Betsi Cadwaladr University Health Board - Patient Safety Goals for BCUHB

Betsi Cadwaladr University Health Board

Betsi Cadwaladr University Health Board - Patient Safety Goals for BCUHB

Tuesday 11 May 2010

Presenter: Dr Brian Tehan, AMD – Patient Safety



Ysbyty Gwynedd

Ysbyty Glan Clwyd

Ysbyty Maelor


Aim

To reduce the Betsi Cadwaladr University Health Board Global Trigger Tool adverse event rate and to also reduce the mortality rate.

Make care safer for patientsAs evidenced by reductions in RAMI and Adverse Event Rate

Outcome Primary Drivers Secondary DriversInterventions

Planned & proposed

P1. 1000 Lives implementation and spread

P2. Target the top causes of Death in BCU

Leadership and a culture of safety

Clinical engagement- challenge through use

The evidence base for what is efficacious

R&D process

Consolidate and spread

“Amenable Mortality”?

“Amenable Harm”?

The “New”- Stroke, Hospital acquired thrombosis, and Pressure Ulcers

Notes Reviews, Global Trigger Tool, IR1, Complaints & Litigation, Serious Incident Reviews, External Notification BCU Governance, Stakeholder Groups etc.

The methodology for Improvement - Spread

Dash-Boards for Safety

Develop the measures and use clinical data

Collaborate- National Campaigns, SPN ,etc.P3. to identify

and prioritise the causes of harm

P4. Validate and standardise the data

Normalization through CPGs & workstreams

Involve patients and families in safety improvement


Top Priorities

1. Rapid response to the deteriorating patient• Safe provision of acute medical care• CG50 NICE

2. Infection prevention & Control

3. Hospital Acquired thrombosis• Outcome measure• Compliance


with the…

PDSA cycle, you

get…

…the Model for

Improvement

What are we trying toAccomplish?

How will we know that achange is an improvement?

What change can we make that will result in improvement?

Act Plan

Study Do

When you combine these 3

questions

The Model for Improvement


1000 Lives Plus and Intelligent

Targets Existing interventions that will continue as mini-

collaboratives: • Preventing stroke through timely management of

Transient Ischaemic Attack (TIA)• Rehabilitation following Stroke • Reducing Chronic Heart Failure• Transforming care – including Reducing Hospital

Acquired Pressure Ulcers and falls in hospital• Preventing Hospital Acquired Thrombosis• Rapid Response to Acute Illness (RRAILLS)• Improving Medicines Management• Reducing Healthcare Associated Infections


1000 Lives Plus and Intelligent TargetsNew mini-collaboratives to be introduced from May 2010

onwards: • Depression• Dementia• Preventing Acute Coronary Syndrome• Patient Identifiers• Enhanced Recovery after Surgery• Reducing Falls in Intermediate Care• Maternity Services


1000 Lives Plus and Intelligent Targets

• Reducing avoidable harm and mortality

• WHO / NPSA Surgical Checklist

• SBAR• Communications• Trigger Tools

• Leadership• Patient Stories• Model for Improvement• Normothermia• Critical Care Bundles• Acute Stroke

Improvement methodologies and maintenance of interventions – through Web-Ex and teleconferencing:


Adverse event rateAdverse Event Rate per 1000 patient days

0

10

20

30

40

50

60

70

Oct-

07

Dec-0

7

Feb-0

8

Apr-0

8

Jun-

08

Aug-0

8

Oct-

08

Dec-0

8

Feb-0

9

Apr-0

9

Jun-

09

Aug-0

9

Oct-

09

Month

Pe

r 1

00

0 p

t d

ay

s

Central

East

West

Data collection commenced

SPI1 2004 – Glan Clwyd Hospital

SPI2 2006 – Wrexham Maelor Hospital

GTT 2008 - NWW


BCUHB CHKS Diagnosis Codes

Top Ten Diagnoses for Deaths at Trust April 2007 to December 2009 RAMI 10

J18:Pneumoniaorganism unspecified 98.80

C34:Malignant neoplasm of bronchus and lung 199.09

I50:Heart failure 105.93

I63:Cerebral infarction 95.75

I21:Acute myocardial infarction 110.50

A41:Other septicaemia 78.96

J44:Other chronic obstructive pulmonary disease 80.87

I64:Strokenot specified as haemorrhage or infarction 133.78

J22:Unspecified acute lower respiratory infection 101.06

S72:Fracture of femur 70.44


Leadership

• Patient Safety Steering Group set up• Making patient safety a priority at high level

meetings –dashboard developed• Patient stories polices agreed for use across

BCUHB – agreed programme of use of Patient Stories

• Previously established Executive WalkRoundsTM – process and programme for BCUHB under development


Culmulative Number of WalkRounds Completed

0

20

40

60

80

100

120

140

160

180

Date

Nu

mb

er

Executive WalkRoundsTM


Global Trigger Tool

Alignment of processes across BCUHB– Inclusion and exclusion criteria

– Number of reviewers

– To apply to notes of patients discharged from April 2010


Primary Care Trigger Tool“The Annual Operating Framework includes the use of the Primary Care Trigger Tool in one in twenty practices. Currently, there are no practices in North Wales consistently using this tool. Consideration needs to be given on how BCU HB encourage and support this work in GP Practices.”

1000 Lives BCUHB organisational briefing, April 2010

For further information please contact:-

[email protected]

mailto:[email protected]


CommunicationDo you have a good news/success story to share?

A template for sharing your story across BCUHB and possibly in the local media is available from [email protected]

Please help to

Spread the learning and celebrate the successes

mailto:[email protected]


Leadership

Intervention Measurement Implementation Date

Executive accountability for each 1000 Lives Plus clinical content area

AOF monitoring tool April 2010

WalkRound programme

Number of Board level WalkRounds

April 2010

“Executive leadership plays a key role in identifying and driving spread of reliable processes – it is therefore imperative for the organisation to identify executive leads for all content areas. Tier 1 and tier 2 posts are now well established and all should be participating in Leadership Walk Rounds.”

1000 Lives Organisational Briefing, April 2010


Leadership


Local targets for harm reduction

Mortality Rate Adverse Events Rate:Trigger tool for hospitalsPrimary care trigger tool (1 in 20 practices required)Ambulance Service trigger tool

April 2010

Mini-collaborative sign-up Number of mini-collaboratives signed up

April 2010


Critical Care


Ventilator care bundle

Compliance with bundle in all adult ITU’s

VAP rate per 1000 ventilator days

April 2010

Ongoing (April 2010)

“Central Venous Catheter (CVC) and Ventilator Care (VC) bundles are well established and sustained across the three sites; the sepsis bundles (sepsis six, sepsis resuscitation and sepsis management) continue to need further improvement focus to produce the same level of reliability.Communication across the three sites is very good – with sharing of good practice and improvement facilitated by the network.”



Critical CareIntervention Measurement Implementation

Date

Central line insertion and maintenance bundles

Compliance with both bundles in all adult ITUs

Incidence of central line infections per 1000 catheter days

April 2010

Compliance with both bundles in remaining areas

April 2011

Incidence of blood stream infections including Staphylococcus aureus

April 2010


Rapid Response to Acute Illness“The campaign team are aware from attendance at the learning sets that the BCU HB teams are involved in this content area but there is paucity of reliable process data on the extranet to comment on progress.

There was excellent work on investigating the cardiac arrest data (east) after a signal within the data identified an increased rate. It is important that any findings from the investigative case note reviews that result in the planning of improvement work is implemented using the methodology advocated by the campaign – the Model for Improvement.”



Sepsis resuscitation bundle

Compliance with Sepsis Six resuscitation bundle in receiving units ( A&E, MAU, SAU etc)

October 2010


Rapid Response to Acute IllnessIntervention Measurement Implementation

Date

Sepsis resuscitation bundle

Compliance with Early Goal Directed Therapy (EGDT) resuscitation bundle in all Emergency and Critical Care Areas (A&E, MAU, SAU, HDU, ICU etc)

April 2011

NICE CG 50 -Admissions, Recognition and Response bundles

Compliance with 3 bundles in all acute areas

April 2011


Medicines Management“Localised work ongoing but very little pace associated with the improvement of warfarin management processes, especially across the interface between primary and secondary care – process mapping event held before the end of 2009 does not appeared to have progressed.”


Intervention Measurement* Implementation Date

Warfarin in hospital and community

Reduction in INR >5 and INR >8

Increase the proportion of INR within 0.5 of target

April 2010


Healthcare Associated Infections“Hand hygiene in secondary care, alongside antibiotic stewardship in both primary and secondary care, remain the key process measures in relation to driving down the incidence of Clostridium Difficile and MRSA. Hand hygiene compliance is not sustained above 95% across the organisation (for medical, surgical and critical care areas) although critical care has demonstrated an improvement in the east – but this is against a background of reduced observation sample size. Antibiotic stewardship demonstrates reliability in both primary and secondary care areas but again this appears to be illustrated in test/pilot areas only.”



Prevent transmission

Hand hygiene compliance Patient equipment decontaminationPatient isolationOutcome measures include incidence of Staphylococcus aureus blood stream infections and Clostridium difficile infections

April 2010


Healthcare Associated InfectionsIntervention Measurement Implementation

Date

Improve Antimicrobial use

Compliance with local antimicrobial use policyAntimicrobial usage data

October 2010

Urinary catheter related infectionsCare bundle for insertion and maintenance of urinary catheters

Bundle complianceInfections surveillance

October 2010


Hospital Acquired Pressure Ulcers


Skin bundle or appropriate alternative technique

Compliance with skin bundle or appropriate technique

April 2011


Surgical Complications“Well established, reliable process measures are sustained for this work stream across all acute sites. Initial engagement with community care (i.e. the use of the WHO checklist and appropriate hair removal) has commenced to support the roll out of these interventions.”



WHO / NPSA Surgical Checklist

Whole team using the checklist April 2010

Prevent post operative wound (surgical site) infection in elective surgery

Surgical site infection surveillance for c section and orthopaedics

April 2010


Surgical Complications


Appropriate pre-operative hair removal

How to Guide April 2010

Maintainperi-operativenormothermia

How to GuideNICE guidelines

April 2010


Hospital Acquired Thrombosis“There is very little engagement with this mini-collaborative at present. The only measurement submitted to support the process of risk assessment, appropriate prescribing and administration of thrombo-prophylaxis currently includes only elective surgical patients, and not medical patients; therefore it is recommended that the leadership team at BCU HB nominate a lead to support participation in this content area.”



Risk assessment of all patients for hospital acquired thrombosis

Risk assessment of all patients April 2010


Intelligent Targets – how much by when

Content Area


Acute Stroke 4 bundles – first hours, first day, first 3 days, first 7 days

Compliance with bundles

October 2010

Transforming care

Programme participation

Sign up April 2010

Quality Improvement Capacity

Active programme to substantially increase skills across clinical and managerial workforce

From October 2010


Organisational Briefing Key Recommendations

The Campaign would endorse the following to ‘stack the cards’ in the favour of Health Boards achieving their goals and aspirations. •Take a strategic approach to quality improvement:

Building the will to make measurable systemic improvement as quickly as possible. This will needs to be generated at all levels, and needs to include the will of senior leaders to make new ways of working more attractive and engage staff commitment and enthusiasm.

Encouraging and spreading ideas about alternatives to the status quo which are robust enough to form the basis of new working systems; and also ideas about how to introduce them.

Attending relentlessly to the execution of an aligned range of improvement initiatives into the daily work of the organisation.


Organisational Briefing Key Recommendations

• Ensure a data-driven approach to measuring progress is maintained in the Health Board. Have the ability to understand the variation in your system and turn data into intelligent and useful information. Boards need to recognise that organisation level measures can mask variation between services. The capability to drill down to examine service level mortality and harm is therefore essential.

• Reliable processes are the key to shifting outcomes. It is essential for leaders to set expectations and use process improvement measures to hold teams to account for local progress.

• Identify executive leads for each work stream and , working with each content team, devise spread plans to enable the good work tested within the pilot areas to be rolled out in a structured and coordinated manner.



Organisation Briefing Overview

“BCU HB has demonstrated throughout the life of the campaign its ability to take on new interventions and successfully test and implement changes through the use of PDSA’s and supported by continuous measurement. What is evident, via the extranet progress reporting is that the ability to spread outside the pilot areas has proved challenging and this limits the effect that process reliability will have on organisational outcomes. Spread is not organic and can only be affected by the continued structured application of the methodology and strong executive and clinical leadership.”



Organisation Briefing Overview

“Participation and commitment of individuals and teams from BCU HB have been highly visible in the majority of work streams. The campaign team have identified that there are significant ‘enablers’ across the organisation, but as their capacity is often limited to their own area of expertise, their ability to drive spread is restricted. Increased capability and capacity must be a priority for BCU HB, if the existing campaign interventions are to be reliably sustained and spread and new interventions are to be taken on and successfully tested and implemented by the organisation.”


Betsi Cadwaladr University Health Board - Patient Safety Goals for BCUHB

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