Human Rights in Healthcare Betsi Cadwaladr University

Health Board

Anne-Marie Rowlands: Deputy Director of Nursing

Sally Hughes-Jones: Head of Equality and Human Rights

Julie Smith: Associate Chief of Staff Nursing

About BCU Health Board

Largest health organisation in Wales

Primary, community, mental health & acute hospital services for a population of around 676,000

Workforce around16,000 staff

Budget around £1.2 billion

3 district general hospitals

22 other acute and community hospitals

90 health centres, clinics, community health team bases and mental health units

121 GP practices and NHS services provided by North Wales’ dentists, opticians and pharmacies.

Acute and Community services

Our Strategic Direction

“Anyone coming in contact with a public service should be treated with respect and dignity, have their health need assessed, be helped and not handed off to someone else, receive a responsive, safe and high quality service that continually improves, is easy to access and understand” (Strategic Directions 2009)

Our Positive Obligation

Positive obligations on public authorities to take a proactive approach to human rights.

FREDA principles (Fairness, Respect, Equality, Dignity, Autonomy) underpin Human Rights and public service ethos.

Supports BCU Strategic Equality Plan & our organisational values

Human Rights Based Approach Empowers service users and staff Protects vulnerable people Improves experience Improves outcomes

Bring human rights to life by applying the principles to a clinical pathway

Leading & Defining the Project

Championed at Board level by the Director of Nursing, Midwifery and Patient Services

Deputy Director of Nursing, whose portfolio includes nutrition

Head of Equality and Human Rights Associate Chief of Staff Nursing, lead for

transformational group

Why Human Rights, Nutrition and Hydration?

Patient Association, Care Quality Commission, Ombudsman, Age Concern

No specific guidance – direct link nutrition, hydration, human rights & obligations of service providers

Evidence, guidance and best practice BCU – huge organisation – different ways of

working

Quality Patient Care

Ward staffing/ nurse : patient ratio review Supernumerary ward sisters/charge nurses Introduction of matrons Strategic nutritional and catering group Saving 1000 Lives – Intentional rounding Striving for excellence– ‘good is not good

enough’

Project Aims Development of a practical toolkit Directly links nutrition, hydration, human

rights & obligations of service providers Increase knowledge and awareness of

human rights, nutrition and hydration Embed dignity and human rights within

everyday ward routine Place the patient at the centre of care.

Achieving the Aims

Multidisciplinary project steering group Redefined the role of nutritional sub group BIHR Human Rights training Brainstorming session - practical starting

point Project plan & driver diagram agreed Draft toolkit developed

Engagement and Involvement

Communication & press briefing Stakeholder event - ward staff, dietetics,

Speech and Language, education, catering, service users, specialist nurses

BIHR training, questionnaire, workshop Draft toolkit –questions posed – positives

and negatives? what would you change? barriers to implementation?

Outcome of Stakeholder Event

Event ideas and feedback discussed Changes to toolkit made 6 pilot wards identified (mix of acute

medical, care of the elderly, acute surgical, acute orthopaedic)

BIHR training for pilot wards, matrons and senior nursing team

Transformational sub group

Reporting to Human Rights steering group

Monthly meetings Leads identified to support pilot wards Focus on establishing the baseline,

identifying areas for change Testing (and changing) the toolkit

Drivers to Succeed

Over arching aim Primary Driver (Patients receive the

required level of support with eating & drinking)

Secondary Drivers (Safety, Environment etc.)

Interventions Cornerstone of the toolkit

Drivers & Key Components of Nutrition & Hydration in relation to Ward Routine

Putting Human Rights at the Heart of Hydration and

Nutrition

Audit compliance and measure improvement

MUST audit and fundamentals of care audits. Identify, monitor and learn from

concerns.

Empower patients and their families.

Ensure and enable regular communication. Ensure patients autonomy and

dignity is respected.

SafetyIdentify vulnerable patients

and those at risk at the beginning of every shift.

Establish an alert system.

EnvironmentEnsure appropriate environment of care including access to

equipment.

ChoiceEnable and promote

choice and ensure 24 hour access to food

and drinks.

Meal timesEnsure mealtimes are protected. Enable and promote appropriate

involvement of carers and volunteers

Principles of Improvement Methodology

Initiative to improve patients nutrition and hydration in various areas of practice using PDSA cycle methodology with fast cycling

Measure it > change it > re-measure it > change itUntil you get it right!

Aims to introduce effective processes and

systems for staff in ward environments

Aims for culture change!

Methodology

Human Rights Strategic Group

Measurements

Mealtimes & EnvironmentPatient Safety &

Empowerment

Patient Choice

In Patient Transformational Group

East Central West

How did we do it ?

East pilot areas Patient safety and empowerment work streams

in line with improvement methodology Wards and teams identified Operational definitions for measurements

developed Baseline measurements undertaken PSDA cycles - process redesignWe stacked the odds in our favour!!

Patient Safety

3 dimensions of patients safety Identification of patients at risk during

safety briefing (measure 1) (Safety briefing – measure 2) Delegation of Nursing orders (measure

3)

Methodology

Baseline measurement on pilot ward showed identification of patients at risk at safety briefing at 59%

Target compliance = 95%

Methodology (2)

Changes introduced Raise awareness of human rights approach and toolkit

development – matrons meeting/staff meetings All Wales e learning directive for all nurses to complete Posters for SBAR Symbols Letters to nurses in charge outlining roles and

responsibilities Red jugs/lids At a glance board Roles and responsibilities e.g. For house keepers for data

collection, Change ward routine in relation to undertaking distribution of red jugs/symbols

Example of reliable design evolution

Implement a system to ensure patients at risk are Implement a system to ensure patients at risk are identified at safety briefs identified at safety briefs Who - All team leadersWho - All team leaders What What –– ensure at risk patients are identified at ensure at risk patients are identified at

safety briefingsafety briefing When When –– during safety briefings (3x daily) during safety briefings (3x daily) Where - Pilot wardWhere - Pilot ward How - How -

DesignDesign –– brief the nurses regarding responsibilities of identifying brief the nurses regarding responsibilities of identifying patients at riskpatients at risk

Redesign Redesign –– re introduce safety briefing into ward 3 times daily re introduce safety briefing into ward 3 times daily RedesignRedesign –– develop a poster to be clearly displayed at nurses develop a poster to be clearly displayed at nurses

station prompting safety brief times station prompting safety brief times Redesign Redesign - change the pm SB time to accommodate shift patterns - change the pm SB time to accommodate shift patterns Redesign Redesign –– introduction of symbols relating to patients at riskintroduction of symbols relating to patients at risk

Reliable Process Design

Safety Briefing

PM ……

AM .......

Nights ……..

Don’t Forget

Don’t forget

Results – weekly dataBCU HB Secondary Care Sites - East Pilot siteRate of Patients at Risk Identified at Safety BriefingsPeriod April - Jun 2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Rate Target

Results – monthly data

BCU HB Secondary Care Sites - East - pilot ward 1Rate of Patients at Risk Identified at Safety BriefingsPeriod April - Sept 2012

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Rate Target

No SB (nights)Re affirmed R&R

Introduced symbols/posters

Delegation of need

Empowerment

Conclusion Through repeated testing and process

redesign, reliability and sustainability achievable

Lessons learnt – At the beginning state who, what, where and

when (prevents defects being the people you forgot to include!

Keep it simple Spread only when processes reliable

Next Steps Project steering group meeting Dec 12 Agree implementation plan Development of ward resource file/website Communication within organisation

Strategic Nursing and Midwifery Committee Improving Service User Experience Committee

Evaluation of impact Sharing across Wales and wider

Thank You

Our contact details:

Anne-Marie.Rowlands@wales.nhs.ukSally.HughesJones@wales.nhs.ukJulie.Smith@wales.nhs.uk