Sign Up to Safety Improvement Plan 2gether NHS F Trust Version 2: January 2015

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Sign Up to Safety Improvement Plan – 2gether NHS Foundation Trust

Authored by: Sally Ashton

Clinical Continuous Improvement Lead:

Sally.ashton@glos.nhs.uk

The Sign up to Safety Campaign has provided us with an umbrella under which to seat patient safety improvement initiatives that 2gether NHS Foundation Trust is implementing. The initiatives outlined in more detail below include:

1. South of England Improving Patient Safety in Mental Health Programme 2. Safety Thermometer – Classic 3. Safety Thermometer – Mental Health 4. Safewards project

Sign up to Safety Leads within 2gether NHS Foundation Trust. These are the people who will link with the campaign.

Executive Lead: Trish Jay, Director of Quality

Co-ordination/Safety Lead: Sally Ashton, Clinical Continuous Improvement Lead

Communications Lead: Gavin Davies

NHSLA Lead for incentivising best practice: Alan Bourne-Jones, Risk Manager

Data requirements/SI reporting: Gordon Benson, Assistant Director of Governance/Paul Ryder, Patient Safety Manager.

1. South of England Improving Patient Safety in Mental Health Programme The Patient Safety in Mental Health Improvement Programme includes these initiatives in a co-ordinated approach as is set out in this document. The overall aim of the Patient Safety Programme is to reduce avoidable harm to inpatients and community patients in our care, by making improvements in the way we work, and thereby improving the patients’ experience of what is provided. Harm reduction to users of mental health services is achieved by focusing improvement efforts on the following work streams:

Senior Leadership for safety

Safe and reliable delivery of mental health care

Getting medicines right & Improving the physical care of patients

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Delivering person and family centred care, along with communication and team work, are integral to the four main work streams above. The vulnerable groups that our organisation service includes people with mental health needs and learning disabilities, and sometimes acutely ill older people who have a mental health problem. The main body of this SIP includes the detailed plan focused on the NHS South of England Improving Patient Safety in Mental Health Programme/Collaborative from page 3 onwards. Appendix [1] offers supporting information. Appendix [2] offers a SIP driver diagram. 2. The NHS Classic Safety Thermometer is embedded within the Trust and is reported on monthly by front line staff as required. The NHS Safety Thermometer "Classic" allows teams to measure harm and the proportion of patients that are 'harm free' from pressure ulcers, falls, urine infections (in patients with a catheter) and venous thromboembolism during their working day, for example at shift handover or during ward rounds. This is reported on quarterly via the Trust Governance Committee by the Deputy Director of Nursing. 3. A pilot of the NHS Mental Health Safety Thermometer is being considered by the organisation and will be further reported on. The Mental Health Safety Thermometer is a national tool that has been designed to measure commonly occurring harms in people that engage with mental health services. It’s a point of care survey that is carried out on one day per month which supports improvements in patient care and patient experience, prompts immediate actions by healthcare staff and integrates measurement for improvement into daily routines. It enables teams to measure harm and the proportion of patients that are 'harm free' from self-harm, psychological safety, violence and aggression, omissions of medication and restraint (inpatients only). This is a point of care survey that will be carried out on 100% of appropriate patients on one day each month. More information can be found at: http://www.safetythermometer.nhs.uk/index.php?option=com_content&view=article&id=2&Itemid=106 4. The Safewards Initiative Information was provided on the Safewards initiative in early 2014 and is led by James Wright, Matron at Wotton Lawn Hospital (WLH). YouTube films and Safewards website resources have been accessed and shared with front line teams. At WLH teams, and service users, have been asked to choose 3 interventions from the 10, to make a start. Each ward has chosen 3 for implementation from June 2014, and will be asked to select another 3 from December 2014 totalling 6 interventions being implemented on each ward. Staying true to the model is very important in terms of being able to evaluate in time and this is not quantifiable as numerical measurement. All Safewards interventions are to be measured where it is possible to obtain feedback from service users. It is important to validate where possible, the efficacy of Safewards. A combination of quantitative and qualitative data will be collated and reported on. Reporting is agreed for 6/12 intervals on agreed measures through a report to be presented at NPAC and Locality Boards. More information can be found at: www.safewards.net

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South of England Improving Patient Safety in Mental Health Programme

Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

Harm from falls STATUS: Spread and further PDSA work.

Reduce by 50% by March 2014. Sub-Aims: Reduce number. Reduce harm. Increase days between. Implement Intentional Rounding.

Yes Yes – number of falls, level of harm and days between for all wards. Reported on Extranet. Harm from falls data provided by Paul Ryder, Patient Safety Manager. Detailed charts are produced. Update: all wards have reduced the number of falls by 50% at times but not sustained. The severity of harm from falls remains consistently low (which includes zero harm), with minor and medium harm as rare events.

Charlton Lane & Stonebow older person’s inpatient areas.

Charlton Lane inpatient areas and Cantilupe & Jenny Lind Other: Trust wide training on falls prevention has taken place. Falls pathway and post falls pathway implemented and staff in other sites aware of it and how to use as required. Review of falls pathway to include family and patient involvement and information exchange. Most of driver diagram implemented. Red walking frames tested on small scale. Supplier sought. Mobility aid pictorial prompts in place in individual’s bedrooms to promote use. Pictorial prompts for hip protectors also tested and in place. Model for improvement workshop delivered to 9 staff at SBU and PDSA’s shared in full. Oxford teams have visited CLH twice.

CLH: Plan robust evaluation of red walking frames on site – link with Oxford colleagues and local acute trust colleagues. Test out bed sensors. Spread visual risk level indicators for white boards from Mulberry to Willow Ward. PDSA rummage box for distraction and occupation as per Cantilupe Wad. Jenny Lind & Cantilupe: Test intentional rounding on JL ward. All areas: Continue to feed data back to teams. Consider transparency and sensitivity in displaying data for both teams and service users/carers. Consider Comms Team assistance with a screen showing data with narrative to demonstrate our story, on a loop system.

Colin Baker, Ward Manager & Dave Anderson, Physiotherapist plus Julie Burchill, Ward Manager. Colin Baker & Dave Anderson. Dave Anderson. Ruth Kyne with Sally Ashton. Mel Jones. Sally Ashton Sally with Kate

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

Our falls story shared with Oxford Colleagues at their Safer Care Conference. Stock take of work to date trust wide has taken place. Falls prevention leaflet for family/patient has been tested out x 2 and revised for use at both CLH and SBU. This provides both information and a safety briefing for patients/carers.

Revisit Intentional rounding on Mulberry Ward (and Jenny Lind ward).

Nelmes. Ruth Kyne with Gemma Coltraro and Mel Jones.

Pressure ulcers grade 2 – 4 STATUS: Monitoring

Reduce to Zero or greater than 300 days between events by March 2014. Sub aims: Complete risk assessment and skin inspection. Comply with Skin bundle.

Yes Yes – Data has been collected since December 2013 and is reported on the IHI extranet. The number of pressure ulcers including those that are acquired and inherited in inpatient areas will be reported on further.

Wotton Lawn, Charlton Lane & Stonebow Unit

Bundle developed and supplied to all areas/wards. Pressure ulcer training has taken place in 2013 & 2014. Safety thermometer being collected in older persons and learning disability inpatients, and community older persons teams. Pressure Ulcer Register has been created on Trust L Drive. Braden tool tested out and rejected in favour of

Confirm re implementation of:

Completion of risk assessment and skin inspection.

Comply with Skin bundle via RIO core care plan.

More planned education – assessment of skin condition - dates to follow.

Louise Forrester. Overseen by Deputy Director of Nursing, John Trevains, supported by Sally Ashton. Louise Forrester. Louise Forrester and frontline

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

Waterlow tool. staff.

VTE STATUS: Monitoring

Risk assessment and appropriate prophylaxis compliance increased to 95% by March 2014.

Yes

Yes – reported on extranet. VTE monthly data collection taking place in all inpatient sites. 95% compliance and over, is sustained.

Wotton Lawn, Charlton Lane & Stonebow Unit

Risk assessment on admission and appropriate prophylaxis compliance is achieved at over 95% at WLH, CLH and SBU.

Continue to sustain 95% or above. VTE audits to be completed within NICE guidance timescales. Review and assess how to report Pulmonary Embolisms within the Trust to identify a process.

Deputy Director of Nursing, John Trevains with Louise Forrester.

Recognition & Rescue of physical deterioration. STATUS: Planning and development.

Patients who trigger a clinical alert receive an appropriate response. Compliance increased to 95% or more by March 2014. Sub-aims: Patients have complete observations. Trigger patients receive an appropriate response.

Yes Yes -local monthly audit in place for 11 implementation sites. Measurement in place on extranet. Audits have been completed monthly. Significant improvement with completing and recording physical observations

Wotton Lawn, Charlton Lane Stonebow Unit & Maxwell Suite. Learning Disability and Recovery Units. Greyfriars PICU at WLH.

All areas: NEWS charts in place for 100% of inpatients. Daily physical observations taken in older adult wards. Weekly observations in other areas. Audit department involved and reporting has commenced. Recording variants on RIO is in place on Mulberry Ward. Raili Worthington and Mags Trewin attended South West workshop in March 2014. Clinical skills training

Develop and ensure that a robust system for MDT involvement in promoting trigger, escalation and response. Continue site NEWS audits monthly. Work towards peer audits in time. Identify names for audits. Identify medical lead for all sites. Abbey, Priory and Mortimer Wards identified as next sites. Continue NEWS & MERT

Louise Forrester & Raili Worthington with medic for each site. Audit leads to be confirmed. Support lead identified. Louise Forrester. Louise Forrester to link with ward based clinicians.

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

overall. 20% reduction in MERT calls at CLH reported.

implemented including NEWS. ELearning NEWS implemented. SBARD training revisited on Willow Ward, CLH.

training. SBARD/NEWS lanyard prompt card tested and refined for use. To be ordered, printed and given out after training.

Raili and Team. Mags Trewin with Raili & Sally Ashton.

Catheter associated UTI’s. STATUS: Development and Planning.

Reduce by 50% by March 2014. Sub-aims: Reduce number of catheters. Reduce infections. Comply with catheter bundles.

Yes Yes via safety thermometer & IHI Extranet.

Charlton Lane & Cantilupe and Jenny Lind Wards.

Safety thermometer being collected monthly in all applicable wards and is uploaded to the IHI extranet. CAUTI Pilot site identified as Chestnut Ward, CLH. Data being collected on numbers of:

Catheters in place

CAUTIs that occur Care plan has been tested out successfully and used, now uploaded to RiO. Training for one nurse planned.

Continue to maintain data collection and action where risk identified. Continue to gather data. Set up measurement the number of patients with a catheter and the number of patients with a CAUTI – show this as a percentage measure on the IHI extranet. Revisit the contract provided by the visiting PHYLS Nurses as skills are needed for catheterisation.

Louise Forrester. Overseen by John Trevains. Louise Forrester & Gemma Doyle. Sally Ashton. Ruth Kyne.

Unexpected death due to physical illness on inpatient wards.

Reduce to zero or 300 days between such events by March 2014.

No

Yes – days between for all areas. Rare event. Days between measure set up

Wotton Lawn, Charlton Lane & Stonebow Unit

This is a rare event which would be notified as a Serious Incident, where there is currently is a process in place.

Link to NEWS implementation and other physical health aims.

Leads: James Wright / Ruth Kyne/Paul Ward.

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

Monitoring. on IHI Extranet. Data has been obtained and reported at PSIP meeting and extranet.

Sally Ashton with Paul Ryder.

Deaths as a result of self-harm on inpatient wards. STATUS: Monitoring.

Reduce to zero or greater than 300 days between such events by March 2014.

Yes. Yes – days between at Wotton Lawn Hospital & Mortimer Ward. Days between are measured via the Extranet.

Wotton Lawn & Mortimer ward.

Wotton Lawn Hospital – all wards plus Mortimer Ward. This is a rare event which would be notified as a Serious Incident, where there is currently is a process in place. Pocket Guide to top tips for suicide prevention produced by the Trust.

ELearning suicide programme being piloted by James Wright. Continue to use Suicide prevention resources.

James Wright. James Wright and Paul Ward.

Severe harm on inpatient wards. STATUS: Development.

Reduce to zero or greater than 300 days between such events by March 2015.

Yes. Datix reports. This is around 0.1% of all incidents so rare event.

Wotton Lawn Hospital. Mortimer Ward

Definition of severe harm has been clarified as incidents resulting in permanent damage. Narrative from Quality report is included on IHI extranet reporting.

Obtain data for reporting. Sally Ashton with Gordon Benson/Paul Ryder.

Deaths as a result of self-harm in community patients.

Reduce to zero or greater than 150 days between by March 2014.

Yes.

Datix and SI reporting. North CRHTT have achieved over 420

CRHTTs North CRHTT identified as pilot site. Model for Improvement has been shared with team and thematic review

Continue to refer to driver diagram as this will inform the plan.

The specific actions and

Jennifer Mudge with Sally Ashton.

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

STATUS: Development and planning.

days between incidents.

undertaken. Baseline data identified for unexpected death and uploaded to IHI extranet. Contact made with Oxford team to share stories. The team have logged the number of incidents using the Safety Cross, and are engaging more with service users to prevent self-harm. PDSA of self-harm care plan has been completed and refined for use with service user. Better understanding of triggers identified. Improved continuity of approach. CRHTT driver diagram drafted for use. Progress of approach shared with Grace Harrison.

practices of using the safety cross, and discussions about self-harm should be developed and progressed to other Crisis Teams. Hereford CRHTT has been identified. Share this with the wider team North CRHTT at team away day. PDSA refined care plan.

Jen Mudge & Sally Ashton with Grace Harrison. Jen Mudge. Jen Mudge. Sally Ashton.

Deaths as a result of self-harm in community patients.

Reduce to zero or greater than 300 days between by March 2015.

No CRHTTs North CRHTT identified as pilot site.

See above work stream. As above.

Severe harm in community patients.

Reduced to zero or greater than 300 days between such

No

CRHTTs. As above As above.

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

events by March 2015.

Unplanned absence from wards. STATUS: Stock take and plan.

Reduce by 50% by March 2014. Sub-aims: Reduce number. Include low secure. Include informal patients. Comply with MDT review post absence. Comply with patient /carers debrief post absence.

Yes

Yes – number of events in place for all wards to reflect local revised policy. Days between when 50% has been sustained or is a rare event. Days between charts set up. Number of AWOLS (detained) and harm from identified as generally low. Absconding overall (including both detained and informal patients) shows a reducing trend over time since 2009. Detailed charts are produced.

Abbey Ward Dean Ward Priory Ward Kingsholm Ward Mortimer Ward Include Montpellier as low secure. Greyfriars PICU.

Abbey Ward piloted using Bowers tool. Learning has been shared. Revised policy with clearer definitions. Run charts with new definitions established. Data collection in place for all wards. Recording of AWOLS has improved, hence more is known about different reasons why AWOL’s occur. Bowers tool is included in RIO risk screen to standardise and embed practice. Pat Jay identified as lead for Mortimer Ward and safety cross being used to log AWOLS. Activities used to reduce AWOLS identified in both hospitals. Paragraph on “Leave” and expectations has been included in new revised

Continue to implement driver diagram. Ward AWOL “champions” to be identified on all wards at WLH. Assess how reliable process is for interventions such has giving out leave cards. 2 parts to be considered:

Does the patient understand the leave process?

Is it explained and recorded that is has been?

Leave care plan to be tested out at WLH. Increase the understanding of AWOLS that result in harm and are reported via the Serious Incident process -gather data.

Lead: James Wright. James Wright. Pat Jay with Sally Ashton. Sharon Elliott (Priory Ward) with Sally Ashton. Sally Ashton with Paul Ryder.

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

ward handbooks from March 2014. Risk Policy now has added appendix detailing the profile of the person most likely to abscond. Stock take of work to date trust wide has taken place. Consistent practices on all wards identified.

Number of blank boxes on medication charts. STATUS: Development and planning

Reduce to zero. Yes

Yes – number of events in place for 17 wards plus days between where zero has been achieved for 3 wards. 65% reduction in blank boxes across the trust from local ward based reporting via the IHI Extranet. This is an 18% improvement on last year. Annual missed

All inpatient units.

Lead medicines management nurse identified for Westridge, Hollybrook, Honeybourne, Laurel House, Cantilupe, Charlton Lane wards, Montpellier, Kingsholm and Priory, Jenny Lind, and Mortimer Ward, plus Oak House and Willow Ward. These units (Westridge, Hollybrook, Honeybourne and Oak) have achieved Zero and are now on days between measures. Learning has been shared. Forum set up for leads to meet in May 2014 at WLH initially.

Continue to implement missed dose driver diagram. Maintain extranet reports to include identified baselines per ward and aims. Continue to share with teams. Continue to meet with Hospital leads using data for improvement. Spread this model of a forum to CLH and SBU. Complete a stock take of what has worked and been spread (as per falls and AWOL work streams).

Helen Elliott. Sally Ashton. Helen Elliott & Sharon Elliott. Helen Elliott with Sally Ashton.

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

dose audit shows that 98.5% of doses of meds are signed for (not blank) and this has been sustained since 2013.

Submission for 2014 Patient Safety Awards was developed but unsuccessful. Posters showing how teams are doing are being sent out regularly.

Number of missed doses due to medication not being available. STATUS: Development stage.

Reduce to zero by December 2013.

Yes

Data collection tool includes explicit collection of missed doses due to medication not being available and missed critical medication. Trust wide missed dose audit has captured this in 2013.

Continue to use driver diagram. Implement the PDSA worksheet for testing change for “drug not available”. Use data collection tool to Identify reasons why by January 2015. Annual audit to take place.

Jenny Romer with Rachel Jackson.

Medication reconciliation on admission in inpatient units increased to 95%. STATUS: Stock take and development plan.

Within 24 hours by March 2014.

Yes

No. Charlton Lane Wotton Lawn Stonebow Unit

Charlton Lane Hospital – Achieved: Monday to Friday. Wotton Lawn Hospital – achieved Monday to Friday. Audit in place to establish how long after admission was meds rec completed at WLH plus use of meds rec box on front of px chart. Model where Pharmacy

Continue to use driver diagram. Explore different model for Hereford. Complexities of contracts. Identify what processes are in place and provide data. Differences exist in different units. Aspiration of 12 hours where

Jenny & Rachel. Jenny with Trish Jay. Jenny Romer

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

technicians visit wards alternate working days to provide prompt assurance for meds rec on admission following collection of baseline data in development. Procedure for Pharmacy led meds rec assurance (WLH) developed for use on Abbey, Dean, and Kingsholm & Priory Wards. RIO step by step guide – significant event recording in place.

pharmacy technical model is used. Data to be collected/reported. Gather baseline data – for example how many meds are reconciled within 24 hours?

with Pip Barber. Jenny Romer /Pip Barber with Sally Ashton.

Medication reconciliation on discharge increase to 95%. STATUS: Stock take and development plan.

Information provided to the GP and Community team within 24 hours.

Yes

No Charlton Lane Wotton Lawn Stonebow Unit

Wotton Lawn, Charlton Lane Hospital wards and Stonebow Unit.

Revisit driver diagram. Process in place for discharge and his has been spread. Provide data. Work with one or two wards to gather baseline data to establish how many meds are reconciled on transfer.

Jenny Romer

Agreed critical medicines

At, or within, 2 hours of, the

No

All inpatient areas.

Definition understood as standard (Anticoagulants

Plan PDSA in 2 areas only – small scale testing.

Leads: Jenny Romer & Helen

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

administered 95% of the time or greater. STATUS: Stock take and development plan.

prescribed time - by December 2015.

Anticonvulsants Antidepressants Anti-infective & Clozapine). Critical meds list agreed locally. Some data collection has taken place at CLH and WLH Red dots for critical meds tested out on 2 wards – results to be confirmed.

Share the agreed critical meds list with teams. Share data that has been collected. Small sample preferred. Develop a mechanism to include missed critical doses as part of missed doses audit.

Elliott. Jenny & Helen. Jenny Romer.

Improve the satisfaction of patients and carers using our services by March 2014. STATUS: Monitoring.

Improve patient survey satisfaction score from baseline by 25%. Family & Friends test occurring in all areas trust wide.

No Yes – service experience report Family and friends data reported within the Trust – 91% of inpatients feel safe.

Charlton Lane Wotton Lawn Stonebow Unit Recovery Units

Family and friends test occurring in all areas. National patient survey & Individual patient feedback also. This is monitored via the Service Experience Department who collects and collates data. Discussion had with Jane - Use quarterly reports which reflect triangulation of methods used. Narrative is reported on the extranet. Intentional rounding at Oak House implemented to improve engagement and satisfaction.

Monitor service user experience via the quarterly reports which includes development plans. Develop plans for spread to another recovery unit. Gather baseline data if possible.

Quarterly reports from Jane Melton. Sally Ashton. Helen Elliott with Andrew Swithenbank & Sally Ashton.

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

Team Work and communication. STATUS: Monitoring

Daily safety briefings.

Yes on extranet All inpatient areas.

Safety briefings are included in each shift handovers. PMHW shift handover module has been used to structure risk and critical information for handover. Developments in handover structure have been shared across hospital sites within the Trust. Revision of handovers on Willow ward.

Sustain in other areas.

Ruth Kyne, Paul Ward, James Wright

Patient Safety Leadership Walkrounds. STATUS: Monitoring

2 walkrounds per month and % of actions completed.

Yes

Yes - number of walkabouts per month and % of actions completed. 2 visits per month agreed and sustained. 94% of actions completed/closed.

All Trust inpatient areas and high risk community teams.

Fully implemented. Ward and team managers regard an annual visit as helpful and timely enough alongside other visits that are programmed in. Annual schedule planned for 2015. Article describing PSLW visits in mental health article published in Nursing Times June 2014.

Continue to sustain 2 visits per month. 94% actions are completed and sustained. % of actions completed/closed is improving. Outstanding actions identified and being robustly followed up for completion.

Trish Jay & Paul Winterbottom with Sally Ashton. Sally Ashton & Michele Shapland. Sally Ashton.

LOCAL AIMS: Improvement Methodologies

More employees will know of improvement methodologies

Yes (local driver diagram).

Continued reduction in harm across the other areas of the program as more

Trust wide “Aspiring Leaders” programme now includes a Model for Improvement workshop from January 2014 and will continue in

As part of the OD strategy include within the work of the training and development group. IHI Open School ELearning to

Carol Sparks and Trish Jay. Ruth Thomas,

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

by March 2015. staff are aware of the safety program and can use improvement methodologies. The number of people trained in the Model for Improvement is reported on via the IHI Extranet. 10% of the workforce would be around 200 people and equates to one person per team.

2015. Improvement workshops delivered to colleagues to spread methodologies. This has included examples such as SBU inpatient areas, GRIP team individuals, and preceptor ship group and therapy colleagues. Register established of those who know and use the model – this is growing.

be piloted. Senior Leaders to be included. Plan in development. Leadership Management Development Training Programme to include improvement methodologies. Transfer onto other relevant training/events to create opportunities.

Jan Draper and Sally Ashton. Ruth Thomas & Jan Draper.

Wider Communication within the Trust.

To share the developments of the Safety Programme with more front line teams.

All clinical areas.

Continue to send charts to leads on a monthly basis for front line staff. Continue to share key messages from PSIP meetings and Learning Sessions. Use poster resources within organisation. Report on Sign up to Safety Campaign.

Contribute to the Patient Safety Programme intranet pages/Quality Section.

Sally Ashton & PSIP team members with support from Becky Poyntz-Wright. Sally Ashton.

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Programme Aims

Specific Aim Driver Diagram

Measurement in place

Applicable in

Implemented Spread/Next steps Responsible Leads

Include patient safety focus in Positive Practice events. Use PSLW visits as a vehicle for sharing information also.

Re-energise Medical Engagement.

To identify medical colleagues to participate in work streams.

Inpatient and high risk community team areas.

Discussed with Trish Jay and Paul Winterbottom. 2 x new Consultants identified as possible team members.

Identify a medical representative. Meet with Amjad Uppal regarding junior doctors and their QI pieces. Consider if this would marry up with the PSIP.

Sally Ashton.

Local Forum Quarterly team meeting to be res-established and chaired by Trish Jay.

Quarterly team meetings arranged for 2015. South of England Learning Events in between times. Plan communicated to team members.

Continue to meet/maintain contact with work stream leads between meetings and learning sessions.

Sally Ashton.