reducing harm and mortality in hywel dda health board may 11 th 2010

Reducing Harm and Mortality in Hywel Dda Health Board

Reducing Harm and Mortality inHywel Dda Health Board

May 11th 2010


Reducing Harm & Mortality in Hywel Dda - Our Main Aims

• Reduce RAMI to below 100 in 2 years

• Reduce episodes of harm by 25% in 2 years


Executive LeadsJanet Wilkinson:-

LeadershipDr Simon Mahon Medical Director:-

Critical Care& Rapid Response to Acute IllnessBernadine Rees:-

Medicines ManagementTony Chambers:-

Healthcare Associated Infections


Executive Leads

Caroline Oakley Director of Nursing:- Hospital Acquired Pressure Ulcers

Chris Wright:- Surgical Complications

Kathryn Davies:- Hospital Acquired Thrombosis

Dr Sue Fish Medical Director:- Acute Stroke


RAMI 2010

Our aim is to reduce the RAMI to below 100 and also to reduce the variation in our monthly RAMI scores

RAMI 2010

90

100

110

120

130

140

150

Apr-0

6

Jul-0

6

Oct

-06

Jan-

07

Apr-0

7

Jul-0

7

Oct

-07

Jan-

08

Apr-0

8

Jul-0

8

Oct

-08

Jan-

09

Apr-0

9

Jul-0

9

Oct

-09

Period

Indi

vidu

al V

alue


How We are going To Achieve Our Aims

• By Using Continuous Quality Improvement Methodology


How We are going To Achieve Our Aims• Each ward/department required to sign

up to at least one quality Improvement project inline with the requirements of the Health Board Quality Improvement strategy and 1000 Lives+ content areas



• Each ward/department has to complete quality improvement project notification and approval form

Quality Improvement Project Notification Form (For guidance on completion please see the how to guide)

1. What is the area/ service for improvement

2. Who are the team members? Name Name Name Name Name

Role Role Role Role Role

3. Improvement Aims (aim should be clear, specific, measurable, time-specific and patient centred)

4. Project deliverables a. What numerical target are you striving for b. What changes in the system are you expecting

Page 1 of form


How We are going To Achieve Our Aims• These forms will be used to track the

quality improvement projects and ensures that each project has a sponsor and has been agreed

• They will also set out the reporting arrangements for the project


Quality Improvement Project Feedback/Communication form Quality Improvement Project

Progress form

Ward/Department

County

Month

Project Leader

Project Progress Planning Testing Implementing Spreading

□ □ □ □

Number of PDSA’s completed so far (please attach copies)

Successes this month Problems this month Signature

Each ward/department will be required to provide updates on progress on to the 1000 Lives+ teams monthly


Driver Diagram

Reduction of RAMI to below 100 and the numbers of harm to patients by 25%

Episodes of harm occurring to some patients

Reduce Mortality Levels within Health Board

Implementation of Quality Improvement and Patient Safety Strategy

Address data quality Issues with CHKS data Address Backlog of un-coded notes Difficulty in coding some patients notes

Execs to drive forward content areas of 1000 lives+ campaign to reduce episodes of harm to patients Leadership Critical Care Medicines management Healthcare Associated Infections Hospital Acquired Pressure

Ulcers Acute Stroke Hospital Acquired thrombosis Surgical Complications

Train enough staff to undertake GTT audits

Undertake GTT audits in all localities (20 sets per hospital minimum

Being Safe Being effective Improving the Patient Experience

Validation of CHKS and coding data in Mortality and Morbidity meetings

Analysis of CHKS data to identify areas of concern to identify specialities that have high RAMI and/or excess deaths

Quality & Safety teams to be setup in each County which incorporates 1000 lives+ and Quality & Patient safety strategy

Weekly review of all deaths in secondary care


Reduction of RAMI and Harm Primary Drivers

• Reduce Mortality Levels– Weekly Review of all Deaths in Secondary Care– First review meeting held (Execs & AMD’s in attendance).– 39 Deaths reviewed

• Implementation of Quality Improvement and Patient Safety Strategy

– How to Guide for Health Board staff being written

• Reduce episodes of harm to our patients– This will be achieved by ensuring all elements of the 1000 Lives+ are

implemented along with achieving the aims of the Quality Improvement Strategy


Reduction of RAMI and Harm Secondary Drivers

• Analysis of CHKS data to identify areas of potential concern

– This work has already started

• Address data quality issues– Reduce backlog of un-coded notes

• 6000 sets of un-coded notes coded in 6 weeks

– Improve systems for coding of patients notes• Discharge summaries/letters being revised



• Improve systems for undertaking GTT audits in 4 main hospitals– 10 sets every two weeks

– Train more staff to undertake GTT audits

– Improve system for obtaining patients details and retrieval of notes



• Executive lead for each content area tasked with driving forward the initiatives helping to ensure that harm and mortality reduction targets are met

• Quality and Safety teams to be set up in each county


Clinician Engagement• Mortality and Morbidity meetings to be rolled out

across the Health Board• Standard Agenda to include

– Mortality Review– CHKS validation– Unexpected admissions to ITU– Cardiac Arrest Qualitative audits– Adverse Incident– Infection control issues– GTT


Key Quality Issues Currently Being Addressed

• Standardised Handover (SBAR)

• Clerking Performa

• Track and Trigger

• Improved discharge/death documentation

• Clinicians engagement with clinical coding

• DNAR


Driver Diagram

Improved general ward outcomes (Reduced infections, crash calls, pressure ulcers, falls, medication errors, increase sense of patient empowerment and improve care, communication and discharge processes)

Provide appropriate, reliable and safe care to patients using evidence-based therapies (Safety & Reliability)

Create a highly effective and collaborative multidisciplinary team and safety culture (Teamwork & Vitality)

Ensure patient and family centred care (Patient and family centred care)

Develop an infrastructure that promotes quality care (Transformational Leadership)

Early warning system (EWS) to identify patient deterioration & early response systems in place to respond to deterioration

Implement Empowering Ward Sisters leadership development standards

Reduce healthcare associated infections by targets contained within the quality strategy and AOF

Reduce pressure ulcers by 50% (See separate Driver diagram)

Reliable multi-disciplinary care planning, communication and collaboration

Reduce patient falls by 50% (see separate driver diagram)

Promote open communication among team, patient and family

Involve patient and family in goal setting processes

Ensure patient centred end of life care planning

Ensure patient’s physical comfort Optimise patient transfer / discharge to their own home or other facility

Ensure the patient care objectives for each ward are aligned to Health Board priorities

Develop strong leadership for ward based integrated multidisciplinary teams

Use of SBAR principles by 100% of staff

Measure, track and communicate progress towards achieving the vision and objectives

Create efficient and sustainable working environments and systems of work

Develop visual information and communication systems to convey patient information

Provide an environment that has efficient and organised systems in place (Releasing Time to Care)


General Ward Primary Drivers• Develop an infrastructure that promotes quality care

(Transformational Leadership)• Provide an environment that has efficient and

organised systems in place (Releasing Time to Care)• Provide appropriate, reliable and safe care to patients

using evidence-based therapies (Safety & Reliability)• Create a highly effective and collaborative

multidisciplinary team and safety culture (Teamwork & Vitality)

• Ensure patient and family centred care


General Ward Secondary Drivers (Transformational Leadership)

• Continue to implement the ‘Empowering Ward Sisters’ principles for leadership & development in all areas

• Establish integrated multi-disciplinary teams supported by the ward/ department Leader

• Ensure patient care & ward objectives are measurable & aligned to the Health Board priorities


General Ward Secondary Drivers (Releasing Time to Care)

Establish open and accessible processes to report outcome measures

‘Knowing How We Are Doing Boards’ are creating opportunities for staff, patients & public to understand the information and it’s implications for practice.

Create efficient sustainable working environments and systems of work

5’s principles are one example being used to achieve sustainable changes with staff commitment

Develop visual information/ communication systems to convey patient information‘Patent Status At A Glance’ Boards are being developed to support this, with some areas investing in white board technology


General Ward Secondary Drivers (Safety & Reliability)

• Reduce Pressure Ulcers by 50% (See separate driver diagram)

• Reduce Patient Falls by 50% (See separate driver diagram)

• Reduce HAI infections by targets within the Quality strategy and AOF


General Ward Secondary Drivers (Safety & Reliability)

• Modified early warning system (MEWS) to identify patient deterioration– Currently 3 different systems in use

– Scoring systems being aligned to ensure consistency

– Health Board wide system being developed


General Ward Secondary Drivers (Teamwork & Vitality)

• Establish accurate & accountable MDT care planning

• Ensure all MDT communication / handover processes apply the principles of SBAR

some areas have linked the handover to the Patient Status At A Glance board, improving accuracy of information, patient safety and effective use of staff time


General Ward Secondary Drivers (Patient & Family Care)• Ensure patients physical comfort• Involve patients & family with care planning goal

setting and discharge planningNational Fundamentals of Care Audit provides information regarding the patients’ perception annually to all wards, additional short stay areas to be included .

• Communicate openly and effectively amongst the MDT, Patient & Family

• Ensure Patients wishes are respected within end of life care planning

– End of life care pathway provides auditable information


Driver Diagram

Reduce the Percentage of Hospital acquired Pressure

Ulcers(per 1000 patient

days By 50% by

2012

Identification, grading

of pressure ulcers existing on

admission/transfer & appropriate intervention

Assess pressure ulcer risk on admission for ALL patients Re-assess skin every 8 hours Initiate and maintain correct and suitable preventative measures

Understand the risk factors for acquiring pressure ulcers Understand the local context & analyse local data to assess patients on ward/unit most at risk Utilise patient ‘At risk’ cards to quickly identify those at increased risk

Risk Assessment

Risk Identification

Reliable

Implementation of the SKIN ‘bundle’

Address these areas: Surface Keep Turning Incontinence Nutrition

Initiate and maintain correct and suitable treatment measures Utilise the local Tissue Viability nursing expertise

Educate staff regarding the assessment process, identification and classification of, and treatment of pressure ulcers Educate Patients & family Develop patient information pack

Education


Falls Primary Drivers• Identification of Risks• Multifactorial risk assessment• Multifactorial interventions• Communication of falls risk status• Education of staff, patient and family

carer


Falls Secondary Drivers

• Each area to assess their local falls risk-– analysis of falls on units by: time of day,

patient’s age range, type of patients, condition.

• Utilisation of warning cards (above patients head) for patient with a history of falls



• Each ward/Department to work with allied health colleagues to assess– Falls History/ Medication review– Gait Balance, mobility, muscle weakness– Osteoporosis risk– Functional ability– Visual & Cognitive impairment– Urinary incontinence– Cardiovascular assessment - Hazards



• Involvement of patient & family– Include falls status in ward handovers and

safety briefings

– Develop a Falls prevention information pack for patients, families and caregivers

– Develop a Falls education pack and Falls preventions program for staff


Driver Diagram

Reduce the Percentage of Falls (per 1000 patient

days By 50% by

2012 Communication

of Falls risk status

Falls History/ Medication review Gait Balance, mobility, muscle weakness Osteoporosis risk Functional ability Visual & Cognitive impairment Urinary incontinence Cardiovascular assessment - Hazards

Understand local falls risk- analyse falls on units by: time of day, patient’s age range, type of patients, condition. Utilise warning cards for patient with history of falls

Multi-Factorial

Risk Assessment

Risk Identification

Multi-factorial Interventions

Medication review/withdrawal Vision assessment Strength & Balance Training Preparing the environment Diversional therapy Falls prevention toolkits Hourly toileting rounds

Use of Visual Cues Involvement of patient & family Falls intervention team Include falls status in ward handovers and safety briefings Develop a Falls prevention information pack for patients, families and caregivers Develop a Falls education pack and Falls preventions program for staff

Education of Staff, Patient and family/

carer


Pressure Sores

• Baseline data for pressure sores within the Health Board

Pressure Sores

-20

0

20

40

60

80

100

Apr-0

6

Jul-0

6

Oct

-06

Jan-

07

Apr-0

7

Jul-0

7

Oct

-07

Jan-

08

Apr-0

8

Jul-0

8

Oct

-08

Jan-

09

Apr-0

9

Jul-0

9

Oct

-09

Period

Indi

vidu

al V

alue

Special Cause Flag

Data is from CHKS


Pressure Sores Primary Drivers• Risk Identification• Risk Assessment• Implementation of the SKIN bundle• Identification, grading of pressure ulcers

existing on admission/transfer & appropriate intervention

• Education


Pressure Sores Secondary Drivers

• All staff to be able to understand the risk factors for acquiring pressure ulcers

• Understand the local context & analyse local data to assess patients on ward/unit most at risk

• Utilisation of patient ‘At risk’ cards to quickly identify those at increased risk



• All patients to have their pressure ulcer risk assessed on admission

• Re-assess skin every 8 hours

• Initiate and maintain correct and suitable preventative measures when needed



• All wards/Departments to implement the SKIN bundle which aaddresses these areas:– Surface– Keep Turning– Incontinence– Nutrition


Time Scales

• May 11th 2010 Health Board Executives and others attend 1000 Lives+ launch

• May 12th 2010 Aims of 1000 lives+ conveyed to all Health Board Staff

• End of May/Beginning of June ward/department sign up to at least one intervention

• The Transforming Care initiative to be implemented into all ward/in-patient areas by the end of 2012


Thank You


Reducing Harm and Mortality inHywel Dda Health Board

May 11th 2010

Presenter: Dr Simon Mahon Medical Director


Reducing Harm & Mortality in Hywel Dda - Our Main Aims

• Reduce RAMI to below 100 in 2 years

• Reduce episodes of harm by 25% in 2 years


Executive LeadsJanet Wilkinson:- LeadershipDr Simon Mahon:- Critical care& Rapid Response to

acute illnessBernadine Rees:- Medicines managementTony Chambers:- Healthcare Associated InfectionsCaroline Oakley:- Hospital Acquired Pressure UlcersChris Wright:- Surgical ComplicationsKathryn Davies:- Hospital Acquired ThrombosisDr Sue Fish Acute Stroke


RAMI 2010

Our aim is to reduce the amount of variation in our monthly RAMI (2010) scores and make it more consistent

RAMI 2010

90

100

110

120

130

140

150

Apr-0

6

Jul-0

6

Oct

-06

Jan-

07

Apr-0

7

Jul-0

7

Oct

-07

Jan-

08

Apr-0

8

Jul-0

8

Oct

-08

Jan-

09

Apr-0

9

Jul-0

9

Oct

-09

Period

Indi

vidu

al V

alue


• By reducing the amount of variation in the RAMI will improve the predictability of patient outcomes and will help to reduce the frequency of poor results.

reducing harm and mortality in hywel dda health board may 11 th 2010

Documents

days of surgery

harm mortality

main aimsreduce rami

yearsreduce episodes

acute strokerami

monthly rami scores

acute illnessbernadine

critical care rapid