Improvement Action Plan Declaration It is the responsibility of the NHS board Chief Executive and NHS board Chair to ensure the improvement action plan is accurate and complete and that the actions are measurable, timely and will deliver sustained improvement. Actions should be implemented across the NHS board, and not just at the hospital inspected. By signing this document, the NHS board Chief Executive and NHS board Chair are agreeing to the points above. A representative from Patient/Public Involvement within the NHS should be involved in developing the improvement action plan. NHS board Chair NHS board Chief Executive Signature: PP Signature: Full Name: LESLEY BOWIE (VICE CHAIR) Full Name: JOHN BURNS Date: 9 November 2017 Date: 9 November 2017 Produced by: NHS Ayrshire and Arran Page 1 of 9 Review Date: 16 weeks following inspection
Ref. Action Planned Timescale to meet action 1. Action Required: NHS Ayrshire and Arran must ensure that all older people, who are being treated in the emergency department or are admitted to hospital, are accurately assessed within the national standard recommended timescales. This includes nutritional screening and assessment and pressure ulcer risk assessments. There must be evidence of reassessment where required. Responsibility for taking action Progress Date Completed Following the 2016 HIS OPIH inspection, we reviewed our inpatient profile. This work was viewed as a quick fix to enable the requirements from the inspection to be met. This was more detailed than expected and required a number of tests of change to ensure that it was correct. It was completed in August 2017, however to ensure resources were not wasted, old copies of the profile were used up before the new ones were made available. August 2017 Quick fix review complete. August 2017 Produced by: NHS Ayrshire and Arran Page 2 of 9 Review Date: 16 weeks following inspection
Clinical areas, depending on stock levels should start receiving these as of Nov 2017. The revised profile, supports better use of PPURA and areas for date, time and signing records has been made clearer. In addition we are also undertaking a radical review of the inpatient profile. This is currently being tested in 2 clinical areas who are now undertaking their 8th, test of change. An improvement project is currently under way in CAU, to review and test new documentation, this includes the testing of a frailty tool. OPiH study day for staff. This would include the key fundamentals of care and the use of documentation. 2. Action Required: NHS Ayrshire and Arran must ensure that clinical staff consistently comply with the national policy on do not attempt cardiopulmonary resuscitation (DNACPR). December 2017 October 2018 Roll out of revised paperwork continues. Use the data supplied by the OPAH team as our baseline for improvement. In conjunction with the resus team we are developing a presentation which explains the issues raised around DNACPR discussion and the recording of that discussion in the notes. This will be shared with all medical staff. We will audit our performance within 3 months of the issue of the educational package with regular updates. June 2018 Associate Medical Director s (UHA & UHC) Produced by: NHS Ayrshire and Arran Page 3 of 9 Review Date: 16 weeks following inspection
The potential to create local champions to prompt the DNACPR process at ward level will also be explored. 3. Action Required: NHS Ayrshire and Arran must ensure that older people in hospital are involved in decisions about their care and treatment. Capacity for decision-making must be assessed in line with Adults with Incapacity (Scotland) Act 2000. When legislation is used, it must be fully and appropriately implemented. This includes consulting with any appointed power of attorney or guardian. It must be fully documented in the patient s health record, including any discussions with the patient or family. We have set up a meeting with the Adult Psychiatry team to create an education package for medical and nursing staff which we expect to launch from end of November 2017. We will audit this within 3 months of commencement. 4. Action Required: NHS Ayrshire and Arran must ensure that patients have person-centred care plans in place for all identified care needs. These should be regularly evaluated and updated March 2018 Associate Medical Director s (UHC) Produced by: NHS Ayrshire and Arran Page 4 of 9 Review Date: 16 weeks following inspection
to reflect changes in the patient s condition or needs. They should also reflect that patients are involved in care and treatment decisions. As part of the radical review of the inpatient profile we are testing removing pre printed care plans and moving to the introduction of a single care plan for each individual patient, rather than problem specific pre printed care plans. October 2018 5. Action Required: NHS Ayrshire &Arran must ensure that fluid balance and food record charts are accurately completed for patients who require them and appropriate action is taken in relation to intake or output as required. OPIH study day for staff. This would include the key fundamentals of care and the use of documentation A scoping exercise is to commence on the various documentation used to record diet and food intake, this will hopefully result in reduced duplication and improve compliance. August 2017 FFN measure in place to measure and monitor August 2017 Produced by: NHS Ayrshire and Arran Page 5 of 9 Review Date: 16 weeks following inspection
The completion of fluid balance charts and food charts is measured through the current food, fluid and nutrition measure carried out in all hospital in patient areas. The completion of fluid balance charts and food charts is monitored through our CNM / senior nurse care assurance walk rounds / visit in all hospital in patient areas. completion of fluid balance charts and food charts. Assurance activity ensures, where necessary, improvement interventions are implemented. We are currently awaiting the new national Excellence in Care food, fluid and nutrition measure. 6. Action Required: NHS Ayrshire & Arran must ensure that oral nutritional supplements are accurately recorded for patients who require them and appropriate action taken in relation to intake as required. OPIH study day for staff. This would include the key fundamentals of care and the use of documentation. A scoping is to commence on the various documentation used to record diet and food intake, this will hopefully result in reduced duplication improve compliance. The completion of fluid balance charts and food charts is measured through the current food, fluid and nutrition measure carried out in all hospital in patient areas. The completion of fluid balance charts and food charts is monitored through our CNM / senior nurse care assurance walk rounds / visit in all hospital in patient areas. Produced by: NHS Ayrshire and Arran Page 6 of 9 Review Date: 16 weeks following inspection
We are currently awaiting the new national Excellence in Care food, fluid and nutrition measure. 7. Action Required: NHS Ayrshire &Arran must ensure that the SSKIN bundles within the active care rounding document are consistently and accurately completed. This is to ensure that the frequency of repositioning is indicated and the result of skin inspection and any changes made to the indicated repositioning times are documented. OPIH study day for staff. This would include the key fundamentals of care and the use of documentation. We are currently reviewing our documentation that supports care and comfort rounds. Testing of the revised tool commences in Nov 2017. The new tool incorporates both the falls for all bundle and SSKIN bundle, the 3 sections are separated, and there is space to record the date and time each section is completed / care carried out. 8. Action Required: NHS Ayrshire &Arran must ensure that wound assessment charts are in place for those patients with a known pressure ulcer or break in skin integrity to support safe and effective care delivery. This must include recording the grade of any pressure ulcers and a clear plan of March 2018 Produced by: NHS Ayrshire and Arran Page 7 of 9 Review Date: 16 weeks following inspection
management. These must be appropriately and consistently completed and be easily accessible. OPIH study day for staff. This would include the key fundamentals of care and the use of documentation. The completion of wound assessment charts and food charts is monitored through our CNM / senior nurse care assurance walk rounds / visit in all hospital in patient areas. 9. Action Required: NHS Ayrshire & Arran must ensure ongoing dialogue and joint working with social work and the joint integrated board to support the safe and effective discharge of patients to improve patient flow. UHC continues to work with our HSCP colleagues (both at strategic and operation levels) to provide the best care possible for our patients; to improve patient flow and effective discharges. Discharge and flow issues are standing agenda items on the Unscheduled care delivery group (This group has enhanced membership of senior managers from the partnerships and acute hospital). Daily discussions take place between partners and the acute discharge team to review and plan discharges with particular emphasis on those patients experiencing delays. We will continue to seek new and innovative / different Immediate (with continuing dialogue at strategic and operational levels) Complete Dialogue continues on a daily basis. Produced by: NHS Ayrshire and Arran Page 8 of 9 Review Date: 16 weeks following inspection
solutions to address these issues in full partnership with the Integrated Joint Boards and social work colleagues. Produced by: NHS Ayrshire and Arran Page 9 of 9 Review Date: 16 weeks following inspection