A Health Board and TrustQuality and Safety Improvement Report

Reporting period:

Situation 2

Background 2

Assessment

Mortality and Harm: Local Targets for Mortality and Harm Reduction Mortality Reviews

Improvement Programmes: Reduce Harm & Variation and Deliver Timely Access to

Services Deliver Effective Care Pathways & Proactive Community

Orientated Care Engaging the workforce

4

4

4555

5

Recommendation 6

Appendices: Appendix 1: Scoring system for improvement

programmes7

Appendix 2: Summary of national 1000 Lives Plus programme measures

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1

SituationThe purpose of this report is to provide assurance about progress on structured improvement activities to reduce avoidable harm to our patients; and to eliminate waste and unacceptable variation in our services.

The report incorporates the monitoring of system-level measures of avoidable harm as well as highlighting the information that needs to be available about progress on individual clinical programmes.

Several of the improvement programmes included in the report are key to delivering the Annual Quality Framework for 2011/12, but the programmes also include those which have been identified as priorities for improvement by the 1000 Lives Plus Programme Board; and those identified within the local context. The goal of each clinical improvement programme is to improve outcomes. However, the focus of improvement activity needs to be on changing the processes that will lead to improved outcomes. This presents a challenge when seeking assurance, as process improvement work may need to continue for some time before any impact on outcomes is detectable.

Each clinical programme is assessed with respect to its current position on an improvement journey and this assessment has been made based on quantitative information which is available for scrutiny purposes. It is therefore intended that this assessment of progress should be as robust and challenging as any other aspect of organisational performance.

BackgroundThe Annual Quality Framework 2011/12 includes 4 primary drivers for change (Figure 1). This report focuses on the third driver: the delivery of excellent services that meet the needs of patients and maximize clinical outcomes.

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Figure 1

Figure 2 provides the detail of the secondary drivers in the Annual Quality Framework and highlights how these are linked to 1000 Lives Plus programmes. There is a high degree of alignment, but it is important to note that some AQF requirements for 2011/12 are not reflected in 1000 Lives Plus programmes and that some of the 1000 Lives Plus clinical programmes are not included in the AQF.

Additional programmes included in this report have been included as a result of local analysis of patterns of avoidable harm, including information from mortality reviews.

Figure 2

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Assessment

Mortality and Harm (AQF area)

Local Targets for Mortality and Harm Reduction

Insert local targets for harm reduction; SPC charts of RAMI and GTT adverse event rate per 1000 bed days, plus explanatory narrative. At least 12 months should be included

Mortality Reviews

Insert information about your latest position on mortality review implementation. It is important to outline your position in relation to the following 6 criteria for effective implementation:1. Agreed frequency, involving relevant people in a sustainable way.2. Agreed case selection process.3. Structured review process that identifies system issues.4. Provision of timely feedback to Clinicians and service leaders.5. Highlight learning about system issues and the review process.6. Process for ensuring outcomes of reviews inform strategy.

As themes emerge, these should be highlighted.

Clinical Improvement Programmes

For each clinical programme listed under the secondary drivers you should provide information covering the following areas: Outcome measure where available (see Appendix 2) Progress Score (see Appendix 1) and explanatory narrative. Progress against expected timescale (see Appendix 1).

You may wish to support your assessment of progress by including charts of process measures relevant to the clinical programme (see Appendix 2).

(You may wish to add additional local programme priorities, to those listed below, but all national 1000 Lives Plus programmes that are relevant to your organisation should be included).

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Reduce harm & variation and deliver timely access to services

Improving medicines management Hospital acquired Thrombosis Transforming Care (AQF link) Hospital acquired pressure ulcer (AQF link) Reducing Healthcare Associated Infections (AQF link) Improving Critical Care Transforming Theatres (Reducing Surgical Complications). Enhanced Recovery After Surgery: Abdominal (AQF pathway link) Enhanced Recovery After Surgery: Orthopedics (AQF pathway link) Rapid Response to Acute Illness Transforming Maternity Services

Deliver Effective Care Pathways & Proactive Community Orientated Care

Preventing Falls in the community (AQF link) Improving Cardiac Services (AQF link)

o Chronic Heart Failureo Acute Coronary Syndrome

Improving Stroke care (AQF link)o Transient Ischemic Attacko Acute Stroke careo Stroke Rehabilitation

Improving Mental Health Care (AQF link)o Depressiono Dementia

Engage the workforce

This section should summarise the leadership context for supporting system-wide engagement in quality improvement. Core relevant information includes: Progress on Board level WalkRound implementation and the

testing and spread at other organizational levels and non-hospital settings.

Progress on use of culture survey reports.

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Recommendation

Recommendation(s) should highlight actions required at organisation level to address progress obstacles relating to Will, Ideas or Execution in leadership or clinical programme areas.

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If scoring 0-3 you should include your outcome measure but make it clear no change is expected. this is the baseline

If scoring 7 or above, you should start to see changes in outcome. An outcome run chart annotated with progressive spread milestones will be a good way to demonstrate this.

If scoring 4-6 you should not expect any change in outcome, but processes should be improving. You may choose to include 1 or more process measures to demonstrate this.

Appendix 1: Scoring system for improvement programmesScor

eNarrative Expected

timescale (months

from launch)

Relevant metrics

10Reliable implementation has been achieved in all relevant areas/populations.

9Reliable implementation has been achieved in half of all relevant areas/populations

Local spread

timescale needs to be set at level

7 & monitored through

successive levels.

Timing will be

dependent on

individual programme

’s scope.

8Reliable implementation has been achieved outside the initial pilot area/ population.

7

A plan to spread reliable implementation is in place and spread is underway beyond the pilot area/population. [Include assessment of the total number of clinical areas where implementation required]

6Reliable implementation has been achieved in the pilot area / population

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5

Changes have been fully tested using multiple PDSA cycles in the pilot area and we are now in the process of implementation

6

4

Testing of changes is underway in the pilot area / population. Data collection has commenced and baseline information is available

4

3The Local implementation and data collection strategy for the programme has been agreed

3

2

A programme team has been set up [include composition of the team], a first meeting has taken place and terms of reference for the programme have been set up

2

1 An organisation lead has been 1

7

.

Score

Narrative Expected timescale (months

from launch)

Relevant metrics

appointed for the programme

0

We are not participating in this programme [This score is only relevant for national programmes. A justification for non-participation should be given].

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Appendix 2: Summary of national 1000 Lives Plus programme measures

This provides a summary of the process and outcome measures that are relevant to current national improvement programmes identified by 1000 Lives Plus.

(For further details on data definitions, see relevant “How To” guides).Reduce harm & variation and deliver timely access to servicesProgramme Outcome measures Process measures included in

1000 Lives Plus improvement analysis tool

Medicines Management

% patients ( or results) with INR>81

% patients (or results) with INR>51

Hospital Acquired Thrombosis

Incidence of Pulmonary Embolism1 Compliance with risk assessment for HAT – Surgical

Compliance with risk assessment for HAT – Medical

Transforming Care

Incidence of in hospital falls Incidence of pressure ulcers

% compliance with falls risk assessment process

% compliance with SKIN bundle (or equivalent)

Healthcare Associated Infections

C diff rate2

MRSA rate2

MSSA rate2

Compliance rate hand hygiene Compliance with local anti-

microbial policy Compliance with urinary catheter

insertion bundle Compliance with urinary catheter

maintenance bundle Compliance with PVC insertion

bundle Compliance with PVC maintenance

bundleCritical Care VAP Rate2

CRBSI rate in ITU’s2

CRBSI rate in other areas2

Days between VAP Days between CRBSI

Compliance with central line insertion bundles (adult ITU)

Compliance with central line insertion bundles (Other areas)

Compliance with central line maintenance bundles (adult ITU)

Compliance with central line maintenance bundles (other areas)

Compliance with VAP bundleTransforming theatres (Reducing surgical comps).

Surgical site infection rates - C section 2

Surgical site infection rates – Orthopaedics2

Appropriate pre-op hair removal. Maintenance of peri-op

normothermia. Compliance with WHO checklist.

Enhanced recovery after surgery: Abdominal

% elective patients readmitted within 28 days

Length of pre-op stay for elective patients

Total length of stay for elective patients

% patients cancelled ‘on the day’ or ‘one day prior’ to day of operation

% patients compliant care bundles for:o Immediate careo Intra-op careo Post-op care.o Discharge/follow-up care

Key to data sources other than analysis tool:1. Local data systems 2.Welsh Healthcare Associated Infection Programme (WHAIP) 3. NWIS

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Programme Outcome measures Process measures included in 1000 Lives Plus improvement analysis tool

Medicines Management

% patients ( or results) with INR>81

% patients (or results) with INR>51

Hospital Acquired Thrombosis

Incidence of Pulmonary Embolism1 Compliance with risk assessment for HAT – Surgical

Compliance with risk assessment for HAT – Medical

Transforming Care

Incidence of in hospital falls Incidence of pressure ulcers

% compliance with falls risk assessment process

% compliance with SKIN bundle (or equivalent)

Enhanced recovery after surgery: Orthopedics

% elective patients readmitted within 28 days

Length of pre-op stay for elective patients

Total length of stay for elective patients

% patients cancelled ‘on the day’ or ‘one day prior’ to day of operation

% patients compliant care bundles for:o Immediate careo Intra-op careo Post-op care.o Discharge/follow-up care

RRAILS Number of Cardiac Arrest Calls Number of do not attempt Resuscitation (DNAR) orders

% patients compliant care bundles for

o Sepsis Six resuscitationo NICE CG50 admissiono NICE CG 50 recognitiono NICE CG50 response

Transforming Maternity Services

VTE incidence per month. % patients compliant care bundles for:o Admission bundleo Recognition bundleo Response bundleo Sepsis 6 bundle

Deliver Effective Care Pathways & Pro-active Community Orientated Care

Key to data sources other than analysis tool:1. Local data systems 2.Welsh Healthcare Associated Infection Programme (WHAIP) 3. NWIS

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Programme Outcome measures Process measures included in 1000 Lives Plus improvement analysis tool

Falls prevention

Number of calls for 999 ambulances as a result of falls from standing height

Number of hip fractures registered on the National Hip Fracture database.

% patients compliant care bundles for:o Trigger Bundleo Assessment Bundleo Intervention Bundleo Monitoring Bundle

Acute coronary syndrome

(Measures being developed). % patients compliant care bundles for:o Continuing Inpatient

Monitoring Bundle

Chronic Heart Failure

% patients readmitted within 28 days3

(Other measures being developed).

% patients compliant care bundles for:o Chronic Heart Failure

BundleStroke - TIA TIA - % patients suspected of TIA

who have a Stroke within 28 days % patients compliant care bundles

for:o Symptom recognition and

referralo Timely specialist management,

Low Risko Timely specialist management,

High Risko Secondary prevention and risk

managementAcute stroke care

% patients surviving 7 days post admission to a hospital with an acute stroke unit

% patients compliant care bundles for:o First Hours bundleo First days bundleo First 3 days bundleo First 7 days bundle

Stroke rehab % of patients discharged that return to normal place of residence3

% patients readmitted at 28 days post discharge

% patients compliant care bundles for:o Seamless transition of care

between acute and rehab setting

o Rehabilitation planningDepression % of patients who have completed

the two depression screening questions.

Dementia Defined Daily Doses (DDDs) of target anti-psychotics per 1000 GP list population

% patients over 65 who have an entry on admission checklist to check if information re dementia diagnosis sought.

Number of patients following agreed dementia pathway (as % of at risk group i.e. over 65s)

% of patients of at risk group(i.e over 65s) on antipsychotic medication

% of relatives’ satisfaction with care surveys completed.

Engage the Workforce

Key to data sources other than analysis tool:1. Local data systems 2.Welsh Healthcare Associated Infection Programme (WHAIP) 3. NWIS

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Programme Outcome measures Process measures included in 1000 Lives Plus improvement analysis tool

Leadership Number of WalkRounds undertaken

Key to data sources other than analysis tool:1. Local data systems 2.Welsh Healthcare Associated Infection Programme (WHAIP) 3. NWIS

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