May 2013 Improvement Programme Initiatives Cwm Taf … Taf... · Cwm Taf Health Board Insert name...

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Improvement Programme

Initiatives

Cwm Taf Health Board

May 2013


Leadership – Walkrounds

Improved

Communication Showcase areas

of excellence

Staff Contribution

and Team Working

discussions

Learning

and

Sharing

Staff Comments:-

“ It’s nice to talk and see board level

members really take an interest in what I

had to say”

“Was a lovely visit, it was our chance to

show off our hard work”

“ I felt I could be honest and listened to”

Displays

staff &

patient

relations

Leadership –Walkround findings


Fresh Eyes Buddy System has been successful within the Maternity

Services and is welcomed by staff, it has proven to be effective and is

working extremely well. Improved safety feature and ensuring staff are continuously vigilant, the smallest change in patients statistics are

noted.

As result of the Walkrounds it’s apparent there is a positive

patient care directive amongst all staff. Ensuring a patient-

centred led approach to individual care throughout the

patients journey

The heightened security procedures within the Maternity Service have been noted and

displays of security measures in place were visible for visitors and

patients to be fully informed. This has improved a general

sense of safety amongst visitors, service users and staff

Enhanced Recovery After Surgery (ERAS) Excellent

feedback has been received and noted in relation to the

1000 Lives+ ERAS programme. Patients are informed and less worried


Mortality Review The population of Cwm Taf experience higher than average levels of deprivation:•62% classed as obese•27% are smokers•44% consume greater than the recommended weekly limit for alcohol consumption•23% have high blood pressure (hypertension)•15% have chronic respiratory disease•9% have a chronic cardiac condition

•34.2% live in most deprived areas (this deprivation translates into lower life expectancy and also lower healthy life expectancy as shown by Public Health Wales Observatory). Continued efforts are being made to focus on Clinical Coding of Co-morbidities.

Next Steps

• Continue to identify themes and trends from Mortality Review• Set up activity groups to review and report on specific mortality conditions• Continue to stream-line the review process in its entirety reducing cost and

time to each session without compromising on quality and reporting• Develop standard operating procedures for all stage 2 cases• Promote joint working approach between Concerns, Clinical Coding and Information

Management


Mortality & Harm Review

Process Mortality

Review: Stage 1*

(data recorded by

Clinical Audit

department)

Mortality Review

Stage 2* (data

recorded by

Clinical Audit

department)

**Condition

specific mortality

STROKE

**Condition

specific mortality

#NOF

**Condition

specific mortality

SEPSIS

**Condition

specific mortalityPOST-

OPERATIVE

DEATH

**Condition

specific mortality

OTHERS

No further

review

Death

potentially

amenable

Death

probably not

amenable

All deaths at

both acute

sites

Global Trigger Tool


0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Feb

2012

Mar

2012

Apr

2012

May

2012

Jun

2012

Jul

2012

Aug

2012

Sep

2012

Oct

2012

Nu

mb

er

Number of triggers

CTHB - Prince Charles Hospital

Values

Average (5.2)

0.0

2.0

4.0

6.0

8.0

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12.0

14.0

16.0

Feb 2012 Mar 2012 Apr 2012 May 2012

Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012

Nu

mb

er

Number of triggers

CTHB - Royal Glamorgan Hospital

Values

Average (8.7)

Royal Glamorgan Trigger

EventsPrince Charles

Trigger Events

Findings:- Top 2 triggers routinely identified across both sites are

• Readmission to hospital within 30days

• Lab Test Module

•Further work ongoing via Faculty of Quality and Patient Safety, to explore this in further

depth


Global Trigger ToolProgress

The GTT programme continues to explore and conduct reviews of current practice and triggers for harm.

• Over a one month period 40 cases are reviewed and all findings are incorporated into a 1000Lives Plus database to present data for comparison of activity.

• The findings of GTT currently give us an organisational overview of care and areas of good practice

• GTT review continues to highlight the importance of the quality of documentation

• It is a frequent finding that trigger events are often a result of the disease process, and not a consequence of poor care


Patient StoriesKey Developments & Improvements

• A central stories database has been designed and developed, and is now available on the intranet for staff to search for a story and request its use following confirmation that patient consent has been obtained.• Five digital stories have been developed which will be used by the Directorates to look at the learning, and how the patient’s experience can be improved:

•“This is Me”

•“Tamara’s Story – Our Nightmares & Hopes”•“Tomos Story – The Transition”

•“Vic’s Story”

• Agreement provided by the University of Glamorgan School of Nursing that patient stories will become part of the Student Nursing curriculum. Currently working on a formal structure with the University to take this work forward

• Working with the RCN Clinical Leadership course leaders with a view to introducing the digital story element onto the course

• Cwm Taf recognised as an area of good practice by 1000 Lives Plus

• Seven additional staff have recently been trained in digital story taking

• Occupational Therapy and Facilities Departments are now involved in the workstream

Rapid Response to

Acute Illness (RRAILS)Outcome measures

April 2012 -Implementation of NEWS in all Welsh HospitalsApril 2013 - Achievement of 95% compliance with all four RRAILS bundles in all acute hospital areasApril 2014 -Demonstrable reductions in mortality from Sepsis and Acute deterioration in all Welsh hospitals

Key Developments in RRAILS•The NHS Early Warning Score Wales (NEWS) is used on all wards across all hospitals, since April 2012

• Maintaining compliance with completion of NEWS remains a challenge. It has been identified that the criteria on the form are more sensitive – this leads to increased scoring when observations are recorded and acted upon

•The principles of RRAILS are implemented on both DGH sites and the use of the SBAR handover tool for escalating deteriorating conditions and early intervention has improved

•RRAILS – currently implemented on Ward 4 Prince Charles Hospital (PCH) and Ward 20 Royal Glamorgan Hospital (RGH). Admission bundle, recognition bundle, response bundle, Sepsis 6 and SBAR all in place and working well.

Cwm Taf Health Board IMPROVING ACUTE CARE

SEPSIS SIX - 24hr

Outcomes


• On ward improved 51

• On ward triggering 21

• On ICU within 4hr 11

• On ICU > 4hr 6

• DNAR 2

• RIP 1

• No Data 8

• Statistically significant drop in NEWS score.

• Biggest drop -8

Percentage favourable outcomes after 24 hours

Cwm Taf LHB. Sepsis Bag Database.

from May 2012 to Dec 2012

RRAILS – SEPSIS BAG

RESPONSE


0

5

10

15

20

1 2 3 4 5 6 7 8 10 12 14 15 19 20 A+E MCDU CMU Blank

• Bags used across wards at The Royal Glamorgan Hospital • Age range 19-91 years, (Mean age 65years)

Reducing Falls in the

Community

Cwm Taf Health Board IMPROVING PRIMARY AND COMMUNITY CARE

Key Developments

• Some key service areas in the Health Board have been engaged, where there are opportunities to identify those who have a falls history.• Tools to use for falls work are being developed and piloted• There is recognition that the tools are appropriate for assessing frailty

• Some staff in Welsh Ambulance Service Trust (WAST) locally, Primary Care, @home services, on wards and in Emergency Care Centre (ECC) and Minor Injuries Unit (MIU) are building competencies in falls work

• Community Integrated Assessment Service (CIAS) will use the falls database to monitor compliance

• The pathway for referring for exercise, gait and balance training is emerging• Local information to give to clients and patients is under development• All Wales networks to share knowledge and skill• The work on reducing falls in the community is cross-referred to reducing inpatient falls

Reducing Falls in the

Community

Cwm Taf Health Board IMPROVING PRIMARY AND COMMUNITY CARE

Next Steps

• Establish fracture liaison services (objective 2)

• Develop capacity within primary care

• Developing a Health Board wide falls database

• Explore capacity to complete the falls database in service areas

•Agreement about where high risk fallers will be referred for further assessment from ECC and MIU if we do screen over 75year olds

•Electronic information sharing and referral from ECC and MIU to primary care and community services through Myrddin

First Episode Psychosis

(FEP) Intelligent Target

Key Developments

• Development of a multiagency steering group for improving services to people in First

Episode Psychosis

• Development of an agreed protocol for reporting FEP cases across Cwm Taf

• Initiatives to promote access to psychological therapy have been developed and

implemented across Cwm Taf such as:-

– Development of a Pilot First Episode service in Merthyr CMHT, to assist to plan a

comprehensive service which will operate across the health board.

– Liaison with established FEP Services elsewhere in Wales which has helped with

planning the service

– Offer of shadowing opportunities for CMHT staff to help with skills development

Cwm Taf Health Board MENTAL HEALTH

First Episode Psychosis

(FEP) Intelligent Target

Cwm Taf Health Board MENTAL HEALTH

0

10

20

30

40

50

2010 2011 2012 so far

FEP Case finding

Reported

Found by detailed search

• Data reporting has improved, particularly in the area of the pilot. Since the process for reporting was agreed at the end of January, we have identified more cases than in the previous 9 months.

• The pilot scheme is well supported within the Merthyr CMHT, and gives us practical opportunities to improve important aspects of service provision.

• We are developing proposals for an invest to save bid, with an initial proposal to provide a dedicated post, as a secondment, to lead these developments across the health board.

Identifying Depression in

Hospital Settings


Progress

• Scoping exercise undertaken

• One area has implemented a pilot – Stoma Care

Background to Implementation• Previously assessments were completed by a Stoma

Care Nurse(SCN) paying specific attention to

physical, social, psychological, sexual needs using a

Dansac Observation Tool (DOT)

• A psychological score identified by the SCN and

appropriate advice offered.


Identifying Depression in

Hospital Settings


Key Developments

• Familiarised with ‘Identifying depression in hospital settings to

improve patient outcomes’.

• CNS Met with Psychologist and Ward Manager in Mental Health

Directorate to provide informal teaching session.

• Developed tool to use within clinic environment.

• Commenced audit for 1 month on ALL patients attending Stoma

Care Clinic.

• SCN assessed patient using Active Listening Skills and scored the

patient as they felt appropriate.

• SCN asked two relevant questions, specific to the above booklet.

If yes to either Question, PHQ 9 Depression Tool Completed.


Identifying Depression

in Hospital Settings


Current Position

• The Stoma Care Team are appropriately assessing patient’s psychological needs.

• The 1000 Lives Plus Depression Tool has its place within the department; the SCN

will identify those patients who would benefit from completion of the tool.

• The tool allows the patient to recognise they have a psychological problem that needs

addressing.

• The tool signposts the patient to seek further support and help e.g. counseling, Book

Prescription Wales.

Next steps:

SCN to continue to collect data using monitoring tool to identify trends and improve

service delivery.

HEALTHCARE ASSOCIATED

INFECTIONS Reducing Catheter Associated Urinary Tract Infections (CAUTI)

KEY OBJECTIVE

• To improve patient care and safety through the implementation of a series of

evidence based interventions in a care bundle format.

PROGRESS/ACHIEVEMENTS TO DATE

• The CAUTI care bundle was originally piloted on three wards in Dewi Sant Hospital and

has since been introduced to:- all community hospitals, all surgical wards at the Royal

Glamorgan Hospital and Prince Charles Hospital, and in theatres at Royal Glamorgan

Hospital.

• Surveillance data is being collected on the surgical wards at Royal Glamorgan Hospital -

data analysis will be performed by a Clinical Audit Facilitator.

Cwm Taf Health Board HEALTHCARE ASSOCIATED INFECTIONS

REDUCING INFECTIONS FROM

PERIPHERAL VASCULAR CATHETERS

Peripheral Vascular Catheters (PVC)

• The PVC bundle was originally piloted on three medical wards and is now being used on:-

all medical wards in the Royal Glamorgan Hospital, all medical and surgical wards at Prince

Charles Hospital, and on the Intensive Care Unit and Endoscopy Unit at Prince Charles

Hospital.

• The original pilot wards have agreed to collect limited surveillance data daily and perform

audits twice monthly to monitor compliance with the care bundles. The Infection Prevention

and Control Team are performing unannounced audits twice per month to monitor

compliance with the care bundle.

• A monthly root cause analysis is performed for all line associated bacteraemias which is

shared with the Directorates.


HEALTHCARE ASSOCIATED

INFECTIONS


Challenges

• PVC and CAUTI bundles have not been spread to all areas – this work is ongoing

• Surveillance data needs to be collected consistently in all areas

• Analysis needs to be performed on the data received to monitor outcome and process measures

• Medical staff need to be fully engaged and represented at the CAUTI and PVC meetings

• The results of the verification audits performed by the Infection Prevention & Control Team shows poor compliance with the care bundles. Following discussion at the Faculty for Quality and Safety, the process is being reviewed and re-energised to ensure the bundles are applied consistently.

Next steps

• A standardised mechanism for reporting outcome and process measures is being established with the aid of a dedicated Clinical Audit Facilitator

TRANSFORMING CARE

Cwm Taf Health Board TRANSFORMING CARE

Progress/Achievements to Date:

•Average increase of 19% in Direct Care Time - Highest to date 80%

More recently we have seen a decline in Direct Care Time as some

improvements have not been sustained in individual areas. This will now

require a detailed review to determine the issues and identify solutions.

•Average increase of 7% in reported Patient satisfaction - Highest to date

98%

We have recently introduced the use of volunteers to carry out patient

satisfaction surveys. This is to ensure no administrative bias or patients

feeling pressured to give positive responses when surveys are administered

by the same staff who deliver care

•Average increase of 5% in reported Staff Satisfaction - Highest to date

92%

TRANSFORMING CARE

Cwm Taf Health Board TRANSFORMING CARE

• Steady decline in adverse events across all Transforming Care areas demonstrated by

examples of some of the highest ‘days since’:

50% Reduction in time taken for nurse handovers

28% reduction in the time taken to locate equipment

45% reduction in interruptions to nursing staff activity

69% reduction in time spent in medicines administration

Significant improvements in direct care time have allowed staff to re-

direct their time. Examples of the time saved are as follows:

TRANSFORMING MATERNITY

SERVICES

Cwm Taf Health Board TRANSFORMING MATERNITY SERVICES

Progress and Improvement

Introduction of :

•DVT Risk Assessment•MEWS chart introduced across all maternity areas Jan 2012 – to date

•White Boards providing information at a glance•Sepsis guideline agreed•Sepsis boxes placed on obstetric emergency trolleys which are highly visible to staff•Sepsis screening tools in place•Sepsis checklist and treatment plans in place•Agreed SBAR Proforma for Maternity Day Assessment areas across sites

•The electronic maternity record prompts midwives to complete the postnatal DVT riskassessment and MEWS post delivery before transfer to the postnatal ward. Thematernity records cannot be completed unless this mandatory risk assessment has beencompleted

TRANSFORMING MATERNITY

SERVICES

Cwm Taf Health Board TRANSFORMING MATERNITY SERVICES

Future Work

•Continue with mandatory training sessions to raise awareness and maintain momentum•Increase use of maternity safety briefing•Continue to forge links with Outreach Teams from Intensive Care Unit•Gain support from NLIAH with measurement supported by dedicated Clinical Audit Facilitator


Key Contact Information

Arlene Shenkorov – Clinical Audit & Effectiveness Manager

[email protected]

01685 728146

Sarah Davies - Senior Facilitator - Programme Support

[email protected]

mailto:[email protected]

mailto:[email protected]

May 2013 Improvement Programme Initiatives Cwm Taf … Taf... · Cwm Taf Health Board Insert name...

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