Quality & Safety Committee Date: 25 th June 2015

Size: px

Start display at page:

Download "Quality & Safety Committee Date: 25 th June 2015"

Morgan McCarthy
8 years ago
Views:

1 SUMMARY REPORT ABM University Health Board Quality & Safety Committee Date: 25 th June 2015 Agenda item: 3.10 Subject Health Acquired Pressure Ulcer Reporting Prepared by Approved & Presented by Purpose Cathy Dowling Interim Assistant Director of Nursing Rory Farrelly Director of Nursing and Patient Experience The purpose of this report is to advise the quality and safety committee on the requirements of the new all Wales reporting for health acquired pressure ulcers and implications of moving to datix rather than care metrics data capture. Corporate Objectives Healthier Communities Excellent Population Outcomes X Sustainable & Accessible Service Fully Engaged and Skilled Workforce Decision Approval Information Other Effective Governance Executive Summary The National Health Service (NHS) delivery outcome framework requires all health boards in Wales to report incidents of health acquired pressure ulcers. The Welsh Government In Safe Hands statutory guidance (2010) also places an expectation that all serious cases -grade 3, 4 and unstageable are reported to Welsh Government as serious incidents and investigated to rule out possible neglect to vulnerable adults. Up until May 2015 the health board recorded hospital acquired pressure ulcers on the care metrics and this was the data used to inform performance reporting to the board and Welsh Government. However these figures did not include community acquired or all categories of hospital acquired only categories requiring serious incident investigation. Since the move to Datix reporting we are now able to capture all grades of pressure ulcer both hospital and community acquired plus severity of harm to patients. This change will result in an apparent increase in overall numbers of reported health acquired pressure ulcers. A review of other health boards in Wales reporting mechanism has also identified a mixed picture making benchmarking with others unreliable. Key Recommendations The Quality and Safety Committee are asked to support the move to the new reporting and investigating procedure and data capture. This will enable more targeted focus on areas for further improvement and shared learning. Assurance Framework Healthcare Standards and NHS Delivery Framework. X x Next Steps 1

2 Adopt the new reporting mechanism and future scorecard into quality and safety monitoring and performance mechanisms to drive forward further improvements and avoidance. 2

3 MAIN REPORT ABM University Health Board Quality & Safety Committee Date: 25 th June 2015 Agenda item: 3.10 Subject Prepared by Approved & Presented by 1. BACKGROUND Health Acquired Pressure Ulcer Reporting Cathy Dowling Interim Assistant Director of Nursing Rory Farrelly Director of Nursing and Patient Experience Pressure ulcers are painful and debilitating and if left untreated can lead to serious harm (NPSA 2010). Extensive work through initiatives such as 1000 lives plus has raised the profile of pressure damage with initiatives such as the SKIN bundle helping the improvement needed in avoidance and reduction of harm for patients. The NHS outcome and delivery framework require all health boards in Wales to report numbers of health acquired pressure ulcers and seek improvement through reduction. The data to inform the health board performance and position has been obtained through the care metrics which has only collated level 3, 4. This has resulted in an inability to determine the organisation wide picture of numbers, grades, severity of harm and place of residence when the patient acquired the pressure ulcers (appendix 1). 2. SITUATION In April 2015 the all Wales tissue viability forum and the all Wales adult protection co-ordinators in Health and Social Care have collaborated to agree a standardised approach to pressure ulcer reporting and investigation in order to safeguard individuals. As a consequence the number of categories of pressure ulcer has increased from four to six. The new categories are: Suspected Deep Tissue Injury and unstageable pressure ulcer. In December 2014 ABMU launched datix web and work has been underway to align the datix template to the reporting and investigation requirements for pressure ulcers. This new reporting mechanism went live in May 2015 and has resulted in the development of the new reporting score card (appendix 2). 3. ASSESSMENT The previous reporting arrangements identified that the average monthly pressure ulcers that were reported within the hospital environment was 20, this did not include environments of care outside the inpatient areas. The May score card (Appendix 2) identifies total numbers of health acquired pressure 3

4 ulcers both hospital and community and severity with an increase in average numbers to 44 in-patient and 29 community. Further benchmarking with other health boards in Wales has also identified a mixed reporting arrangement through datix, metrix and ward based safety crosses. This makes accurate comparisons with other health boards unreliable. 4. RECOMMENDATION The Quality and Safety Committee is asked to support the move to the new reporting and investigating procedure and data capture. This will enable more targeted focus on areas for further improvement and shared learning. 4

SAFE CARE - I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOW HARM Measure 1: Number of healthcare acquired pressure ulcers Strategic Aim : Excellent patient outcomes and experience Strategic

5 SAFE CARE - I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOW HARM Measure 1: Number of healthcare acquired pressure ulcers Strategic Aim : Excellent patient outcomes and experience Strategic Change Programme: Quality & Safety IMTP Profile Target : WG Target : Period : Mar-15 Executive Lead : Rory Farrelly Current Movement : 10 Reduce Status : Worsening Current Trend: Mar 14 - Mar 15 How are we doing? There has been a steady decrease in the numbers of Pressure ulcers reported since January 2015 but as Pressure Ulcers seen in the attached graph, incidences are slightly higher than March The Tissue Viability team have been rolling out a training program on the correct identification and 25 grading of pressure ulcers across ABMU HB. This may influence the number of pressure ulcers reported as improving awareness can cause an increase in reporting, which may continue for the next few months Benchmark What actions are we taking? The Datix proformas used to report pressure ulcer incidence have been changed to improve the data submitted by the reporters and also to incorporate the All Wales PU Investigation Tool into the investigation page of the Datix form. The purpose of this is to improve compliance with investigations and achieve uniformity for ABMU HB acquired pressure ulcers thus enabling easier identification of trends causing pressure ulcers. There have been some issues with the availability and reliability of the pressure relieving mattresses in some parts of the HB, in order to address this work in underway to prepare a business case in conjunction with Procurement and EBME for the replacement of the equipment. How do we compare with our peers? The total figure across Wales for February was? ABMU HB reported 20. What are the main areas of risk? issues with the availability and reliability of the pressure relieving mattresses Source : NHS WALES OUTCOMES FRAMEWORK, ALL WALES PERFORMANCE SUMMARY FEBRUARY 2015) 5

6 SAFE CARE - I AM PROTECTED FROM HARM & PROTECT MYSELF FROM KNOW HARM Measure 1: Number of healthcare acquired pressure ulcers Strategic Aim : Excellent patient outcomes and experience Strategic Change Programme: Quality & Safety IMTP Profile Target : WG Target : Period : May-15 Executive Lead : Rory Farrelly Current Movement : 10 Reduce Status : Worsening Current Trend: Feb 15 - May 15 How are we doing? In april 2015 the healthboard adopted the all wales guidelines for pressure ulcer reporting which Grade 1&2 Hospital Grade 3+ Hospital increased the number of categories to six these are stage 1, 2, 3, 4, suspected deep and unstageable Previous Healthboard reporting was through the care matrix and only captured hospital acquired grade and 4. With the introduction of datix web, reporting of pressure ulcer incidents it is now collected real time and both within the hospital and commuity setting. The datix reporting and investigation also allows for 0 categorisation of severity of harm cased to the patient through the grade of pressure ulcer. May data Feb-15 Mar-15 Grade 1&2 Community Apr-15 Grade 3+ Community May-15 demonstrates an increase in numbers from a monthly average of 20 hospital acquired only to 44 hospital aquired and 29 community. This is due to improved real time reporting and acurate capture of incidents, 60 investigation and validation of severity of grading Feb-15 Mar-15 Apr-15 May-15 Benchmark What actions are we taking? Each reported pressure ulcer is investigated using the All wales tool for pressure damage. Each directorate, hospital, locality management team have developed an pressure ulcer reduction and improvement plan which is monitored through monthly performance reviews. All management teams have been advised of the requirement to report all stage 3, 4 and unstageable are reported to welsh government. Further targeted work is being directed with the support of the tissue viabilty nursing teams education and training plans with high incident areas and care home setting. How do we compare with our peers? Benchmaking demonstrates variability across wales in how healthboards capture and record pressure ulcer prevelance thus making benchmarking unreliable. What are the main areas of risk? Mis-categorisation of reporting by staff Source : NHS WALES OUTCOMES FRAMEWORK, ALL WALES PERFORMANCE SUMMARY MAY 2015) 6

Trust Board 8 May 2014

Trust Board 8 May 2014 Title of the Paper: Quarter 4 (1 st January 2014 31 st March 2014) CLIPS Report Agenda item: 205/17 Author: Jackie Ardley, Interim Chief Nurse Trust Objective: 1) Achieving continuous