presenter improving quality together: making improvement a habit
TRANSCRIPT
Presenter
Improving Quality Together: Making Improvement a Habit
Dominique Bird
National Programme Lead
1000 Lives Improvement Service
Public Health Wales
• Population of 3 million
• Served by 7 Health Boards and 2 Trusts – cross primary, secondary and community services
• 84,000 staff
NHS Wales
Decisions about change
Knowledge about what change is needed
Improvement led by the frontCardiology adapted ADULT ACUITY/DEPENDENCY TOOL
Levels of Care Inclusion Criteria Guidance on Care Required Examples of Cardiology Patients
Level 0
Patient requires hospitalisation. Needs met through normal ward care.
Elective Medical or Surgical Admission, Routine Post Diagnostic/Surgical Procedure care. May have underlying medical condition requiring on-going treatment. Patient awaiting discharge.
Routine post-op / post procedure care (Incl 1/2 hrly obs until stable), Regular observations 2 -4 hourly, ECG monitoring to establish stability, Fluid management, PCA, Oxygen therapy 24 - 40% (Specialist Surgical Areas ONLY - single chest drain). Requires routine nursing assistance
Patients NEWS score <4 Stable A.C.S transfer (pain free, no arrhythmias) Post Diagnostic angio (complication free) Pre &post T.O.E. In house pre-op CABG+/-AVR Stable patient pre/post PPM/ ICD Elective patients pre procedure. Ward attenders. Patients awaiting discharge.
Level 1
Appropriately managed on in-patient ward but requires more than baseline resources. Level 1a- Acutely ill patient requiring intervention or those who are UNSTABLE with a GREATER POTENTIAL to deteriorate.
Observation & Therapeutic Intervention - "Step Down" from Level 2 care. Post-Op care following Emergency or Complex Surgery, or following peri-operative event. Emergency Admission requiring immediate therapeutic intervention. Deteriorating Condition or Fluctuating vital signs.
Instability requiring continual observation/ invasive monitoring, Support of Outreach Team but NOT higher level of care. Oxygen Therapy greater than 40% +/- Chest Physiotherapy 2 - 6 hourly. Arterial Blood Gas analysis - intermittent. 24-48 hours following Tracheostomy, insertion Central lines/ Epidurals/ Chest drains.
Patients with new NEWS >4(review at each NEWS trigger) Arrhythmia patients with rate<40; or h/o V.T; or temp wire insitu. Immediate care post PCI 4hrs Post complex PCI/ Rotablation /CTO 6hrs Sheath in situ post procedure Central line in situ Chest drain in situ Patients receiving IV GTN with stable observations Not true STEMI patients – see below Post emergency diagnostic angiogram i.e confirmed normal coronaries, pericarditis and Takotsubo to await repat to DGH or bed in appropriate area. STEMI patients <24hrs post event painfree, haemodynamically stable,rhythm stable and oxygenation stable & consultant review needed. Post GITU transfer 12hrs then reassessed
LEVEL 1 b -
Patients who are in a STABLE condition but have an increased dependence on nursing support.
Severe infection, Sepsis, Complex wound management. Compromised Immune system. Psychological Support/Preparation. Requires Continual Supervision. Spinal
Complex Drug regimes, Patient and/or carers require continued support owing to poor disease prognosis or clinical outcome. Completely dependent on nursing assistance for all activities of daily living. Constant observation due to risk of harm.
Pulmonary hypertensive patients. Endocarditis patients requiring 4hrly IV ABX End of Life patients Heart failure patients requiring continuous IV frusemide &increased nursing support All care patients
Team working
Students leading improvement• “Language such as ‘she’s been
padded’ and ‘we’ve given her pads’ are regularly heard in situations such as handover rather than saying we will do 2 hourly toileting”
• Design and implement a leaflet titled ‘Be in the know, don’t wrap and go.’– A 14% increase in patients not using any
continence aids by night and a 43% increase by day;
– A 29% decrease in the use of ‘nappy pads’ by night and a 61% decrease by day
Improvement led by the front
So how did we do it?• Common language of improvement• Focus on person-centred care• Consolidation of quality improvement in
NHS Wales to date
Learning programme of quality improvement skills:– Quality improvement backbone for
NHS Wales– Integrated in learning & development– Integrated into practice
IQT Learning Programme
• 3 levels of development:– Bronze – what – 2 hours– Silver – how – 3 days– Gold – teach - network
• Complemented by Board level development.
So how are we doing?
“Improving Quality Together will release some of the untapped potential that we’ve got in the workforce, enabling everyone to have the understanding and permission to make small changes that will make things better for patients,”
Rachel Robins, Nurse Metrics Lead
Thank you!Diolch!Merci!
www.iqt.wales.nhs.uk