Quality Matters A focus on Annual Quality Improvement Priorities

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1 I S S U E 4 S e p t e m b e r Dorset HealthCare University NHS Foundation Trust Quality Matters A focus on Annual Quality Improvement Priorities Annual Quality Improvement Priorities p.1 Quality Matters; Welcome to this month s Quality Matters. This edition of Quality Matters has been produced to focus on progress against the Board s agreed Annual Quality Improvement Priorities which were also highlighted in the Spring edition of Quality Matters. To achieve these priorities, we need all our staff and teams to help champion and deliver them. We would ask all Managers and Team Leaders to discuss the priorities with their teams and to consider with their team how they are performing against each of the priorities and how they can make further improvements in these areas. It is only by all working together addressing the same priorities that we can bring significant improvements to the quality of care that we deliver. Best wishes, Jane Elson, Director of Quality Every year, the Trust consults with our staff, professional advisory committees, key external stake holders and service user and carer groups to identify 3 annual Quality Improvement Priorities which will bring about the most significant changes in delivering high quality care and improve the patient experience. The Annual Quality Improvement Priorities for 213/14 are shown in the picture to the right. This issue of Quality Matters focuses on sharing with you, current work programmes and performance towards meeting these goals. The Annual Improvement Priorities contain at least one priority for each of the domains Quality, i.e. patient safety, clinical effectiveness and patient experience. By consulting and involving staff and stakeholders in agreeing the three quality improvement areas and by clearly communicating these to all staff (clinical and non clinical) our aim is to ensure that everyone understands the priorities and will help to support and deliver the programmes in place to achieve these objectives. Reducing hospital acquired pressure ulcers p.2 Pressure ulcer risk assessments p.3 Implementing the Dementia Care Pathway p.4 The Friends and Family Test p.5 It is only through the collaborative working and shared vision that we can achieve the three Annual Quality Improvement Priorities.

2 Patient Safety Priorities for 213/14 Reduce the number of avoidable hospital acquired pressure ulcers Throughout 213/14 we aim to reduce the number of hospital acquired pressure ulcers that are avoidable. The diagram below shows the areas that staff are focusing on in order to reduce the avoidable pressure ulcers that patients can acquire in our hospitals. Pressure Ulcer - Driver Diagram So how do we know if they were avoidable? All grade 3 and 4 pressure ulcers a subject to a Root Cause Analysis (RCA) which breaks down the causes of an incident so that we can understand why it occurred and if anything could have been done to prevent it. All RCA s are then reviewed by the Trust s Physical Health Panel and this group decide whether the PU was avoidable in line with guidance issued by the NPSA. In 212/13 we had a total of 4 pressure ulcers that were avoidable, these occurred on Stanley Purser Ward, Swanage Hospital, Radipole W ard, Out Comes Primary Drivers Secondary Drivers Westhaven Hospital (x2) and Fayrewood Ward, St Leonards Hospital. In 213/14 there have been 4 grade 3 and above hospital acquired pressure ulcers reported, these were on Fayrewood Ward, St Leonards Hospital; Stanley Purser Ward, Swanage Hospital; Guernsey Ward, Alderney Hospital and Saxon Ward, Wareham Hospital. These have been reviewed by the Physical Health Panel and have been deemed as unavoidable. Reduce Avoidable pressure ulcers in hospital Risk identification Risk Assessment Reliable implementation of the SKIN bundle Identification, grading of pressure ulcers (site acquired/transferred in) Education Understand pressure ulcer risk factors / who s most at risk in this ward/home? Understand local context and analyse local data to assess patient/residents at risk (where & when) Utilise visual cues/verbal and written communication systems to quickly identify those at risk Assess pressure ulcer risk of ALL patients on admission Carry out a four-eyed skin check Reassess risk daily/or when change in patients condition/needs Using the SKIN bundle ensure all components are addressed according to need S Surface (e.g. mattress/bed /cushion/inspect skin) K - Keep moving- regular re-positioning I Incontinence- attentions to areas of increased moisture/dryness N - Nutrition- regularly offer fluids/ check dietary intake/ fill water jug and keep it near to patient Utilise Grading tool (e.g. Waterlow community / Braden) Initiate and maintain correct and suitable treatment Utilise local tissue viability nursing expertise Staff education Educate patient and family develop utilise Patient/Carer leaflet Patient & family education What have we learnt from the Pressure Ulcers we have reviewed? We need our trust experts to be involved in staff training - a training programme has now been developed and delivered by Specialist Nurses who reinforce the principles of best practice. Mental Health Services need improved access to Tissue Viability Services a review of the Tissue Viability Service to consider resources and capacity is being undertaken. We have found that some staff are not carrying out or documenting that an assessment took place (even if the pressure ulcer would continue to get worse due to the patient s condition). Proper documentation would help to reduce avoidable incidents. We need to improve education and understanding for patients and carers 2 Quality Matters September 213

3 Patient Safety Priorities for 213/14 continued... As shown in the driver diagram on Page 2, carrying out risk assessments to ensure that the correct care can be provided is a key part of the overall package to reduce pressure ulcers. In Community Hospitals and Older People s Mental Health Wards we use the Braden Tool to determine whether patients are at risk of developing pressure ulcers. Braden Scores should be completed within 4 hours of admission; by quickly identifying those that are at risk we can ensure preventative strategies are implemented at the earliest opportunity. We have monitored the timeliness of completing Braden Assessments in Community Hospitals since December 212 and also began doing this in June 213 in Older People s Mental Health Wards. Each month matrons and ward managers do a snapshot audit of patients when completing their monthly Safety Thermometer submission (which measures harm from pressure ulcers, catheter associated urinary tract infections, falls and VTEs). Linking the two audits is an important quality improvement tool, as this allows the auditor to assess any correlations between the timeliness of assessment and pressure ulcer incidence. The two graphs below demonstrate compliance with the 4 hour target, as at August 213. Within our contract with Dorset Clinical Commissioning Group we are required to achieve at least 95% compliance trust wide, on a monthly basis. Compliance tends to be better in community hospitals as these wards have been now been auditing regularly for some time. Mental Health teams are working on improving this and staff are being supported on how assessment is key to the delivery of a reduction in pressure ulcers. Michelle Hopkins Head of Patient Safety and Risk 9% % 7% % 5% 4% % Braden Risk Assessments completed within 4 hours of admission OPMH Wards - August % 7% Target 95% % 3% 25% 2% 1% % Chalbury Melstock Meyrick Springbourne 95% % Braden Risk Assessments completed within 4 hours of admission Community Hospital Wards - August % Target 95% 9% % 83% 84% % 76% 83% 75% 86% 7% % 5% 44% 4% 3% 2% 1% % 3 Quality Matters September 213

4 Clinical Effectiveness Priorities for 213/14 To implement the dementia care pathway across all services In 213/14 three new services for people with dementia were introduced the Memory Assessment Service (MAS), the Memory Advisor and Support Service and the Intermediate Care Service for Dementia (ICSD). These services are essential developments towards implementing a dementia care pathway across all services. The Trust s Associate Medical Director is working with older people s consultants and operational leads to implement individual care pathways for these new services, with clear auditable standards. The Memory Assessment Service supports Dorset residents who are worried about their memory. Memory loss can have a number of causes including stress, depression, bereavement or dementia. The MAS work with the person and their family to provide a comprehensive assessment and diagnosis. In some cases treatment can be offered to slow down memory loss and information, support and signposting to other services is also provided. The service aims to decrease the overall diagnosis gap to below average for the UK by working with primary care to encourage individuals to access diagnostic services during the early stages of memory loss. In addition the service will establish a baseline referral rate from staff within Community services and Community Hospitals to encourage all health care services in touch with clients who may have memory problems to refer. The Trust is also currently developing the Memory Advisor and Support Team, and how this fits into the wider dementia care pathway. The team provides low level support, advice, information and signposting for people with memory loss in the Bournemouth and Poole area, as well as a number of memory cafes. In addition, the team are working on establishing an increase in the access to Steps to Wellbeing (talking therapies) services for carers of individuals with dementia. The team works closely alongside the Memory Assessment Service to ensure that individuals are encouraged to access a diagnosis. The ICSD service was set up in April 213 and currently provides support and treatment for patients in East Dorset with a diagnosis of dementia who already access DHC secondary services. The service was developed to assist in delivering the first National Dementia Strategy ensuring service provision that is evidence based and fit for the 21st century. The service provides intensive support for people with dementia who become more acutely unwell, aiming to help the person remain in their own home whilst receiving assessment and treatment from the team, and avoid admission to hospital. Standards for delivery of care have been agreed for the Memory Assessment Service and the Intermediate Care Service and are currently being implemented. These standards are monitored monthly and are based on the specification with Dorset Clinical Commissioning Group. The table below shows these standards and the latest available results. These new services are considered essential for the development of a Dementia Care Pathway, which the Trust will continue to work to develop across the County in partnership with the CCG. Standard Referral screening within 24 hours ( target) Initial assessment offered within 4 weeks of referral ( target) Number of referrals and re-referrals per month split by locality Number of new and follow up face to face and telephone appointments per month split by locality Numbers diagnosed each month with dementia, mild cognitive impairment and dementia with LD Latest Achievement (July 213) 99.5% 23 received 972 undertaken 142 Number of home visits each month 338 Number of referrals not accepted with reasons Numbers discharged each month and whether they were in receipt of an anti dementia drug prescription or not Number of DNA s and cancellations as % of all appointments Number of scans requested by type Number of complaints per month (target to be less than 5% of treatments) Hazel McAtackney Head of Clinical Effectiveness and Audit 4 Quality Matters September discharged on a prescription, 34 discharged not on a prescription 4.15% DNA s and 13.25% cancellations 11 CT, 8 MRI, 2 DAT Number of 6 month reviews 215 Standard Number of Referrals Referred Outside Core Hours (7:3-19:3) Number of Referrals - By Source Number of Discharges Referral to Discharge within 6 weeks Number of Admissions prevented MAS I ICSD I Memory Support Team MAS Standards ICSD Standards Latest Achievement (July 213) 74 referrals 74 referrals, outside of core hours - 7 internal (52 OPCMHT, 17 OPMH Ward, 1 AMH Ward) - 1 Local Authority Social Services - 3 Other (1 other clinical speciality, 2 other) 66 discharges 65 Discharges within 6 weeks 62 prevented admissions

5 The Friends and Family Test has been used by Community Hospitals and Minor Injury Units since April 213 and has also recently been introduced to Mental Health Wards. We report on our response rate and net promoter scores internally and on our website on a monthly basis our recent scores and response rates are shown below. We need your help to encourage patients to undertake the survey! Net promoter scores are calculated using the: Proportion of respondents who would be extremely likely to recommend (response category: extremely likely ) minus Proportion of respondents who would not recommend (response categories: neither likely nor unlikely, unlikely & extremely unlikely ) Patient Experience Priorities for 213/14 To implement the principles of the national Friends and Family Test (FFT) across Community Hospitals and Minor Injury Units 12 1 How likely are you to recommend our service to friends and family if they need similar care or treatment? The survey has been translated into 8 different languages, and sign language, and is also In 213/14 the Friends and Family Test has been implemented in Community Hospitals Wards, Minor Injury Units and Mental Health Wards and is offered to all patients on discharge. available in larger text. Results are published on the Trust website as well as Ward Quality Notice Boards. One of the key milestones for this priority was to reach a 15% response rate by the end of Quarter 1 (June 213). Unfortunately this was missed by just 2%, and DHC achieved an % 88 86% 91% 82% 25 Response rates and net promoter scores for Community Hospitals and MIU's August % overall response rate of 13%. Now, the aim is for each unit to achieve a response rate of 2% or more by the end of Quarter 4 (March 214). Most Community Hospital Wards now regularly achieve over 2%. In August Tarrant Ward was the highest performing ward (91%), followed by Jersey ward (86%). These scores were both higher than the national average for In-patient units in July (27.8%). At the other end of the scale Langdon and Ryberry wards at Bridport Hospital and Swanage MIU all had a response rate of %. In August 1 out of 19 mental health wards had a response rate of %. Conversely, Florence House, Glendenning, Haven and Twynham achieved, followed by Flaghead (94%) and Alumhurst (83%). The Friends and Family Test is a new initiative within mental % % % 32% 81 5% % 7% 24% health and was introduced to wards in July. 213, however It is important we all work together to achieve this priority. A trust wide response rate of 2%+ is only achievable if all teams participate and actively encourage patients to complete the friends and family test. The survey captures valuable patient feedback that will allow teams to reflect on, celebrate and improve the care their provide. 86 6% 9% 84 22% 1 8% Response Rate Net Promoter Score Response rates and net promoter scores for Mental Health wards August 213 Katie Childerhouse Patient Experience and Customer Services Manager % 94% % -5 Response rate Net Promoter Score 5 Quality Matters September 213