Safety Improvement Plan. Phao Hewitson Head of Clinical Governance

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1 Meeting Trust Board Date 29 th January 2015 ENC No 8 Title of Paper Lead Director Author Sign up to Safety Safety Improvement Plan Amir Khan Medical Director Phao Hewitson Head of Clinical Governance PURPOSE OF THE PAPER To advise the Board of: 1. The purpose of Sign up to Safety 2. The organisation s Safety Improvement Plan SUMMARY OF THE KEY POINTS We have Signed up to Safety a Department of Health voluntary initiative, whose 3 year objective is to reduce avoidable harm by 50% and save 6,000 lives. We are committed to our Sign up to Safety pledges which have been submitted to the Department of Health and broadly encompass the priorities in the Quality and Safety Strategy This paper describes our Sign up to Safety Safety Improvement plan for 2015/16 We have identified 3 areas of clinical care requiring improvement: Inter-ward transfer of patients Pressure Ulcers Insulin management In addition, we have identified 3 specialties where improvements have the potential to reduce clinical negligence claims: Obstetrics Orthopaedics Accident and Emergency/Imaging RECOMMENDATIONS The Board is asked to approve the contents of the paper and to make a public declaration of the organisation s commitment to the Plan 1

2 LINKS Strategic Objectives Safe High Quality Service Annual objectives Safe High Quality Service Monitor / CQC / Regulatory Requirements IMPACT Patient Experience High safety incidents impare the quality of patient experience Quality & Safety High patient safety incidents can be indicators of inadequate clinical and nursing care Financial Moderate - risk of litigation Workforce n/a Equality & Diversity n/a Estates n/a IM&T n/a Communications / Engagement n/a RISKS Clinical Risks Business Risks Finance & Performance Risks Reputation Risks External standards PREVIOUS CONSIDERATION Quality and Safety Committee, 22 January

3 Walsall Healthcare NHS Trust Sign up to Safety Safety Improvement Plan Submitted to NHS England January 2015 Amir Khan Medical Director Kathryn Halford Director of Nursing 3

4 Introduction Walsall Healthcare NHS Trust is committed to continually improving the quality and safety of patients who use our services and to taking action to prevent avoidable harm. We are supporting the NHS England Sign up to Safety initiative and have developed our Safety Improvement Plan with the aim of reducing avoidable harm. In 2012/13, we launched our Quality and Safety Strategy for 2012/ /17. Our Strategy has six strategic objectives, one of which concentrates on safe high quality services : We are now almost 3 years into the term of our strategy and there has been significant progress in relation to patient safety: Sustained improvement in HSMR The level of adverse incident reporting, a key indicator of the safety culture climate within an organisation, has increased to a level where we are in the upper quartile of medium acute trusts reporting rate Significant reduction in MRSA bacteraemia cases Reduction in C. Diff cases Reduction in patient falls Reduction in numbers of patients developing pressure ulcers Improvement in VTE risk assessment Embedded a quality system aimed at improving leadership and empowering staff to make safety and quality improvements 4

5 However, we fully recognise areas that require improvement, both from within the original strategy and others that have emerged since its launch. We have Signed up to Safety a Department of Health voluntary initiative, whose 3 year objective is to reduce avoidable harm by 50% and save 6,000 lives. We are committed to our Sign up to Safety pledges which have been submitted to the Department of Health and broadly encompass the priorities in the Quality and Safety Strategy (Appendix 1) This paper describes our Sign up to Safety Safety Improvement plan for 2015/16, sets out the accountability and governance frameworks and timescales for implementation. Priorities for our Safety Improvement Plan We recognise areas requiring improvement, both identified in our original strategy and others that have emerged since its launch. For our safety improvement plan, the following areas have been identified as a priority: Preventing incidents related to inter-ward patient transfers Preventing pressure ulcers Preventing harm from high risk medications, particularly insulin NHSLA Incentive Bid The three areas identified above feature significantly in reported incidents and therefore are priority issues for improvement, but they rarely arise as clinical negligence claims. On close scrutiny of the claims information provided by the NHSLA to inform incentive bids and local intelligence related to claims at disclosure stage, we have identified three specialties where action has the potential to reduce clinical negligence claims: Orthopaedics, particularly upper limb surgery Delayed diagnosis related to missed fractures in Accident & Emergency and imaging reporting errors Obstetrics, particularly maintaining our success at CNST level 3 and preventing incidents of retained products of conception following caesarian section The plan for clinical negligence claim reduction has been submitted to the NHSLA and Department of Health. 5

6 Walsall Healthcare NHS Trust Safety Improvement Plan Plan Do Study Act (PDSA) cycles will be used to implement improvement initiatives. We have also implemented a Ten Message campaign to assist with improvement initiatives and will be continuing to use this method of communication. Preventing harm related to inter-ward patient transfers National Reporting and Learning System (NRLS) data demonstrates that the organisation reports a higher than average number of incidents relating to admission, discharge and transfer. Category Total number of incidents - average across cluster Proportion of all incidents reported Total incidents reported WHNHST Proportion of incidents reported Access, admission, transfer, discharge (including missing patient) % % In addition, local intelligence shows that a significant proportion of the incidents reported involve the transfer of patients, particularly between wards in the hospital setting, both for clinical and non-clinical reasons. Audit reveals a high level of non-compliance with trust policy which in itself requires a improvement by way of standardising and revision of procedures. 6

7 Quarter /15, admission discharge and transfer incidents reported Quarter /15, transfer incidents reported The following driver diagram shows the primary and secondary drivers for improving inter-ward transfers and reducing incidents causing harm: 7

8 Primary Drivers Secondary Drivers Process Metrics Organisational factors Transfer of Care procedure Criteria for non-clinical and clinical transfer % patients experiencing a fully compliant transfer Reduction in transfer related incident reports Staffing factors Responsible clinician agreement to transfer Staffing and skill mix on receiving ward Medical review outlying ward % patients who were transferred with responsible clinician agreement % additional staffing requests fulfilled % outlying patients receiving daily review Outcome Metrics No. of incident reports relating to transfer between wards No. of patients suffering harm as a result of a poor transfer Communication factors Patient factors Comprehensive care plan and handover documentation Timely tests and investigations Appropriate equipment provided at time of transfer % patients with care plan & handover documentation complete on transfer % patients with NO delay in investigations % patients with equipment in place at time of transfer Medication available at time of transfer % patients with all medication available at transfer The target for reduction for 2015/16 is that incidents causing harm will be reduced by 50%. Pressure Ulcer Prevention An organisation wide programme of pressure ulcer prevention has been in place over the last 3 years and improvements have been made. Year Community Actual Community Target Acute Actual Acute Target 2011/ No target 296 No target 2012/ / Q / Up to 2014/15, although the target set was not achieved, there was a year on year reduction in patients developing pressure ulcers whilst receiving community or hospital care up until 2013/14. So far in 2014/15, there are indications that there will be a failure to meet the targets and in addition, more patients will develop pressure ulcers than in 2013/14. Additional improvement work is therefore required. The following driver diagram shows the primary and secondary drivers for preventing patients developing pressure ulcers. A Ten Message initiative (Appendix 2) is being implemented alongside mandatory training for staff in 8

9 pressure ulcer prevention. Customised root cause analysis is currently completed for all category 3&4 pressure ulcers and is being considered for category 2s. Primary Drivers Secondary Drivers Process Metrics Patient Assessment Risk assessment Preventative care plan in place Nutrition plan and food diary % patients with Waterlow assessment accurately completed as necessary % patients with full PU prevention plan Pressure ulcer (PU) prevention Outcome Metrics No. of PU developing in hospital per month No. of PU per 1000 bed days Care Management Factors Patient factors Medication factors Environment factors Mobility problem plan of care in place Incontinence individualised toiletting programme Patient carer involvement with preventative plan Consideration to medication in relation to skin integrity Ensure appropriate pressure relieving equipment provided % pts with PU where pt is incontinent % PU where pt had an individualised toileting programme implemented % pts/carers provided with prevention information % pts with PU where consideration has been given to medication % pts on an appropriate pressure relieving surfaces Staff factors Education & training pressure ulcer prevention % staff attending clinical update The targets for reduction during 2015/16 will be: Hospital - Zero tolerance avoidable category 3 and avoidable category 4 Community - 60% reduction avoidable category 3 - Zero tolerance avoidable category 4 Preventing harm from high risk medication Insulin Since 2012/13, there have been 2 Never Events and 2 serious near misses related to insulin administration. Since October 2013, 54 incidents involving insulin were reported, both from community and hospital settings. Education has been provided to nursing staff, but has not been mandatory. It is clear that further work is required, to involve medical and nursing staff. The following driver diagram shows the primary and secondary drivers for preventing insulin related incidents. A Ten Message initiative (Appendix 3) has also been developed and an e-learning package identified for use in mandatory training. 9

10 Primary Drivers Secondary Drivers Process Metrics Insulin Policy Organisational factors Standardised procedures Control of usage Labelling & Storage in wards and depts % wards labelling & storing insulin and devices correctly Insulin related adverse events Care management Staff education & training Equipment % staff completing mandatory diabetes training % patients with correct equipment use Outcome Metrics No. of patients who receive 25-50% glucose to correct insulin induced No. of adverse events per 1000 bed days Patient factors Diet and blood sugar monitoring Prescribing Administration % patients with monitored as per care plan % patients with correctly prescribed insulin % doses correctly administered Patient education and involvement % patients seen by diabetes nurse specialist The targets for reduction for 2015/16 are that there will be no Never Events and incidents causing lower levels of harm reduced by 50% Measurement Progress against the targets set out above will be measured on a monthly basis and reported to the Quality and Safety Committee. This will be achieved by measuring the system level process and outcome metrics set out in the above driver diagrams against the targets descibed for each of the improvement areas on a monthly basis. Governance arrangements are described below. Leadership and Involvement The Trust Board acknowledges that improvements to patient safety can only be achieved when leaders of an organisation commit to cultural change to enable staff to deliver safety improvements. The Chief Executive has sponsored the safety improvement plan and it will be led by the Medical Director and Director of Nursing supported by the Associate Medical Directors and Heads of Nursing. 10

11 Clinical Directors are undergoing a programme of development to enable them to provide effective leadership to clinical teams and drive quality and safety improvements. Matrons and senior managers will actively encourage staff from wards and departments to participate fully in improvement initiatives. This work will be overseen by the Care Group and Divisional Quality Teams with successes and exceptions reported to the Board via the Quality and Safety Committee. The organisation s clinical governance team will provide support and facilitation to staff in improvement work, monitoring and reporting successes and exceptions. The organisation s quality and safety champions will play a pivotal role in driving, measuring and supporting patient safety improvement work, whilst working closely with the Quality Teams and clinical staff. The communications team will have a vital role in ensuring that staff are fully involved in our journey towards meeting our aim and goals over the next three years. A sustained campaign of communication of our progress and achievement will be communicated via newsletters, reports and the intranet. Education and Training Case scenarios arising from clinical incidents are used to provide updates on pressure ulcer prevention and insulin management in our clinical mandatory training days. Our Ten Message framework, developed to provide aide memoirs on specific areas of care will be used to assist with staff development in the areas for improvement A programme of Leadership Development is in progress for staff at Band 7 and above. The programme includes a module related to service improvement methodology. Governance Arrangements 11

12 Delivery of the Safety Improvement Plan will be overseen by the Quality and Safety Committee which is chaired by a Non - Executive Director and reports to the Trust Board. Our Divisional Quality Teams will implement improvement initiatives, monitor performance and report highlights and exceptions to the Quality and Safety Committee A Safety Improvement Plan report will be provided to the Board each quarter. Performance against related safety targets will be included. Implementation Improvement initiatives will be implemented concurrently over three phases during 2015/16: Implementation Reinforcing and embedding Sustaining Evaluation Continuous monitoring will be carried out during 2015/16 in order to identify areas of slippage against target trajectories. A final report will be compiled during quarter 4. 12

13 Appendix 1 Sign up to Safety Pledges Pledge Put safety first Continually learn Honesty We will: Make a public commitment to Sign up to Safety at our January 2015 Trust Board: demonstrating our commitment to avoid preventable harm to patients. commit to ensuring that all staff understand their responsibility in preventing harm to patients ensuring lessons are learned at all levels in the organisation to drive improvements in quality and safety Strive for full achievement of our Quality & Safety Strategy aims for a safe service and ensure that our patients experience consistently safe services through improvements across a range of clinical indicators Ensure our Strategic Plans: are underpinned by our commitment to avoiding preventable harm Include publication of our Quality and Safety Strategy and our progress in towards its full implementation engage our workforce in our commitment to avoid preventable harm engage with stakeholders to support our commitment to avoid preventable harm Carry out staff led reviews of achievements against key quality indicators to inform improvement work Ensure our service and divisional level Quality Teams are empowered and supported to make improvements as a result of lessons learned Seek the views of staff and patients about our services Listen and act upon what our staff tell us about quality and safety issues Listen and act upon what our patients tell us about their experiences Ensure that staff are given feedback on lessons learned from incidents and complaints and from information gleaned from patient surveys Continue to develop our service, divisional and board level dashboards to ensure that staff are fully aware of the risks and issues arising in their services Improve our processes for providing assurance that action plans developed as a result of incidents and complaints are fully implemented and sustainable Openly publish our patient safety performance information, benchmarked against other organisations along with our progress against plans made to tackle patient safety issues Openly publish upheld complaints and our responses Ensure that when something goes wrong, it is identified and acted upon at an early stage using the systems we have embedded within the organisation. Promote incident reporting and supporting staff to raise concerns through a range of systems we have in place. Ensure full compliance with the Duty of Candour. Provide training to staff which equips them to be supportive and candid with patients and their families if something goes wrong Provide support to patients and families if something goes wrong 13

14 Collaborate Support Be transparent with people about their progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong. Openly demonstrate our commitment to safety and promote a culture of collaborative learning lessons and taking remedial action Reinforce our quality governance structures and mechanisms to ensure that staff at local level are supported and empowered to make improvements required to achieve our aim and goals. Further develop our aim and goals with staff from across the Trust to promote ownership of learning at every level Ensure that the aims and goals for our learning culture are established and overseen at every level of governance Listen to our patients and involve them in our improvement work Encourage staff to take action in the face of patient safety issues rather than passively report concerns Reinforce our structures and mechanisms to support the improvements required to achieve our aim and goals Facilitate and support our service and divisional quality teams in the process of identifying risks and issues within their wards and departments Improve our mechanisms for carrying out root cause analysis when incidents occur or complaints are received Improve the capability of our service level quality teams to learn lessons and make sustainable improvements Provide robust training programmes for root cause analysis, human factor analysis and improvement methodology Identify, support and train patient safety champions who can work with staff in wards and departments to to change thinking and behaviours in order to generate and sustain improvements Nurture our culture of high levels of incident reporting, by ensuring staff receive feedback and are confident that improvements are made as a result of their raising concerns 14

15 Appendix 2 Ten Messages Campaign. Pressure ulcers All patients must have a risk assessment and full body skin assessment completed within 6 hours or at first point of contact / episode of care. 1. A patient identified as at risk of pressure damage, must have a plan of care developed. 2. As part of the patient s holistic assessment: nutrition, mobility, continence and manual handling must all be assessed. 3. The provision of suitable pressure relieving equipment must be based on both the holistic assessment and clinical judgement. 4. Staff must continuously evaluate progress against the plan of care. 5. Re assessment must be completed a minimum of weekly or when the patient is transferred or where clinical status changes. 6. Assessments, evaluations and care plans must be documented escalated and reassessed when changes occur. 7. Referrals must be made to Tissue Viability Nurses in a timely manner. 8. Advice regarding the treatment plan and preventative care must be given to the patient and documented in the patient s notes. 10.The risks associated with non-concordance with advice and treatment must be documented in the patient s notes and escalated to the clinical manager. Think about MUST do s: Have your patients pressure areas been checked to day? If not, why not? What MUST you do? 1

16 Appendix 3 1. Never omit insulin in type 1 patients. 2. Promote self administration of insulin where possible (policy on intranet) 3. Always give basal insulin ( lantus, levemir, humulin I, insulatard) a long side IV insulin. 4. Overlap S/C insulin with IV insulin by 30 mins when changing Over. 5. Use correct IV insulin policy ie, DKA, VRII, HHS. 6. Give S/C insulin on time with meals 7. Treat hypoglycaemia as per policy. Continue insulin with meals, contact diabetes nurse if hypo s persist. 8. Ensure all patients with diabetes have a foot assessment. 9. Test for capillary ketones with high blood glucose levels. 10. Refer any patient of concern to the diabetes nurse bleep Version: 0.2 Vev Ten Messages Campaign. Safety Campaign For Diabetes If in doubt call for help 1