Bernadette George, Head of Safety, Risk & Patient Experience. Em Wilkinson- Brice, Deputy Chief Executive / Chief Nurse

Transcription

1 Agenda item: 8.1, Public Board meeting Date: 29 th July 2015 Title: Prepared by: Bernadette George, Head of Safety, Risk & Patient Experience Presented by: Em Wilkinson- Brice, Deputy Chief Executive / Chief Nurse Responsible Executive: Summary: Actions required: Status (*): Em Wilkinson- Brice, Deputy Chief Executive / Chief Nurse This paper provides the detail of the Trust s 2015/16 Patient Safety Programme The Board of Directors is asked to receive and not the report Decision Approval Discussion Information x x History: Link to strategy/ Assurance framework: The issues discussed are key to the Trust achieving its strategic objectives. Monitoring Information Please specify CQC standard numbers and tick other boxes as appropriate Care Quality Commission Standards Outcomes Monitor Finance x Service Development Strategy Performance Management x Local Delivery Plan x Business Planning Assurance Framework Complaints Equality, diversity, human rights implications assessed Other (please specify) 29 th July of 6

2 1. Purpose of Paper 1.1 The purpose of the paper is to share with the Board of Directors the Trust s 2015/16 Patient Safety Programme. 2. Background 2.1 For many years the Trust has developed and delivered an annual Patient Safety Programme. The programme has been developed and informed in the following way: A review of the organisational temperature check in relation to Risk and Patient Safety presented at the April 2015 Safety & Risk Committee to identify key work streams Alignment and review of national Commissioning for Quality and Innovation (CQUIN) and local patient safety priorities through the Academic Health Science Network which have Sepsis and Acute Kidney Injury as key programmes of work. Working with key leads to agree stretch outcomes for the identified work streams Review and agreement on priorities through the Patient Safety Group Creation of implementation plans to deliver the programme The Safety and Risk Committee will monitor implementation and progress of the Patient Safety Programme, providing regular reports including both success and challenges, to the Trust s Governance Committee and thereby to the Board of Directors. In parallel to the delivery of the 2015/16 Patient Safety Programme, the Deputy Chief Executive/Chief Nurse and the Medical Director will explore alternative approaches to leading the Trust in further improving safety for patients. This will include clinical conversations focussed on consideration of broader aspects of clinical practice, such as make up and deployment of clinical teams and clinical leadership. 3. Analysis : 2015/16 Patient Safety Programme Work Streams 3.1 Think Glucose Think Glucose was part of the 2014/15 Patient Safety Programme and a local CQUIN. Further work is required to make this a sustained change. All ward areas will continue to participate but focus from the Diabetes Team will be on the acute assessment areas and on the triple assessments. This involves assessing if the patient needs review by the in-patient diabetes team, has high risk feet (and needs review by the in-patient podiatrist) or needs review by a dietician. The measurement will be: 75%% of the triple assessments completed within 24 hours of admission by the end of Quarter th July of 6

3 >90% of the triple assessments completed at some point during the hospital admission. 3.2 Skin Matters It is now over 2 years in the Trust since a patient developed a grade 4 pressure ulcer as a result of our care. Last year s programme delivered a 40% reduction in grade 3 pressure ulcers and a 40% overall reduction in grade 1-4 pressure ulcers. The Tissue Viability team for this year s programme will focus on wards with higher incidence of grade 2 pressure ulcers. The measurement across all wards will be: >20% overall reduction in grade 1-4 pressure ulcers >85% compliance with the Skin Bundle as measured on Safety Thermometer day. 3.3 Reducing Harm From Falls Falls remains a key priority for this year. Learning from our pressure ulcer prevention work over recent years, the focus will be the newly launched falls bundle and ward compliance. Key interventions such as cohort bay nursing and toilet / commode tagging and the perfect night shift in addition to this are being tested and adopted through the in-patient wards. The measurement for this will be: >85% compliance with the falls bundle at ward and Trust level by the end of quarter 4 30% reduction in avoidable harm from falls from incident reporting 3.4 Medication Safety The traditional NHS Safety Thermometer is firmly embedded within the Trust and performance is consistently in the upper quartile nationally. The Patient Safety Programme last year tested a Medication Safety Thermometer on five ward areas. The aim of the programme this year will be to adopt a Trust wide approach on alternate months to support the improvement in Medication Reconciliation, Allergy Status, Medication Omission, and identifying harm from high risk medicines in line with Domain 5 of the NHS Outcomes Framework. This will be supported by a nonrecurrently funded project looking at medication safety and human factors at ward level, funded from a successful bid to Health Education South West. 3.5 Reducing Acute Kidney Injury (AKI) AKI was part of the Trust s Patient Safety Programme last year. AKI is a national CQUIN this year and focuses on discharge information back to primary care. There are 4 elements: Early recognition of AKI Medication review and documentation of any changes Communication back to the General Practitioner of AKI including what needs to happen next for the patient 29 th July of 6

4 When to follow-up and which bloods need to be re-checked Recent discharge summary audit figures over the past three months show that we are 20% compliant with the above when patients have had an AKI. The measurement will be: >90 of patients through the discharge summary will have all 4 elements recorded by the end of quarter Surviving Sepsis As expected this is a national CQUIN this year. Building on the Sepsis work from the Trust s Patient Safety Programme from last year. We have agreed with the commissioners to focus on assessment and administration of antibiotics within an hour in the Emergency Department, Surgical Assessment Unit and Acute Medical Unit. The measurement across these areas will be: >90% of eligible patients screened for sepsis by the end of quarter 4. >90% of eligible patients receive antibiotics within an hour by the end of quarter 4. As part of the Trust s improvement work in relation to the recognition and treatment of the deteriorating patient, with the launch of the revised Early Warning Scoring chart, we will be launching the Sepsis Six bundle for in-patients who develop sepsis during their admission. 3.7 Reducing Mortality The revised Mortality review process is due to launch where all unexpected deaths will be reviewed. Lessons learnt from this will be shared with individuals and teams. Continued focus on sepsis and deterioration should deliver a Standardised Hospital Mortality Indicator (SHMI) of better than expected. 3.8 National Sign Up to Safety Campaign The national Sign up to Safety Campaign is harnessing the commitment of staff across the NHS in England to make care safer. This Patient Safety campaign is one of a set of national initiatives to help the NHS improve the safety of patient care. Collectively and cumulatively these initiatives aim to reduce avoidable harm by 50% and support the ambition to save 6,000 lives. There are five key pledges to the campaign. The five pledges are outlined below: Putting safety first. Commit to reduce avoidable harm in the NHS by half and make public our locally developed goals and plans Continually learn. Make our organisation more resilient to risks, by acting on the feedback from patients and staff and by constantly measuring and monitoring how safe our services are Being honest. Be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong Collaborating. Take a lead role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use Being supportive. Help people understand why things go wrong and how to 29 th July of 6

5 put them right. Give staff the time and support to improve and celebrate progress. We had previously signed up to the campaign as part of membership with NHS QUEST. Signing as an individual organisation will allow us to promote our work further aligned to the national pledges. 4. Resource/legal/financial/reputation implications 4.1 Financial implications There is significant health economic data which supports the notion that poor care costs money therefore safe care is better value for money. 4.2 Legal implications None identified 4.3 Reputation implications It is vital that the Trust continues to expect patient safety to be a minimum standard. The Patient Safety Programme is an embedded and integral element of the Trust s fabric. 5. Link to BAF/Key risks 6. Proposals 6.1 The Board is asked to note and support the 2015/16 Patient Safety Programme. 29 th July of 6

6 Appendix 1 29 th July of 6