice and nationally recognised outcomes. To support the delivery of these three priorities we have set a fourth: 4. To embed the effective use of a quality improvement methodology that builds capacity and capability. Four key priorities explained Priority 1: Improve safety Improving safety is about reducing risk and minimising errors. The NHS has embarked on a journey to become one of the safest healthcare systems in the world and we are aiming to be in the top 10% of hospitals in the UK for safety and to achieve an outstanding Care Quality Commission report by 2022. Key to this is achieving the standards set out in NHS England s 7-Day Services framework. This means we will ensure patients receive a consultant review of their care soon after admission, and then at least once a day, with access to the right tests and treatments (simple and complex) irrespective of the day of the week. We will ensure continuity of care with good handover of patient information between shifts at all times. This is particularly important at handover times between weekday normal working hours, and out-of-hours night/weekend shifts. We will introduce a Hospital at Night working system to improve patient care by ensuring the correct interventions by the correct staff. Hospital at Night will also engender improved team-working and handovers, with task lists that are more robust and easier to complete in a timely manner. We know the being admitted to hospital is often stressful and generally fitness deteriorates very quickly whilst sitting in a hospital bed. We will keep the patient journey through hospital moving as quickly as the patient s care allows, continuing to learn the lessons from our Red to Green approach which focuses on reducing the number of days each patient is in hospital where no active progress in their treatment occurs ( Red days). 4

We will continue to work with our system partners to transform our discharge arrangements so that when patients are medically ready to be discharged from hospital any extra care they need to assist them in the community is put in place rapidly. Priority 1: Improve safety Our aim is: No avoidable deaths We will deliver this by: Reducing the number of ward moves Improve internal processes to reduce the risk of harm for patients Improve our adverse events reporting rate so that we are in the top 25% of reporters on the NRLS database Embedding lessons learnt from mortality reviews & audits, adverse events and complaints Developing care bundles for high risks conditions Improving handover arrangements 24/7, 7/7 Priority 2: Improve patient and carer experience We know from patient feedback that there can be variations in patient experience depending on how and when they come into our services. We want to improve this experience and improve communication between patients, carers and staff at all points along the whole journey. We want to demonstrate that we are a learning organisation, with a culture that uses all sources of insight, including from complaints, to improve services and quality of care. Treating patients in the right place, at the right time is essential to good patient and carer experience. Care is too often provided in an acute setting and we need to continue to use our community services more effectively, and working with primary, social care and the voluntary sector to meet our patients clinical, emotional and physical needs with a different type of care, where the hospital is seen as the last resort. For example, the Better Birth agenda sets a national vision to improve the care given to mothers by delivering a number of work streams including the creation of community hubs to improve the continuity of midwifery care to the mother and partner. We are committed to working with our partners to deliver this vision. Priority 2: Improve patient and carer experience Our aim is: To improve information provided to patients and carers To ensure that each patient experiences fair, inclusive, respectful treatment We will deliver this by: Implementing ticket home Developing accessible, comprehensive patient information across a range of mediums e.g. paper, computer, phone Patients will receive the right care in the right Embedding national standards for mental health, learning disabilities and children & young people 5

place Re-designing end-to-end system pathways Improving end of life care Priority 3: Improve clinical effectiveness The opportunities for improving clinical effectiveness are in reducing variation and introducing reliable care processes, understood by everyone. We need to work to evidence the delivery of care in accordance with best practice and nationally recognised outcomes. Eradicating unwarranted clinical variation is a driver for quality and cost improvement. Recommendations from the Carter review have identified areas for us to improve. Enabling our teams to provide reliable and consistently high standards of care, which are evidence based and measurable, is a key component of our plan. Our workforce needs to work differently and not simply work harder and longer. We have a committed workforce keen to improve but they may be working within systems and processes that do not enable them to deliver great care. We want our patients to be cared for consistently, equitably and with high quality treatments that are in line with national best practice. We know that receiving care in an acute hospital is clinically indicated for most of our patients but we also know that by improving our prevention work, particularly with the frail elderly, people with chronic health conditions, people with mental health conditions and children can support earlier detection and treatment of ill health enabling treatment to be received in their own home. We also believe there are benefits to patient care that will be explored through working differently with other organisations and are seeking ways to improve care through the partnership with CHUFT and the Community Alliance in Ipswich & East Suffolk. Priority 3: Improve clinical effectiveness Our aim is: People with the same condition will receive equitable treatment and care 24/7, seven days a week We will deliver this by: Working with CHUFT to identify joint clinical models for 24/7 and 7/7 working Use clinical audit as a tool to demonstrate change has occurred Implementing recommendations from the national Get It Right First Time programme Improve the long term health of our population and increase the use of self-care tools Working with public health and system partners to deliver the Suffolk prevention strategy Increasing the number of conversations our staff are having with patients about their health and well-being Priority 4: Embed the effective use of a quality improvement methodology Our staff tell us that they know what needs to be improved but do not always know how to do it. With support from partners such as the Academic Health Science Network we will provide 6

training that will result in them being skilled in a quality improvement methodology that enables them to implement change and measure success quickly and robustly. Our organisation has an involved and strong service user voice through our Ipswich Hospital User Group (IHUG). We want to take this to the next level by developing and implementing a co-design framework which is used within our quality improvement work, through our business planning and service development programme. We believe if we co-design services, the services will be right for the service users from the outset and will incorporate what matters to them. Priority 4: Embed a quality improvement methodology Our aim is: Robust approach to quality improvement is embedded throughout the organisation To develop a co-design framework that integrates with the quality improvement methodology to ensure service user voice is always incorporated We will deliver this by: Working with HEIs and Eastern Academic Health Science network to agree a quality improvement methodology Working with Ipswich Hospital User Group (IHUG) to develop a framework of how to involve service users and embed across business as usual 7

Delivery plan Priority 1: Improve safety Aim KPI Action SRO Timeframe No avoidable deaths Reduction in number of Revise models of care to reduce the number of ward moves across 2017/18 - ward moves per patient / specialties 2019/20 Improve internal processes to reduce Reduction in number of ward moves out of hours (to be defined) Top 10% for SHMI score An improvement the HSMR for these conditions Reduction in adverse events that cause Establish a way of recording all ward moves in real time, identifiable by patient Prioritise mortality reviews and audits, adopting the NHSI mortality review process CIO 2018/2019 2020/21 2017/18 Improve accuracy of coding of diagnosis on admission to hospital Improve End of Life Care by improving identification, at time of admission, of patients requiring end of life care Implement robust and systematic multidisciplinary learning from deaths audit days, morbidity and mortality (M&M) meetings Development of care bundles to reduce variation and strengthen our clinical effectiveness in high risk areas:- Pneumonia Sepsis Acute Kidney Injury #NOF COPD Improve the reliability of medical and nurse handover of clinical information / / 2019/20 2017/18-2019/20 2017/18-2017/18-8

Aim KPI Action SRO Timeframe the risk of harm for patients moderate harm, or above Improve access to and acknowledgement of diagnostic tests to decrease risk of harm that could have been prevented Implement a technology enabled approach to enable accurate care planning Implement the national Carter Hospital Pharmacy Transformation Project including improved medicines reconciliation, increase in Pharmacist resources utilised for direct Medicines Optimisation activities, medicines governance and safety remits CIO / Chief Pharmacist 2017/18-2020/2021-2021/2022 2019/20 Reduction in the number of areas reporting as high risk Adherence to 7 day service standards 2, 5, 6 & 8 TBC Improve management of staff and ward safety, through implementation of Trust Staffing Tool to monitor patient acuity and dependency Implement Hospital at Night programme for timely consultant review (standard 2), improved access to diagnostics (standard 5), consultant directed interventions (standard 6), and ongoing review in High Dependency Areas (standard 8) Develop a quality management system that supports real time identification of clinical risk Directory of 2018 2017/18 Governance / 2019/20 CIO Improve our adverse events reporting rate Top 25% of reporters per Implement red learning folders across clinical areas to raise awareness of adverse events and complaints Q1-2 2017/18 and learning from adverse events and complaints 100,000 bed days when benchmarked against our peers on the NRLS Implement daily safety huddles across all clinical areas to drive shared understanding of recommendations from adverse events and complaints Q1-2 2017/18 database Undertake team level safety culture surveys (SCORE) across the organisation to enable teams to identify attitudes to risk and safety Governance Q1-2 9

Aim KPI Action SRO Timeframe and to take local accountability to improve together Launch the new Datix reporting system and build customised reports to support team access meaningful information providing trends over time. Governance Q1-2 2017/18 Positive trend analysis for types of adverse events over time Utilise the output of the safety culture surveys to develop team level improvement plans covering identified local level quality issues; quality procedural improvements e.g. adverse event reporting and increasing quality improvement expertise. Governance Q3-4 2018/2019 Priority 2: Improve patient and carer experience Aim KPI Action SRO Timeframe To improve information provided to patients and carers Quarterly patient survey Reduction in total emergency bed days TBC - either app downloads as % of elective patients; or % of elective patients that have downloaded app (via NHS number) 30% reduction in the proportion of complaints regarding attitude and communication Implement Ticket Home to ensure all inpatients or carers will understand the answers to four key questions: What is wrong with me? What will happen next? What do I need to achieve to get home? If there is no unnecessary waiting, when can I expect to go home? Develop patient held information for all elective patient pathways that details what the patient can expect at each stage of their treatment Implement a customer culture for patients wanting to access information about their own care or our services e.g. helpdesk, internet / Medical Director / 2017/18 2021/22 10

Aim KPI Action SRO Timeframe Communication To ensure that each 100% coverage of patient experiences fair, inclusive, standards applied across all interactions with children Embed children s standards across the Trust, i.e. chaperoning, child and young person voice in service development 2017/18 respectful treatment (through audit) TBC Embed mental health standards across the Trust 100% coverage of standards applied across all interactions with patients with learning disabilities Embed learning disability standards across the Trust (through audit) Did we make best efforts to achieve what mattered to the patient as evidenced through documentation Incorporate What matters to each patient into their individualised care plans audit Number of patients with an integrated care plan Embed Alliance principles to support teams to work together to treat patients as one person, with one care plan CIO 2022 Patients will receive the right care in the 5 volunteers per ward per day No more than 3% growth in emergency attendances, Increase the number of volunteers available to support mealtimes and activities for patients Work with the alliance to reduce the need for acute services through redesigning end-to-end patient pathways from primary to HR Director / 2022 / 11

Aim KPI Action SRO Timeframe right place and emergency admissions constrained to 16/17 levels acute care and adapt the workforce accordingly Operations TBC Work with the CCG to implement the Better Births agenda Work with the alliance and education providers to reduce the Reduction in <18 years number of children and young people seeking urgent and emergency attendances emergency care through better proactive support and treatment Reduction in total Roll out the up for breakfast initiative across the Trust to reduce emergency bed days the effects of deconditioning 2017/18 Develop stronger working relationships and joint working with the Reduction in emergency care home network to ensure their clients receive the appropriate attendances from care treatment and care in their home to prevent admissions to hospital homes where appropriate 2017/18 Review all patient pathways as part of the alliance to identify Reduction in DTOC days opportunities for early supported discharge, admission prevention 2017/18 Operations or delivery of service in community setting / day case unit Work with system partners and alliance to improve the services that 25% reduction in in-hospital can support patient s choice of place to die and ensure individual deaths 2019/20 end of life pathways are used across the Suffolk system. Increase in proportion of day case and outpatient Ensure the default position to delivering care as a day case procedures, as compared Operations to non-day case elective 12

Aim KPI Action SRO Timeframe inpatients Decrease the number of day cases who go through inpatient beds Refurbish one ward per year to become dementia friendly Others completed by target date Continue to work with estates to ensure the care environment is fit for purpose: - Dementia friendly - UIS relocation - Breast clinic - Neurophysiology - Child health Estates & Facilities 2019/20 Priority 3: Improve clinical effectiveness Aim KPI Action SRO Timeframe People with the same condition will receive equitable treatment and care 24/7, seven days a week Outcomes from the National 7 day services audit TBC Work within the Partnership with CHUFT to identify clinical models that can improve care and opportunities to improve 24/7 and 7/7 working Re-organise the workforce across seven days a week, 24 hours a day Implement improvements from the national Get It Right First Time programme, by engaging with the expanding number of GIRFT / / Operations / 2019/20 2017/18 13

Aim KPI Action SRO Timeframe Use clinical audit as a tool to demonstrate change has occurred Improve the long term health of our population and increase the use of self-care tools CQC outstanding % full compliance with NICE clinical guidelines (applicable to our service portfolio) Constrain emergency admissions to 2016/17 levels Constrain growth in ED admissions to 3% from previous year TBC Increase in rate of the detection and treatment of hypertension, atrial fibrillation, COPD and diabetes reviews and implementing recommendations in a timely manner Ensure all CQC fundamental standards are embedded to achieve an overall level of outstanding To apply quality improvement methodologies to all areas where best standard practice is not achieved; using clinical audit methodologies to provide a baseline and outcome measures of improvement Work with public health to embed Making Every Contact Count (MECC) and Health coaching across the workforce to support staff to have a different conversation with our patients Work with public health to explore pre-habilitation which utilises pre-op assessment as an opportunity to promote health and improve outcomes Continue to work with system partners to develop a joint approach to keep people healthy for longer, in line with local and national health and wellbeing strategies, for years 3 to 5 Operations Governance Governance HR 2017/18 / Operations / 2019/2020 2021/2022 14

Aim KPI Action SRO Timeframe Reduced need for acute admission Provide patients and their carers with the tools (e.g. apps), TBC education, support and encouragement to self-manage their / 2021/22 condition / CIO Priority 4: Embed the effective use of a quality improvement methodology Aim KPI Action SRO Timeframe Robust approach to quality improvement is embedded throughout the organisation To develop a codesign framework that integrates with the quality improvement methodology to ensure service user voice is always incorporated Methodology in place 75% of staff trained Staff feedback using survey monkey TBC Work with HEIs and Eastern Academic Health Science network to agree a quality improvement methodology that can be used across the system Work with HEIs and Eastern Academic Health Science network to develop a quality improvement training plan and infrastructure to support staff using quality improvement methodologies Develop a framework of how to involve service users and embed across business as usual 2017/18 15