TRUST BOARD MEETING 5 February 2014 Title of the Paper: The Fundamentals of Nursing Care. Test Your Care Update. Agenda item: TB 113/14 Author: Executive Lead: Maxine McVey, Deputy Director of Nursing Jackie Ardley, Interim Chief Nurse Achieving continuous improvement in the quality of patient care Trust Objective: that we provide and the delivery of service performance across all areas. Patient Safety. Purpose: This paper identifies how assurance on the fundamental of nursing care will be monitored and progressed forward within the Trust. It informs the Trust Board on progress to date in implementing the Test Your Care Pilot which is process Quality Indicators which will inform and drive safe, effective and compassionate nursing care. Previously Discussed And Date For Further Review (list relevant committees) Fundamental of Care Panel. NMSG Benefits To Patients And Patient Safety Implications Safe Effective and compassionate nursing care. Risk Implications for the Trust (including any clinical and financial consequences): Failure to achieve compliance with fundamentals of nursing will affect the rating for the Trust and CQC Outcome 4 Mitigating Actions (Controls): A framework exists within the Trust to manage the fundamentals of nursing care which include NMSG, The newly formed Fundamentals of Care Panel. Links to Board Assurance Framework, CQC Outcomes, Statutory Requirements CQC outcome 4 Care and Welfare of People that uses services. Legal Implications: (if applicable) Financial Implications :(if applicable) Bid with the Nursing Technology Funds currently. Communications Plan (if applicable) 1
Recommendations This report demonstrates the progress so far and the Trust Board are asked to note the following recommendations. For data from Test your care to be part of the Performance metric of the Trust. To support the endorsed metric assurance framework in Appendix 3 and support it being incorporated into Divisional business. 2
Agenda Item: 113/14 Trust Board Meeting, 5 February 2014 West Hertfordshire Test Your Care Progress Report Presented by: Jackie Ardley Chief Nurse DIPC 1. Introduction The Trust s vision and strategy for Nursing builds on Compassion in Practice (Department of Health, 2012) and requires the establishment of appropriate quality metrics, development of supervisory ward leaders (as recommended in the Francis Public Enquiry Report) and provision of a clear performance assurance framework that can provide accurate feedback on nursing care quality both to ward staff and to the Trust Board. The Test Your Care project will support these requirements both directly (by providing the mechanisms to collect, collate and present the required metrics in real-time) and indirectly (by providing a focus for the supervisory ward leader which demonstrates to them a new way of working). This Report updates the members of the trust board on the progress made with the Test your care pilot. 2. Background The report State of the Art Metrics for Nursing: a Rapid Appraisal (Kings College London, 2008), commissioned by the Chief Nursing Officer, Department of Health, reviews the status of the evidence base on Nursing Metrics and provides a road map and set of recommendations for taking nursing forward, and how they will improve quality, focusing on safety, effectiveness and compassion. High Quality Care Metrics for Nursing (Kings Fund, London 2012) built on this work and added underpinning factors of workforce, staff experience and systems. At a time when cases of poor quality care and lack of compassion have become the focus of media attention nurse leaders need to advance the way we use measurement for best effect. Measuring the quality of care is central to providing an NHS that is more transparent, accountable and focused on improvement. In response, and since September 2013, the Trust has successfully piloted an approach to providing rapid-feedback indicators of nursing care. The initiative improved the nurse s ability to collect and use data (using a Back to the Floor model) to enhance the quality and safety of care. The nursing care indicators are: Patient observations; Pain management; Falls assessment; 3
Tissue viability; Nutritional assessment; Continence assessment; Medication administration; and Infection control and Privacy and Dignity. The standards behind these indicators are listed in Appendix 2. The care indicators are evidence based and follow advice from bodies such as the NPSA, NICE and the Royal College of a Nursing. Since September 2013 this tool has have been piloted on three wards in the Trust selected by the Heads of Nursing - Cleves Ward, Stroke and Blue AAU Level 3. These are unannounced audits by senior nurses and an audit of records of 10 patients every month. This initiative will improve the nurse s ability to collect and use data to enhance the quality and safety of care. These metrics measure our standards of record keeping for the core activities that we undertake for our patients. It is vital that they also demonstrate our professional behaviour and give accurate and contemporaneous record of our patients. This project seeks to roll out the above pilot to the ward areas throughout the Trust. The project will: Establish the project management structures and resources to monitor and maintain management control of the roll out; Depending on the Technology bid will purchase the software licences and supporting hardware (notably ruggedised tablet computers) for each of the wards; Ensure the training of Ward Mangers and other nurses in the use of the system and the use of the information derived from the use of the system; Ensure integration with the existing Trust IT infrastructure and IT support mechanisms; Extend the system to implement a patient feedback function to provide a real time system for collecting and reporting patient feedback; and Establish the benefits realisation activities to monitor and ensure the project achieves its economic and clinical aims. Establish a ward to Trust board framework of assurance. The project will deliver patient safety and experience benefits including: Consistent and pertinent patient information across care environments; Faster identification and dissemination of quality improvement steps; Reduced costs due to reduced incidence of falls; Enhanced nursing skill through early identification of training need; Dramatically reduced reliance on paper audits. Increase quality Trust board assurance of the practice on the wards. 3. Progress with implementation It has been important to pilot carefully and monitor results. To remove bias we have mandated that auditors will not audit their own areas and this audit involves a deputy director of nursing/senior nurse a matron and a ward sister/charge nurse. Getting the ward sisters / charge nurses engagement has been essential to this project as after all it is these clinical leaders who ultimately have to be accountable for improving practice. The emphasis is on the quality improvement aspect of the project. If this is seen as a performance management 4
tool there could be staff disengagement. The ward sisters from the pilot wards are involved with the relevant matrons in the task and finish group. The three wards have now completed results for three months. However the auditors of Stroke in September did not upload the results. These results are Appendix 1. A Service Level Agreement has been agreed with the Heart of England for a year to access and adapted the tool for the whole Trust. A bid has been submitted to NHS England technology for the hard ware to support this project. Staff engagement and accountability To create a monitoring and reporting system individualised for each ward to provide. An assurance framework that ensures nurses responds to their results has been agreed. This has been explicitly linked to the ward sisters/charge nurse s job descriptions and development. A Management of change is being completed in February to change their job descriptions. The aim is to share best practice and to identify areas of excellence and to develop a reward scheme for the ward sisters/charge nurses and their clinical areas that achieve the standards. Patient feedback Part of the system has patient feedback element. To be able to develop a real time system for collecting and reporting patient feedback - this element still needs trialling and it proposed that the volunteers and the friends and family team supports this part of the pilot in January/February 2014. A RAG system introduced with a target of all wards achieving Green status -90% and above for this element. 4. Risks identified during implementation and issues that are being solved. The pilot has also identified a number of risks to the aims of the project which will be addressed as part of the rollout. These include: Documentation and policy not aligned to the standards being agreed and set. Tool can be seen as performance management and therefore could lead to poor engagement. Need to involve both Clinical Nurse Specialists and ward sisters in the setting of standards. Initially can be seen as time consuming (it takes about two hours to audit a ward area). Identification and agreement of the standards have been formally sign off but need to be promoted and owned. Lack of the technical equipment to support the project for example the ipads for the whole Trust. 5. Trust Board Assurance To provide monthly board assurance re standards of nursing care in the Trust will commence in April 2013. We are expecting the majority of indicators to be Red for the first year based on the experience of Heart of England Foundation Trust. 5
The assurance framework provides a systematic improvement programme. We will provide assurance to the Trust Board. The aim is for wards to successfully raise their improvement when measured against the metrics which will signify an improvement for patient safety and patient experience. Aiming for the sharing of good practice opportunity to trouble shot support and teach from senior nurses. A competitive element will be developed and targeted support to those areas that are having difficulty in achieving a satisfactory score. The target for Green is 90% with the opportunity to move this to a high level once this has been achieved. Assurance Framework this is table in Appendix 3 The expectation is that there is month on month improvements in the first six months. First real measurements across the wards will be reported on in March 2014. Each ward area will be given six month to get above 90% after this time the above assurance framework will be implemented.this will only be acted upon if there is no improvements. Recommendations This report demonstrates the progress so far and the Trust Board are asked to note the following recommendations. For data from Test your care to be part of the Performance metric of the Trust. To support the endorsed metric assurance framework in Appendix 3 and support it being incorporated into Divisional business. The information presented in this report and more detailed analysis will be continued to be shared with the Nursing and Midwifery workforce and work streams to improve performance will be progressed via the task finish group. January 2014 6
Appendix 1 Results from each of the ward areas on the pilot. Stroke 7
AAU Blue level 3 8
Cleves 9
10
An example of the action plan on the system Appendix 2 The Standards that need to be agreed are listed in this document General Care Indicators 2013 these have been agreed by the task and finish group and endorsed by the members of the Fundamental of Care Panel. Key Black are the current questions audited. Red is the guidelines to the standard we are auditing and observing. Blue is question changes or future suggestions re questions once the SLA with Heart of England has been agreed. The process is that the Auditors approach the nurse in charge on arrival to the ward and introduce themselves and explain this is the Metric monthly audit. The audit tool opens on the first of each month and closes on the last day of the month. The auditors will take a random sample of 10 patient documentation; if a patient is isolated with C diff or MRSA or has a urinary catheter that patient will be included in the audit. The audit team will have one senior nurse from the corporate team a matron and a ward sister/ charge nurse. The matron cannot audit one of her own areas and the ward sister/charge nurses audit their own ward area. Medication Y /N The medicine trolley is locked and attached to the wall when not in use Not necessary to be locked to wall if in locked room Only answer once, all other times put Control drug keys are kept separate from other keys. No other keys are kept with them. Medicines are secured Even if behind locked door - discretion can be used if TTOs have recently been delivered This does involve checking bedside cupboards. Only answer once, all other times put Medicine cupboards are locked suggest we combine these two questions Medicines fridge temperature has been documented for the past seven days The minimum, maximum and current temperature must be documented for the last 7 days if the area has no fridge storing medications please enter ) 11
The patient is wearing an ID Band with details of their first name, last name, Date of Birth and PID Number? YES/NO Answer for every patient Printed ID Label If applicable the name on the ID Band matches the name above the bed YES / NO / Only needs to be answered if patients name is displayed by bed or outside room, otherwise IV fluids are stored in a secured area i.e if in a lockable cupboard - the cupboard is locked Evidence on drug chart that no medication has been omitted in the last 24 hrs Unless clear rationale documented Infection Control Privacy and Dignity Alcohol gel is available within arm's reach at point of care in line with Trust guidance Recent Hand Hygiene audit results are on display only answer once, all other times put The Previous week's Hand Hygiene audit results are on display. If Auditing before a Tuesday it will be the previous week after a Tuesday the current week. Care pathway documentation is evident for those patients who are identified with an alert organism/condition (MRSA, C Diff, Norovirus) Care plan is evident for those patients who are identified with an alert organism/condition (MRSA, C Diff, Norovirus) These are on the infection control web site Current sheet should be complete. Always try to include 1 patient, otherwise 8 hourly VIP score in use for patients with a PVC Checks for current PVC should be complete decision this is 12 hrly Evidence of adherence to uniform policy and PPE is worn according to Trust guidance - no watches, stoned rings, or other jewellery and bare below the elbows Evidence of adherence to the uniform dress code in all staff - no watches, stoned rings, or other jewellery and bare below the elbows Evidence of adherence to Personal Protective Equipment is worn according to Trust guidance. There is evidence that a patient's bed space has been cleaned in between patients There must be a way of establishing that the bed and bedspace has been cleaned and who has cleaned it before a patient is admitted to 12
that bed space Suggested checklist on the bed Has the mattress been checked for visual inspection/wear/rips/staining/loss of permeability between patients. Is the bed environment visibly clean and uncluttered. Patient can reach their call bell Patient appears warm and clean with modesty maintained Patient has appropriate screening for privacy and dignity Observations NEWS chart has patients Name, PID and Ward clearly documented Wards to write this on the observation charts The frequency of observations is documented If the frequency has been exceeded still put YES but if frequency is, for example, QDS and has only been done BD then put NO The patient has received twice daily observations of temperature, pulse, blood pressure, respirations, level of consciousness, urine output and oxygen saturation for past 3 days (unless otherwise indicated) Unless otherwise indicated e.g. on care of the dying guidelines documented rationale The patient has received twice daily observations of temperature, pulse, blood pressure, respirations, level of consciousness, and oxygen saturation for past 3 days or since admission (unless otherwise indicated) There is evidence of documentation of referrals to critical care outreach team or medical staff when the patient has a NEWs score of 4 or more during their admission Sometimes it is unncecessary for a doctor to be informed e.g. when NEWS trigger is due to pyrexia or low oxygen sats could be corrected by adjusting position or replacing oxygen mask. However documentation must be evident for the treatment that occurred Observations are rechecked within 30 minutes when they have a NEWs score of 4 or more this is not our policy to be checked. 24hr cumulative balances are evident on all fluid balance observations For past 3 days Pain 13
The pain status of all patients is assessed on admission to the ward using the Trust pain scoring tool The pain status of all patients is assessed on admission to the ward using the Trust pain scoring tool documented on the NEWs chart The pain status of the patient is recorded using the Trust scoring tool every 24 hours Care plans are evident for the patient requiring analgesia These are patients that have pain scores of more than 1 or regular analgesia on the drug chart The patient is reassessed when required and in accordance with care plan documentation Analgesia administration and efficacy will be recorded for the patient as indicated as per care plan documentation Tissue viability The patient received a pressure ulcer risk assessment and skin inspection on day of admission, or transfer to the ward, which was dated and signed by the assessing staff member and includes patients name and PID Assess previous 4 weeks - all elements must be complete The patient received a tissue viability risk assessment within 6 hours and on transfer to the ward, which was dated and signed by the assessing staff member Trust care plan is evident for the patient if identified at risk Prevention careplan. If alternating mattress is in place the care plan correctly states name of mattress The patient is re-assessed at least weekly in accordance with care plan documentation Assess previous 4 weeks A daily skin inspection has been recorded for the patient if identified as at risk Assess previous 7 days A skin inspection was conducted within 2 hours of admission/transfer which was dated and signed by the assessing member of staff. SSKIN is in place if Waterlow score is more than 10 For patients who are who are independently mobile or Waterlow less than 10 put The repositioning frequency has been completed Check previous 3 days on the 72 hour care record. 14
The suggested frequency of change of position has been adhered to for past 3 days Check previous 3 days - (includes sitting out) the position of the patient must have changed in line with the time frequency of repositioning selected If patient has oxygen/niv therapy or other device in place the 'Other TV Risks' Section is complete Check previous 3 days Nutrition The patient receives a nutritional screening which will lead to full assessment, if required, on admission to Trust Assess previous 4 weeks within 6 hours The screening or assessment has been dated and signed by the assessing staff member The patient was weighed on admission to hospital If unable to weigh due to serious clinical condition put, however if the patient is sitting out one would presume they could have been weighed Patients at moderate or high nutritional risk are weighed weekly Assess previous 4 weeks All Patients are weighed weekly Care plans demonstrating nutritional support interventions are evident for the patients identified at medium and high risk Individual instructions on them. The patient is re-screened or assessed at least weekly or as required in accordance with care plan documentation Assess previous 4 weeks All patients identified as a High Risk are referred to a dietician Falls The patient receives a falls risk assessment on admission to the Trust Assess previous 4 weeks The assessment is dated and signed by the assessing staff member Trust care plan to minimise the risk of falls is evident for the patient if assessed as being at risk A further assessment is undertaken at least weekly for the patient if identified as being at risk Assess previous 4 weeks A bedrail assessment is undertaken on the 15
patient if identified at risk and/or using bedrails Bedrails should be checked daily if in use. Assess previous 7 days Has a manual handling risk assessment been completed Continence Patients with continence problems : Have received a continence assessment Only necessary if patient has a problem with continence, usually identified by seeing wet bed / pad on charts All continence assessment documentation provides details of patient's name, patients identity number, ward and date Patients with continence problems : Trust continence care plan is evident for the patient Patients with continence problems : Trust continence care plan completed fully and signed by staff member. For patients with a catheter in situ : There is a care plan for catheter care There MUST be a date of insertion or when the catheter is due to be changed on the form For patients with a catheter in situ : The catheter care plan is signed and dated For patients with a catheter in situ : The catheter care plan is completed fully, signed and dated for the insertion For patients with a catheter in situ : Catheter bags are attached to a catheter holder Catheter bag must be off the floor Evidence of appropriate intervention on bowels movement. - laxatives started/given or stopped as needed. Bowels are recorded on stool chart daily 5,6,7 at least twice a day. For patients with a catheter in situ : Catheter leg bags are worn by all patients who are sitting out ( unless urimeters are insitu). Resuscitation trolley Is the defibrillator working at the time of audit and has the appropriate supporting equipment? To give a yes the following must also be present manual defibrillator : 2 sets of pads, 3lead monitoring cable, roll ecg paper, ecg electrodes, plugged in.or automatic defibrillator: 2 sets of pads 16
Are the equipment trays intact & in date? Is a drug box is available on the trolley and in date? Drug box should be Blue for all trolleys and in date - an additional red box may be present in some cases this is acceptable Is all other equipment listed on the checking chart present and in date? To answer yes all of the following equipment must be present: Size 4 mask, sharps bin, gloves, BVM, non-rebreath mask & suction catheters Any additional equipment on the trolley, has been previously agreed? Some specialist areas may have had this agreed with the Resuscitation team. They should have email confirmation with their kit list if this is the case If there is no additional equipment put Has every check been signed and initialled by the staff member checking the trolley? Is the trolley in a clean condition? Has the trolley been checked every day the department is open within the previous 30 days? Is an O2 cylinder attached to trolley and at least? full? Is the Suction machine plugged in, set up for use (with tubing yankur sucker attached) and working? 17
Assurance Framework. Appendix 3 Metric Assurance framework Target 90% Results are available on the intranet as soon as the metrics are completed. At the beginning of each month the wards achieving Green in all standards will receive a letter of achievement from the Chief Nurse Senior Sister/ Charge Nurse and Matron to meet monthly to compare with previous month results. Have there been adequate improvements? Targets Score less than 85% Must have an immediate improvement to 85% the following month Action plan within the test your care tool has to be completed. Score 85% to 90% Must show incremental improvement each month to achieve 90% within 6 months Score 90% and above Sustain and celebrate Senior sister/charge nurse and matron agree target and implement actions to sustain progress Monthly review by the head nurse Ward performance dashboard with red exception reports to Fundamental of care panel to be produced. Divisional Performance Score Care Reports Target achieved. Monthly monitoring Target not achieved and unsatisfactory progress with action plans Question any extenuating circumstances? Has it been flagged? Eg auditor competence staffing issue dependency of patients on the day of auditing. Specifically measures - month 1 Inform the Chief nurse Head nurse set up a meeting with senior sister divisional manager clinical divisional director and matron to create an action plan Action plan agreed Monitored monthly via Head Nurse Chief Nurse updated on progress Achieved back to monthly monitoring Not achieved Special measures - month 2 Diagnostic whole performance dashboard reviewed Confirm and challenge meeting with the chief nurse Continue monthly monitoring of results Action plans to consider: Support from the corporate nursing team or relevant CNS Weekly metrics Full diagnostic review Staffing review Skill mix review Leadership. 18
G:\Corporate Nursing\Nursing Directorate\TRUST BOARD PAPERS\2014 TRUST BOARD PAPERS\5TH FEBRUARY 2014\- Test your care Board paper.doc 19