Meeting of Lanarkshire NHS Board: Lanarkshire NHS Board Kirklands Fallside Road Bothwell G71 8BB Telephone: 01698 855500 www.nhslanarkshire.org.uk SUBJECT: QUALITY ASSURANCE AND IMPROVEMENT 1. PURPOSE This paper is coming to the Board: For approval For endorsement To note The purpose of this paper is to provide NHS Lanarkshire Board with an update on Learning from Adverse Events across NHS Lanarkshire. It also includes a summary of, and actions from, the recent Board seminar on Quality Assurance and Improvement held on 29 August 2017. 2. ROUTE TO THE BOARD The content of this paper relating to adverse events has been: Prepared Reviewed Endorsed By the following Committee: Healthcare Quality Assurance & Improvement Committee 3. SUMMARY OF KEY ISSUES NHS Lanarkshire s quality vision is to achieve transformational improvement in the provision of safe, person centred and effective care for our patients and for our patients to be confident that this is what they will receive, no matter where and when they access our services. To achieve our quality vision, we are committed to transforming the quality of health care in Lanarkshire aiming to: be the safest health and care system in Scotland have no avoidable deaths reduce avoidable harm deliver care in partnership with patients that is responsive to their needs meet the highest standards of evidence based best practice be an employer of choice develop a culture of learning and improvement deliver effective and inclusive services so that all individuals, whatever their background, achieve the maximum benefit from the services and interventions provided, within available resources. In supporting the delivery of these aims this report focuses on learning from adverse events. The cover paper also provides feedback on the recent Board seminar on quality improvement.
Learning from Adverse Events Adverse event reporting is one of the key methods used to alert an organisation to issues that, if left unattended, may pose a serious risk to patients, staff and/or others for which it has a responsibility e.g. visitors, contractors and volunteers. Without an effective system, the organisation may be blind to some of this risk exposure and cannot make the necessary improvements to support safety. NHS Lanarkshire has in place an adverse event reporting and recording system that supports good practice and compliance with legal duties. This is underpinned by an Adverse Event Management Policy which was revised in June 2016. The Transforming Patient Safety and Quality of Care Strategy Implementation Plan for 2017/18 contains an action (11b) to ensure that learning from adverse events is embedded throughout the organisation through implementation of the Adverse Event Management Policy and associated procedures. The main body of the attached paper provides an update on the learning coming from adverse event reporting and the actions which are being taken forward to reduce the frequency of Category 1 adverse events related to falls and suicide. In doing so, it is acknowledged that the causation of these adverse events is multi-factorial and a range of interventions are necessary to make an appreciable impact on incidence. Feedback from the Board Development Session on Quality Improvement Board Development Sessions are delivered and attended by both Non-Executive and Executive Directors and supported by appropriate senior managers. The development session on 29th August 2017 focused on Quality. The session was structured around the role of the Board in: The development of the NHS Lanarkshire Quality Vision Ensuring accountability for quality outcomes Shaping the quality and safety culture Session 1 - Board Leadership for Quality This session considered the IHI Framework for Safe, Reliable and Effective Care which was published in 2017. This framework was referenced extensively in the Patient Safety Officer Executive Development Programme and Irene Barkby completed a self-assessment document during and following her attendance. The Board were split into 4 groups and each group was asked to rate themselves against the self- assessment document for each of the criteria. Session 2 - Data/Measurement needs at a Board level Information is a vital component of the Lanarkshire Quality Approach. Any Board meeting will include discussions about triangulating data, understanding data over time and approaches to measurement for quality. Board members will often be asked to understand data for one of three purposes: measurement for accountability/scrutiny, measurement for research and measurement for improvement. Interpretation of, and actions resulting from this interpretation can vary according to the purpose the data is being used for. Outcome The Director of Quality, Board Medical Director and Director of NMAHPs have been tasked with developing an Action Plan to detail the next steps required in creating the conditions to deliver the Lanarkshire Quality Approach. This Action Plan will be discussed at the next meeting of the Healthcare Quality Assurance & Improvement Committee (HQAIC) on 9th November 2017 and then presented to the Board for approval. The Director of Strategic Planning & Performance and the Director of Quality will develop an Information Management Strategy and Implementation Plan which will include, as a priority, a review of the data considered by the NHS Lanarkshire Board and sub-committees with a particular focus on visual simplicity, ease of understanding and ability to support decision making. This process 2
is being coordinated through the Corporate Management Team (CMT) with a paper being considered at its meeting on 27 th November 2017. Further Board development sessions on Quality will be scheduled over the next year. 4. STRATEGIC CONTEXT This paper links to the following: Corporate Objectives LDP Government Policy Government Directive Statutory Requirement AHF/Local Policy Urgent Operational Issue Other 5. CONTRIBUTION TO QUALITY This paper aligns to the following elements of safety and quality improvement: Three Quality Ambitions: Safe Effective Person Centred Six Quality Outcomes: Everyone has the best start in life and is able to live longer healthier lives; (Effective) People are able to live well at home or in the community; (Person Centred) Everyone has a positive experience of healthcare; (Person Centred) Staff feel supported and engaged; (Effective) Healthcare is safe for every person, every time; (Safe) Best use is made of available resources. (Effective) 6. MEASURES FOR IMPROVEMENT The Transforming Patient Safety and Quality of Care Strategy and implementation plan provide measures for improvement including Key Performance Indicators (KPIs) relating to adverse events. Building organisational capacity and capability in quality improvement is also a key strategic aim outlined in the plan. 7. FINANCIAL IMPLICATIONS No financial implications are identified in this paper. 8. RISK ASSESSMENT/MANAGEMENT IMPLICATIONS The Healthcare Quality Assurance and Improvement Committee and Steering Group oversee a corporate risk with controls in relation to achieving the quality and safety vision for NHS Lanarkshire. Corporate Risk 1280 - Maintaining quality of care and prevention of harm and injury to patients - is rated as medium. 9. FIT WITH BEST VALUE CRITERIA This paper aligns to the following best value criteria: 3
Vision and leadership Effective partnerships Governance and accountability Use of resources Performance management Equality Sustainability 10. EQUALITY AND DIVERSITY IMPACT ASSESSMENT An E&D Impact Assessment has been completed Yes No An assessment has been completed for the Transforming Patient Safety & Quality of Care Strategy. 11. CONSULTATION AND ENGAGEMENT The Transforming Patient Safety and Quality of Care Strategy Implementation Plan for 2017/18 was approved by the Healthcare Quality Assurance and Improvement Committee in July 2017. 12. ACTIONS FOR THE BOARD With respect to category 1 adverse events the Board is asked to note: work which is currently being taken forward in relation to falls and suicide prevention the number and overall performance for the closure of category 1 adverse events In relation to the recent Quality seminar the Board is asked to note that: an Action Plan detailing the next steps required to create the conditions to deliver the Lanarkshire Quality Approach will be discussed at the next meeting of HQAIC and then presented to the Board for approval an Information Management Strategy and Implementation Plan is being developed and will include a review of the data considered by the NHS Lanarkshire Board and sub-committees further Quality Assurance and Improvement Board seminars will be held in 2018 Approval Endorsement Identify further actions Note Accept the risk identified Ask for a further report 13. FURTHER INFORMATION For further information about any aspect of this paper, please contact Lesley Anne Smith, Director of Quality. Telephone: 01698 858100. Iain Wallace Medical Director 4
1. LANARKSHIRE QUALITY APPROACH QUALITY ASSURANCE AND IMPROVEMENT LEARNING FROM ADVERSE EVENTS 1.1 NHS Lanarkshire is committed to delivering world leading, high quality, innovative health and social care that is person-centred. Our ambition is to be a quality-driven organisation that cares about people (patients, their relatives and carers, and our staff) and is focused on achieving a healthier life for all. Through our commitment to a culture of quality we aim to deliver the highest quality health and care services for the people of Lanarkshire. 1.2 Adverse event reporting is one of the key methods for alerting an organisation to issues that, if left unattended, may pose a serious risk to either the patients in its care, the staff it employs or to others for which it has a responsibility e.g. visitors, contractors, volunteers etc. Without an effective system, the organisation may be blind to some of this risk exposure, and cannot make the necessary improvements to support safety. 1.3 NHS Lanarkshire has in place an incident reporting and recording system that supports good practice and compliance with legal duties. This is underpinned by an Adverse Event Management Policy which was revised in June 2016. 1.4 This policy sets out how NHS Lanarkshire will identify and manage adverse events, with a clear emphasis on transparency, prompt remedial action, and learning for quality improvement so that recurrence of adverse events is minimised. The policy also emphasises our commitment to supporting patients and/or their families/carers and staff when adverse events occur. NHS Lanarkshire is committed to promoting an open and honest culture, based on understanding why things go wrong, supporting those affected and working hard to minimise the impact and the recurrence of adverse 1.5 A Category 1 significant adverse event is an event that fulfils at least one of the following: An event which caused or had the potential to cause serious harm to an individual or group of individuals (patients or staff); An unusual or unexpected clinical or non clinical event with or without an adverse outcome that has the potential for significant learning; An event that may cause reputational damage to the organisation, or undermines public confidence in the organisation to deliver safe services. It is important that we carry out a review of these events in a timely manner in order that we can take prompt remedial action, support patients and/or their families/carers and staff when adverse events occur, and to ensure learning for quality improvement so that recurrence of adverse events is minimised. 5
2. ANALYSIS OF CATEGORY 1 ADVERSE EVENTS 2.1 Reports continue to be produced monthly to monitor compliance with the 90 day timeline for review of category 1 adverse events. These are shared widely within the organisation including senior and operational management teams. 2.2 During the time period from June 2016 to May 2017 a total of 124 category 1 adverse events were recorded on the Datix system. 118 of these events have been reviewed and closed. Work is ongoing to ensure the others are closed within the near future. 2.3 The most frequent category 1 event (42%) was categorised as Slips, Trips & Falls with the majority occurring within Care of the Elderly wards in the three acute hospital sites. A category 1 fall is one which results in serious harm such as a fracture of a long bone. 2.4 The next highest category 1 event (14%) is Self Harm with the majority of incidents occurring out with the Board s premises. All suicides of people who have been in contact with Mental Health Services within the previous 12 months are defined as Category 1 adverse events and these comprise the majority under this category. 2.5 More detail on how the Board is responding to category 1 adverse events in these two areas is outlined below. 3. FALLS Background 3.1 The Board has identified reducing falls, particularly falls resulting in harm, as its top patient safety priority. As a result Category 1 falls (falls with harm) are reviewed each week at the Corporate Management Team (CMT) Quality Huddle. 3.2 Following a 12% reduction in falls in acute hospitals in 2015 there has been no further improvement in the overall falls rate (fig 1). In addition, despite significant focus on this issue there has been no improvement in the acute hospital falls with harm rate (fig 2). 6
3.3 During the Patient Safety Collaborative some pilot teams at Wishaw General managed to achieve a 58% reduction in falls with harm, however, despite best efforts it not been possible to replicate this elsewhere. Actions in response to falls data 3.4 Recognising this lack of progress, the Patient Safety team has developed a work programme in collaboration with senior nurses on each acute hospital and the Practice Development Unit. Between April and August 2017 activities have focussed on developing new operational definitions for falls, improving Datix and testing new documentation. A falls leads group has been established to support this work. 3.5 The Care Assurance and Accreditation Standards (CAAS) falls standard has been implemented in acute hospitals. Each ward/department has a falls link nurse and process measurement and testing is ongoing. Practice Development and the Patient Safety team have been working collaboratively to develop the measurement plan and infrastructure to support CAAS. 3.6 The Lanarkshire Community Falls Service consists of a Falls Register Team and a Specialist Falls Team. They work across Lanarkshire supporting staff in North & South HSCP s to implement The Prevention and Management of Falls in Community: a Framework for Action (Scottish Government 2014). 3.7 The team have developed an education and training framework that is currently being rolled out across Lanarkshire. To date, 4000 patients have had a falls conversation. The team also links to acute hospitals across the 3 sites and contributes to Acute Care Prevention and Management of Falls and the CAAS programme. 3.8 NHS Lanarkshire, in partnership with National Services Scotland, has undertaken a project to improve continence in care homes. An outcome of this Health Foundation funded project has been a reduction in falls in both care home pilot sites. 3.9 The Chief Nursing Officer s Excellence in Care initiative will have a focus on falls measurement as part of its first wave of measures. 3.10 Healthcare Improvement Scotland (HIS) Living Well in Communities teams have been supporting development and implementation of the Scottish Ambulance Service s Falls pathway in the North and South Health and Social Care Partnerships. 3.11 In response to individual category 1 adverse event reviews, learning points are shared widely across Board services. An example is attached as Appendix 1. 7
Further planned actions 3.12 The Director of NMAHPs has commissioned a whole system falls group, to be chair by the Director of AHPs. The remit of this group includes: To draft, agree and have authorised a whole system, cross corporate Falls Prevention Strategy; Identifying and collectively agree upon gaps/areas of improvement in current service delivery, as matched against the nationally recognised best practice; In support of the whole systems falls group, a one-off falls summit is being arranged to bring together a number of work streams with the aim of better understanding the reasons for our current performance. 4. SUICIDES 4.1 Following regular review of category 1 adverse events at the Healthcare Quality and Assurance Steering Group, Dr Linda Findlay, Consultant Psychiatrist and Associate Medical Director for South Health and Social Care Partnership, was asked to update the Group on the learning that had taken place from suicide reviews. As noted above, suicides are included within the second most frequent category 1 of adverse event Self harm. Following this presentation, Dr Findlay led a session on this topic at the Healthcare Quality and Assurance Committee. 4.2 In introducing the topic, Dr Findlay provided some background information on suicides nationally including gender, age and deprivation profile. She also explained the approach being taken nationally and locally with respect to suicide prevention including the lessons learned from serious adverse event reviews. 4.3 Since 2002 there has been a 19% reduction in the suicide rate broadly in line with the target set at that time as part of the Choose Life strategy and action plan. 4.4 Based on 2015 data there is an overall downward trend for both Health and Social care Partnership areas. There were 72 deaths by suicide in 2015 representing a reduction for the fifth consecutive year and an overall reduction of 15% since 2001. Of the 72 deaths, 24 involved individuals who were known to our mental health and learning disability services at the time of their death or had input from services in the preceding 12 months. 4.5 NHS Lanarkshire has the fourth lowest death rate from suicide in Scotland. However, inequalities remain a key issue. In Scotland in 2011-15, the suicide rate was more than three times higher in the most deprived decile of the population compared to the least deprived. Nonetheless, it should be noted that this difference has reduced between 2001-05 and 2011-15. 4.6 Improvements to reduce the incidence of suicide have been taken forward through North and South Lanarkshire Choose Life Implementation Groups. These groups have been successful in coordinating the collective efforts of mental health teams and partner agencies. 4.7 In order to learn from adverse events involving suicide, a review is undertaken into all deaths where the person has been in contact with mental health services in the 12 months prior to their death. From these reviews improvements have been taken forward in the following areas of practice. Risk assessment and management o o Changes to the definition of constant observation Multi-disciplinary team (MDT) decision-making around reducing observation levels 8
o Relational security the knowledge and understanding staff have of the patient and their environment; and the translation of that information into appropriate responses and care o Involvement of patients and their families in risk assessment and discharge planning o Addressing environmental risks such as ligature points o The use of safety plans o Management of unplanned absence o Introduction of a discharge pause Distress brief interventions Stigma Free Lanarkshire Suicide first aid training 4.8 In response to individual category 1 adverse event reviews, learning points are shared widely across Board services. An example is attached as Appendix 2. 5. CONCLUSION 5.1 It is vital that the Board has an effective system to review and learn from adverse events. It is essential that adverse event reviews are carried out in a timely manner to maximise learning and ensure corrective actions are put in place to reduce the likelihood of a similar event occurring again. It is also important for patients, their families/carers and staff that reviews conclude promptly. This report focuses on category 1 serious adverse events and particularly on the actions being taken forward to reduce falls with harm and prevent suicide. 9
Appendix 1 10
Appendix 2 11