Contents FOREWORD Introduction from the Chief Executive 2 BACKGROUND 3 OUR TRUST VALUES 4 OUR AIMS FOR QUALITY 5 - Our achievements so far - Our aims for quality 2017 2020 AIM 1: AIM 2: AIM 3: AIM 4: Reducing Mortality Preventing Harm Enhancing Patient and Carer Experience Creating a Continuous Learning Culture HOW WE MEASURE QUALITY 16 DELIVERING THE QUALITY IMPROVEMENT STRATEGY Methodology and Enablers 17 - Our Quality Improvement Methodology - Quality Improvement capability building - Enabling resources STRATEGY GOVERNANCE AND DELIVERY 20 COLLABORATION WITH PARTNERS 20
Foreword Introduction from the Chief Executive I m delighted to be introducing our second Quality Strategy for Bolton NHSFT having made excellent progress together over the past three years. I think it s important that we take this opportunity to stop and reflect on our journey as well as to refresh our objectives for the next three years. Over this time we have seen a tremendous commitment from our staff who, no matter where they work in the organisation, have come to work every day to contribute to, or deliver, high quality care in order to secure the best outcomes and experience for our patients. The outcome of Good following this year s Care Quality Commission inspection was a ringing endorsement of that commitment and an absolute credit to all our staff. We now need to turn our attention to the future and an ambition of achieving Outstanding which I personally believe is absolutely possible. This strategy aims to set out clear objectives and further enablers to help us get there; it once again sets the direction of travel for quality improvement for the next three years. So I look forward to seeing the continued improvement of all the quality and safety metrics and to knowing that the care we provide here is the best it can possibly be. I truly believe that we can become one of the best, if not the best, provider of high quality healthcare in the country and this strategy once again, gives us the road map to get there. Best wishes Dr Jackie Bene Chief Executive 2
How we developed this strategy At Bolton we believe our staff have two jobs, to deliver quality care and to continuously improve how that care is delivered to and in partnership with our patients and carers. Our staff are the experts in their field of work and in conjunction with patients and relatives are best placed to develop and lead ideas for improvement. This Quality Improvement Strategy builds on the foundations and achievements from the previous strategy; and was developed in collaboration with members of staff, whilst highlighting further areas of quality improvement. Staff from all areas of the organisation were invited to provide their thoughts on key areas the organisation should focus it s quality improvement efforts; this was then collated and merged with the ideas developed from senior leaders in the Trust. Furthermore, trends and feedback from the rich sources of information such as patient, families and carers, patient and staff surveys and governance intelligence sources such as complaints and incident reports gave us the direction for this re-envisioned Quality Improvement Strategy: Better Care Together 2017-2020. 3
Our trust values Our Trust values, associated practices (behaviours) and effective leadership will support the delivery of our new Quality Improvement Strategy and the provision of high-quality care to our patients and their families. Our Trust Values were refreshed in 2016 following a consultation process with our staff. We sought their views on what values represented Bolton NHS Foundation Trust now and the type of organisation they wanted it to be in the future; from which the following values were chosen, forming the acronym VOICE : VISION OPENNESS INTEGRITY COMPASSION EXCELLENCE In terms of our new Quality Improvement Strategy, the key values are VISION and EXCELLENCE. This strategy represents our VISION for the organisation, outlining our key aspirations, intended actions and measureable outcomes in terms of quality. EXCELLENCE is about putting quality and safety at the heart of all our services and processes, ensuring we strive for continuous improvement in the standards of healthcare we provide here at Bolton. But we also want our staff to live the other three values in their everyday work. COMPASSION underpins our approach to patient care; we take a person-centred approach in all our interactions with patients, families and our staff. We actively encourage a culture of OPENNESS where our staff can communicate clearly with honesty, encouraging feedback both positive and negative to help drive further improvements. Furthermore, we expect our staff to act with INTEGRITY, demonstrating fairness, respect and empathy in their interactions with others - taking responsibility for their actions, speaking out and learning from any mistakes. VISION COMPASSION My role is about how we can continue to deliver safe and quality services for patients and their families. My patients are at the heart of everything I do. 4
Our aims for quality We are striving to be an organisation that delivers safe, effective and compassionate care to every patient; every time they access our services; and are committed to putting the needs of our patients, their families and carers first. In order to do this we will build on the foundations and achievements from the previous Quality Improvement Strategy and work in collaboration with our patients, our staff and other partners to ensure we deliver Better Care Together. Achieving the ambitious goals outlined in this strategy will give Bolton NHS Foundation Trust a national reputation for high quality patient care delivered by staff with high levels of staff engagement, ensuring our patients and public receive the highest quality of healthcare they deserve. These four key aims are: Aim 1: Aim 2: Aim 3: Aim 4: Reducing Mortality Preventing Harm Enhancing Patient and Carer Experience Creating a Continuous Learning Culture The strategy outlines four key quality improvement aims and under each aim will be a portfolio of work streams that will lead to demonstrable improvements in outcomes, safety and patient experience. Each work stream will involve patients and staff from across the organisation, working systematically, sharing best practice and using proven quality improvement methodology to ensure consistent delivery of improved quality and performance. Reducing Mortality Creating a Continous Learning Culture Better Care Together Quality Improvement Strategy Preventing Harm Enhancing Patient and Carer Experience 5
Our achievements so far The previous Quality Improvement Strategy helped the Trust achieve a CQC rating of Good in August 2016 and realised a number of key quality improvement achievements including: Reducing mortality: Since the launch of the last strategy our mortality rates have fallen year on year, demonstrated by the following: A reduction in annual deaths from 1348 (2012/13) to 1161 (2015/16) representing a 14% improvement. The reduction in crude mortality from 2.4% to 1.9% represents a 21% improvement. Our chosen risk adjusted mortality indicator, Standardised Hospital Mortality Index (SHMI) has reduced from 107 to 100 (latest data April 2015 March 2016). The lowest on record representing a 7% improvement. Reducing harm: Focussed work to strengthen the infection control culture in the organisation, including infection control champions in all clinical departments has enabled us to deliver a reduction in Clostridium difficile cases from 38 (2013/14) to 21 (2015/16). We have also had demonstrable improvements in reducing other types of harm including: 40% reduction in preventable falls with harm * 47% reduction in falls where patients experience severe harm* *Comparing data from April 2014-March 2015 with April 2015-March 2016 3.0% Crude in-hospital mortality rate 2.8% Percentage of discharge 2.6% 2.4% 2.2% 2.0% 1.8% 1.6% Source: HED 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Bolton NHS Foundation Trust North West England 6
Improving patient experience In order to ensure we are providing a good quality patient experience we must actively seek and learn from what our patients and their families are telling us about the services we provide. We have made good progress in not only widening the opportunities for feedback, but displaying improvements made as a result of this feedback. This has helped us achieve the following: We are particularly proud of the fact that in the latest National Inpatient Survey (2015) our patients rated us amongst the best in the country (31st out of 148 trusts) and placed us 15th for the care and treatment we provide. Monthly Friends and Family Test (FFT) dashboard have been developed for each ward, alongside You said we did boards on each ward to demonstrate to patients and their carers response to feedback and action taken as a result. 96.3% (average Jan 15 Mar 16) of responding patients rate extremely likely or likely when asked How likely are you to recommend our service to friends and family if they needed similar care or treatment? (FFT) Responding and learning Since 2014 there has been a demonstrable rise in the number of incidents reported, which puts Bolton in the top 25% of Trusts for the first time. We welcome this rise as evidence suggests an increase in incident reporting is an indication of an increased level of awareness of safety issues amongst healthcare professionals. In addition, we distribute monthly learning slides to every member of staff in the Trust to facilitate trust-wide learning from incidents, complaints, inquests and other issues. Whilst we acknowledge these achievements, we recognise further work is required and this strategy aims to refocus and reinvigorate our quality improvement efforts. 7
Our aims for quality 2017-2020 Aim 1 Reducing mortality We have made good progress in relation to reducing the overall number of patients who die whilst in our care. However, we accept further work is required to achieve our goal of no needless deaths. How we measure mortality: We use a variety of methods and sources to measure patient mortality, which is monitored monthly and used to investigate how further improvement can be made; these include the following: Standardised Hospital Mortality Index (SHMI) Number of patient deaths in our organisation (crude mortality) Key ambitions for improvement: By the end of 2020 we aim to: Reduce our Standardised Hospital Mortality Index to less than 90. Continue our year on year reduction in crude mortality. Reduce avoidable cardiac arrests that result in death by 50%. The Risk-Adjusted Mortality Index (RAMI) Cardiac arrests Serious untoward incidents that result in patient death 8
What we will do: Work to reduce mortality is already in progress across the organisation. However, for the duration of this strategy we will focus on the following areas: Mortality review process: We aim to ensure we carry out a mortality review on all patients who die whilst under our care; this is to highlight areas for improvement and enable the sharing of good practice. Cardiac arrest root cause analysis clinics: These clinics involve a multi-disciplinary team of staff that review all patients who had a cardiac arrest whilst under our care. The aim of this is to assess if the level of care the patient received was both appropriate and timely, whilst investigating if there are any opportunities to improve and put actions in place to do so. Recognising and responding to the deteriorating patient Evidence shows that timely recognition and response to patients whose condition deteriorates improves the likelihood of survival and reduces further complications. This work stream is multi-factorial and will focus on the following areas: Sepsis Handover Processes and systems to alert staff to deteriorating patients End of life care We will reliably ensure high quality end of life care across Bolton by educating and empowering our workforce in the principles of advance care planning, needs assessment and bereavement care. We aim to ensure all patients who are at the last stages of their life are fully involved in the design of their care and treatment with their preferences accounted for including preferred place of death. We will also work with relatives and carers before and after death. 9
Our aims for quality 2017-2020 Aim 2 Preventing harm Harm can be defined as unintended physical or emotional injury resulting from, or contributed to by clinical care (including the absence of indicated treatment) that requires additional monitoring or treatment. The previous strategy focussed on harm caused by healthcare associated infection. However, we wish to widen this area of work to include all potential sources of harm such as medication errors, pressure ulcers and falls; whilst strengthening our reporting and learning system to enable our staff to recognise and prevent potential harms occurring. How we measure harm: We use a variety of methods to measure and track the level of patient harm in our organisation, again using this information to inform continuous improvement; examples include the following: Healthcare associated infections Pressure ulcers Falls Medication errors Trust key performance indicators (KPIs) Harm free care panel reviews Never Events Serious untoward incidents that results in patient harm Key ambitions for improvement: By the end of 2020 we aim to: Achieve a 10% reduction in lapses in care that result in the following harms: - Pressure ulcers - Inpatients falls - Omission of critical medicines (excluding clinical reasons and patient choice) Be the top performing trust in Greater Manchester for Clostridium difficile rates (measured by rate per 100,000 overnight occupied bed days) 10
What we will do: Infection prevention control: We will continue to focus on key outcomes relating to healthcare associated infections including Clostridium difficile, MRSA and MSSA bloodstream infections, CPE cases and blood culture contaminants, improving our understanding of infections using critical analysis and root cause analysis. Pressure ulcers We will continue to focus on: - Education and training - Equipment - Innovation and evidence Based Practice - Documentation - Harm free care panel process and timely completion of RCAs - Analysis of data and collation of thematic analysis We will support the Pressure Ulcer Collaborative Group in partnership with Bolton Clinical Commissioning Group, enabling a whole system approach to reducing pressure ulcers within the Bolton Health and Social Care Economy. We will bring together healthcare professionals and other stakeholders across Bolton to share learning, information and good practice, in order to work towards a zero tolerance of pressure ulcers. Falls Falls prevention continues to be a high priority for our organisation. The Falls Steering Group will continue to work on areas to reduce falls; which include: Analysis of data to see trends and address areas of concern. Falls harm free panel to understand reasons why falls occurred and what can be done to prevent future falls. Falls prevention training, use of equipment and technology. Medication reviews involving the assessment for medication likely to increase the risk of falls and adjustments made where appropriate. Medication errors The Medicines Safety Group will continue to focus on reducing the number of critical medicines missed through: A review of the audit process within divisions to collect data on omitted doses. Thematic analysis of omitted doses of critical medicines with clear actions. Trust wide education on the importance of critical medicines and the potential harm from omission. 11
Our aims for quality 2017-2020 Aim 3 Enhancing patient and carer experience Providing a good quality patient experience requires actively seeking, responding to and learning from patient feedback. The Trust has a dedicated Patient and Carer Experience Strategy and this Strategy will support the delivery of certain objectives within the Patient and Carer Experience Strategy. How we measure patient and carer experience: Some examples of how we measure patient and carer experience include: National patients survey Friends and family test (FFT) Ward/departmental specific patient surveys Patient and carer stories Complaints Trust key performance indicators (KPIs) Bolton System of Care Accreditation (BoSCA) Key ambitions for improvement: By the end of 2020 we aim to: Be in the top 10% of NHS trusts in the National Patient Survey. Increase the number of patients completing the Friends and Family Test in all areas by 50%. Increase the number of wards that are accredited Bronze, Silver and Gold BoSCA status by 10% each year. 12
What we will do: The Patient Experience Feedback Group will focus on a range of interventions that will not only increase patient and carer involvement, but aim to enhance the experience of our patients and their families whilst under our care. These include: Capturing and responding to patient and carer feedback We will implement a sustainable patient feedback mechanism to capture and increase the level of real time feedback and demonstrate change as a result of this feedback. Always Events: Patient and carer representation We aim to ensure by the end of 2020 there will be patient or carer representation on every committee; thus ensuring the active participation of patients and carers in the future direction of the organisation. Furthermore, we will continue to use patient stories in our committee meetings. Always Events are aspects of care or experience that our patients and their carers should always expect to receive. We will work with our patients and carers to develop and launch our Always Events and work with our wards, departments and community teams to ensure they are reliably embedded at a local level. Learning from complaints: Unfortunately we recognise there are occasions when we do not provide the service our patients and their carers expect. It is important that we review both favourable and less favourable feedback in order to highlight themes and address areas for improvement. Our aim is to rebalance the focus from complaints managements to pro-active patient experience improvement, by identifying opportunities to enhance patient experience so that complaints can be avoided. We will do this by supporting our staff to ensure they are confident to address challenges when they occur, rather than letting the matter escalate. 13
Our aims for quality 2017-2020 Aim 4 - Creating a continuous learning culture Our previous strategy focussed on responding to and learning from harm and errors, and we have made great progress in this area. However, we also recognise we should be capturing and learning from the opposite of incidents (i.e. when things go right). We recognise that our staff have a wealth of knowledge and expertise in their profession and want to empower them to identify and lead improvements in their own area of work; providing them with the knowledge, skills and support to do so. How we measure continous learning: Some examples of how we measure learning for improvement purposes include the following: Complaints Incidents and investigations Staff experience metrics Audits Trust compliance with NICE guidance Key ambitions for improvement: By the end of 2020 we aim to: Have 100% of priority R1 recommendations from Serious Incidents to be implemented within agreed timescales (R1 recommendations relate to the root cause of the incident and must be urgently addressed) Be in the top 10% of NHS Trusts for staff feeling able to contribute towards improvement at work (NHS Staff Survey KF17 score) 14
What we will do: We will continue to encourage incident reporting and ensure we learn from complaints, incidents and investigations. We will also widen our reporting system so we can learn from occasions where our patients have received exemplary care or members of staff have put ideas for improvement into practice that could benefit the wider trust. We aim to do this via the following: Idea for Improvement and sharing good practice We will establish mechanisms to allow members of staff who have ideas for improvement to put these ideas forward. This would be strengthened by the development of an Innovation Forum; where individuals and teams can bring their idea for improvement to an arena for advice and assistance on how it can be taken forward, whilst also hearing case studies of improvement in action. Quality improvement skills transfer In order to enable staff to make change happen they will be supported by improvement experts who will provide training in improvement methodology and mentoring support to allow them to put their idea for improvement into action. 15
How we measure quality Measurement for quality improvement: The ability for our organisation to deliver on all aspects of this strategy also depends on our ability to measure progress. It is important to measure performance for improvement purposes as it enables us to fully understand the processes we are looking to improve, but also allows us to provide evidence that ideas for improvement work in practice and as a result increases the appetite for improvement amongst our staff. For all our quality improvement work streams and projects we will use Statistical Process Control (SPC) charts, a method wisely used in the science for improvement arena. A SPC chart is used to study how a process changes over time, from which conclusions about an improvement intervention can be made based on statistics. In addition to the specific metrics set against each aim, we will also use the following mechanisms to measure and track quality improvement in the organisation: Trust key performance indicators (KPIs) Delivering high quality and appropriate care to patients is of paramount importance; one method of measuring the quality of care we provide and highlighting areas for continuous improvement is the monthly Key Performance Indicators (KPIs). The process involves a number of audits to assess the quality of care provided and are undertaken with the ward manager and an external buddy to enhance objectivity, transparency and standardisation. The process is underpinned by a clear performance framework which includes an escalation process in the events of non-compliance. This information is used as supporting evidence for the Bolton System of Care Accreditation (BoSCA). Trust KPIs are now established in ward areas, with the roll-out to Community Teams, Theatres, A&E and non-clinical departments by 2017. Bolton System Of Care Accreditation (BoSCA) The Bolton System of Care Accreditation (BoSCA) is a multidisciplinary structured assurance framework designed to support nurses and clinicians to monitor the quality of patient care they deliver, identify what works well and where further improvements are needed. BoSCA is the vehicle we will use to help us continuously raise the standards in patient care. The BoSCA framework is based on the Trust s Better Care Together approach to service delivery and incorporates Essence of Care standards and key clinical indicators, whilst also providing evidence for the Care Quality Commission s Core standards. The process also takes into account retrospective KPI data and other key audits and includes a thorough inspection of the ward/departmental area. Following review the area is given a grading of White, Bronze, Silver, Gold or Platinum. The BoSCA framework was launched in 2016 and is now in operation across all inpatient wards and Community/District Nursing Teams with future plans to roll-out to Theatre and non-clinical departments. 16
Delivering the strategy Our quality improvement methodology We are committed to ensuring all our staff are empowered to make improvements for the benefits of our patients and their families. At Bolton, we will use the Model for Improvement as our framework for quality improvement; but will also use other appropriate quality improvement methodology as required on a project by project basis. Model For Improvement: The Model for Improvement is a framework for improvement widely used in NHS organisations. The framework has three fundamental questions: 1. What are we trying to accomplish - Setting an aim for improvement 2. How will we know that change is an improvement - Measurement for improvement 3. What change can we make that will result in improvements - Ideas for improvement Ideas for improvement are then tested and refined prior to implementation through the use of PDSA cycles: Plan: Do: Planning the test, predictingwhat will happen Running the test Study: Learning from the test Act: Based on learning adapt, adopt, abandon the test Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Study Plan Do 17
Quality improvement capability building We recognise improvement is more likely to succeed and be sustained if it is designed and led by the staff doing the job. In order to enable staff to make change happen they will be supported by improvement experts and quality improvement will be applied via the following mechanisms: Breakthrough Series Collaborative Model (BTS): The Breakthrough Series Collaborative is an improvement model which brings together front-line teams enabling them to learn from each other and experts relating to a specific area highlighted for improvement. The emphasis of the BTS cycle is collaborative learning, testing ideas for improvement and collecting data to validate the impact of improvement, prior to trust-wide roll-out of ideas. Improvement events: This is a focussed, short term period of time where members of staff test change in a real work setting and refine that change so that by the end of that focussed period the change is fit for purpose and implemented. Improvement mentoring Improvement mentoring is available for teams or individuals who have an idea for improvement they would like to implement. The idea is two-fold; to spread improvement capability via the mentoring whilst working on an idea for improvement selected by the team. Quality improvement capability building: Training sessions on the Model for Improvement and other key improvement tools will be available; supported with on-line training material. Quality improvement also features as a key component in leadership programmes offered at the Trust. 18
Enabling resources Business intelligence: As mentioned previously, it is crucial we measure performance for improvement purposes, and with the support of our Business Intelligence Department we will use specialist measurement for improvement techniques and methodologies to develop a Quality Improvment Dashboard to allow us to track progress against our aims. Furthermore, over the next three years our BI Department will develop closer working relationships with our teams and departments to help transfer learning regarding measurement for improvement. Clinical Effectiveness: Trust Quality Lead (Patient Safety Lead) and Quality Improvement Programme Manager: Linking back to our Trust values, we expect all our staff to put quality and safety at the heart of all we do and to strive for continous improvement in the standards of healthcare we provide. However, we do recognise the need for key individuals to lead the quality improvement programme at the Trust. We have a senior clinical Quality Lead whose role is to engage clinical staff in patient safety and quality improvement. In addition, the Quality Improvement Programme Manager will oversee the delivery of the quality improvement work streams we have in place. Our Clinical Effectiveness Department is crucial to the delivery of this strategy, The Clinical Audit Plan will support and prioritise audits related to the four aims of this Strategy. The audit template for support will ask which aim the audit relates to - this will drive up interest and interconnectivity between the QI Strategy and clinical audit. 19
Quality improvement strategy governance and measurement Governance and delivery The Better Care Together Group will oversee the operational delivery of improvement areas in this strategy and will report to the Clinical Governance and Quality and Quality Assurance Committees. A number of key work streams have been highlighted that clearly link to each aim of the Quality Improvement Strategy, these will sit under the remit of the Better Care Together Group and will use a robust quality improvement project framework comprising of a project initiation document, driver diagram, clear aims and measurement strategies to drive improvement forward. Working in collaboration with our partners This strategy has clear links to the People, Patient and Carer Experience and Risk Management strategies and should be read in conjunction with these strategies. We also recognise that in order to achieve our aims outlined in this Quality Improvement Strategy, collaborative working with our partners is essential. Some of our partners include: NHS Bolton Clinical Commissioning Group Local Authority Greater Manchester Academic Health Science Network Bolton Clinical Commissioning Group 20
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Ref: 78415 Bolton NHS Foundation Trust 2016. All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. Booklet Design and Photography by Medical Illustration, Royal Bolton Hospital