Paper K LLR PCT Cluster Board meeting 13 September 2012 LEICESTER, LEICESTERSHIRE AND RUTLAND PCT CLUSTER BOARD MEETING Front Sheet Title of the report: Report to: Section: Pressure Ulcer Ambition Progress Report PCT Cluster Board Public Date of the meeting: 13 September 2012 Report by: Sponsoring Director: Presented by: Lisa March, Head of Quality Liz Rowbotham, Director of Quality, Communication and Engagement Liz Rowbotham, Director of Quality, Communication and Engagement Report supports the following corporate objective(s) 2012 2013: Handing over a good legacy to the successor organisations Continue to improve health outcomes, clinical quality, patient safety and Ensure safe transition to successor organisations patient experience Oversight of performance and assurance. Purpose of Paper: Please state reason why this paper is being presented to the LLR PCT Cluster Board (rather than elsewhere e.g. a CCG Board) The Cluster Q&CGC agreed this report should be submitted to the Cluster Board. The CCG Q&CGC have received this report in August 2012 Equality Act 2010 positive general duties please complete one of the two boxes below: Due regard to the positive general duties of the Equality Act 2010 has been taken in the development of this paper and: 1. It is judged that it is not proportionate on the basis that the report is based on actual data This completes the due regard required
EXECUTIVE SUMMARY: 1. The purpose of this report is to provide committee members with an update on progress against the Midlands and East Strategic Health Authority Ambition relating to the elimination of avoidable Grade 2, 3 and 4 pressure ulcers by December 2012. The report also presents actions being taken by Commissioners to ensure delivery of the Ambition. 2. The report provides the background and aims of the ambition and summarises the findings of the SHA led intensive support team visits that took place at the end of May 2012. 3. Pressure ulcer data that has been collected via the National NHS Safety Thermometer tool is included in the report showing the proportion of patients who have acquired a new pressure ulcer whilst receiving care. In addition the percentage of harm free care (when considering the four risks included within the tool) is also provided. 4. Finally the report provides a summary of the actions being taken by Commissioners which includes the introduction of a strategic group to oversee the delivery of the ambition and the development of a commissioner operational plan to ensure the desired outcomes are achieved. RECOMMENDATIONS: 5. The PCT Cluster Board is requested to: note the content of the report suggest further actions as necessary
LEICESTER, LEICESTERSHIRE AND RUTLAND PCT CLUSTER BOARD MEETING September 2012 Pressure Ulcer Ambition Progress Report (July 2012) 1 Introduction 1.1 The purpose of this paper is to provide an update on progress against the Midlands and East Strategic Health Authority Ambition relating to the elimination of avoidable Grade 2, 3 and 4 pressure ulcers by December 2012. The report also presents actions being taken by Commissioners to ensure delivery of the Ambition. 2 Background to the Ambition 2.1 There are a number of published reports that continue to identify failings in the care patients receive. 2.2 The Francis report of 2009 identified eight key themes including the patient experience. This section highlighted bladder and bowel care; safety; personal and oral hygiene; nutrition and hydration; pressure area care; cleanliness and infection control; privacy and dignity; record keeping; diagnosis and treatment; communication; and discharge management. 2.3 In February 2011 the Parliamentary and Health Service Ombudsman published Care and Compassion a damming report on ten case studies of the care of older people in the NHS. The report raises important issues for Boards, leaders, individual professionals and healthcare teams. The findings did not purely focus on the patients clinical needs, but also found that some staff displayed a dismissive attitude, a disregard for process and procedure and an apparent indifference all contributing to deplorable standards of care. The key themes identified correlate with those raised in the Francis Report in terms of neglect, lack of compassion and dignity for patients, and highlighted: Suffering unnecessary pain Dehydration Indignity and distress Malnutrition Poorly managed medication Lack of dignified end of life care Poor individualised care Cleanliness Communication and attitude. 2.4 During the winter of 2010 and the spring of 2011, 100 trusts were inspected by the Care Quality Commission (CQC). The focus of the inspections was on dignity and respect and nutrition Outcomes 1 and 5. This review was CQC s response to the issues raised in the Ombudsman s report and Age Concern s Hungry to be Heard campaign. A consistent theme throughout the final report published in October 2011 was the variable level of importance that ward staff appeared to place with regard to feeding patients and monitoring
patients nutritional intake. Some of the trusts that were required by CQC to improve have since been re-inspected and improvements have been evidenced. 2.5 Pressure ulcers are a significant burden to the NHS and have a detrimental effect on patients health and wellbeing. Original estimates in 2009 based on 10.2% prevalence of pressure ulcers in hospital patients, estimated the following: 29,800 acquired in hospital, 20,700 acquired in the community with subsequent admission to hospital 2,838 cost of hospital care and 2,286 cost of follow-on community care per patient (total 5,124) These figures suggest a potential annual saving of 154 million. 2.6 Pressure ulcers are also a recognisable proxy measure for quality and safety of care patients receive and therefore standards of nursing care and hence why the elimination of avoidable pressure ulcers is an Ambition. 3. Objectives and Outcomes 3.1 The aim of the ambition is to use the elimination of avoidable Grade 2, 3 and 4 pressure ulcers as an outcome measure for nursing care which includes; hydration, nutrition, pressure area care, medication management and individualised care. Pressure ulcers are more likely to occur in patients who are malnourished, elderly and obese and those with underlying medical conditions. Therefore it is important that the fundamental aspects of high quality nursing care are in place. 3.2 A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear (EPUAP/NPUAP 2009). 3.3 There are four categories of pressure ulcers from Grade 1 to 4. This Ambition concentrates on the elimination of Grade 2, 3 and 4 avoidable pressure ulcers. Reductions will be monitored via the NHS Safety Thermometer data collection and triangulation with the Serious Incident Reporting process that is already established (for grade 3 and 4 only). 3.4 Pressure Ulcers are also graded avoidable and unavoidable. Avoidable means that the person receiving the care developed a pressure ulcer and the provider of care did not do one of the following: evaluate the person s clinical condition and pressure ulcer risk factors; plan and implement interventions that are consistent with the persons needs and goals, and recognised standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate (Department of Health). 4. Intensive Support Team Visit 4.1. On the 31 st May 2012 a Pressure Ulcer Prevention health economy peer review visit took place at both Leicestershire Partnership Trust and University Hospitals of Leicester (LRI site). The purpose of this review was to provide a fresh pair of eyes using a number of professionals from across the SHA in order to:
Review the actions the Cluster and Provider Trusts are taking to determine if the systems and processes in place are sufficiently robust to deliver the ambition of eliminating avoidable grade 2,3,and 4 Pressure Ulcers by 2012 Determine if there are additional actions organisations could take Identify areas of good practice that can be shared widely Add to the learning of what is required to achieve sustainable change in this aspect of care. 4.2. The feedback following the peer review included areas of good practice and recommendations where improvements could be made. Table 1 provides a sample of the good practice areas identified. 4.3. The peer reviews had four components: Gain an understanding of the Clusters strategy to delivering the ambition Presentations from both Trusts to each review team Review of data, policies, information of Trusts we are asked to visit Interviews with range of staff, including TV specialists, Clinicians, Executives, matrons and equipment provision team observation and discussion through visiting clinical areas. Table 1: Good Practice identified UHL Quality focus of the wards visited - Staff were passionate, the environments were clean and uncluttered, patients praised the staff and the level of care. The reviewers stated that all wards visited in their opinion passed the Friends and Family test Use of recognised acuity tools to determine appropriate numbers and skill mix of nursing staff Moving towards making ward leaders supernumerary to enable them to effectively lead their clinical areas, thus enabling leadership sufficient focus on improving quality and reducing harm Use of an agreed set of Clinical Quality Metrics which are owned by medical and nursing staff and used to monitor, track progress, inform improvement action with results visible on most of wards visited Use of VITAL training and assessment tool to enable large scale training and assessment of clinical skills and knowledge LPT The Nurse and Medical Director demonstrated a joint commitment to maximise the organisation s effort to achieve the ambition Investment in Nurse leadership - the new Nurse Leader appointments were considered to be vital resources that provide a key opportunity to realise the pressure ulcer ambition investment in IT solutions to enable the safety thermometer and tissue viability data to be collected in a real-time paperless fashion
4.4. Recommendations were also included for each provider. For UHL these focussed on strengthening the actions that are already in place in relation to training and assessment of staff competency, to review the corporate and clinical business unit level action plans, to simplify associated documentation and review of risk assessment tools in specific areas. For LPT the recommendations included developing a detailed pressure ulcer communications plan, to review the organisational development plan, to establish a dedicated PU governance and assurance mechanism and a review of the existing tissue viability policy should be undertaken. 5. NHS Safety Thermometer 5.1. In order to address the challenge of data collection the method of monitoring progress will be through the NHS Safety Thermometer. The NHS Safety Thermometer is a measurement tool which can be incorporated into everyday clinical practice (such as handover, daily visits etc), and is applicable across all healthcare settings, and can to be completed within a short time span, It is being used to collect data on a monthly basis by all healthcare providers across the whole organisation and District Nurse caseloads for that day, thus forming a point prevalence study. Data is collected on four key harms; VTE, Falls, Catheter Associated UTI s and Pressure Ulcers. The rationale for collecting on all four harms is to ensure that improvements in one area of care do not have a detrimental effect on another. 5.2. The NHS Safety Thermometer provides the opportunity to measure each of the four harms at the level of the individual patient whilst the patient is still in the care setting. Data once collected is sent to the NHS Information Centre for collation and sent back to the organisations in order that improvement can be tracked at a provider and system level. 5.3. Figure 1 provides the proportion of patients with a new pressure ulcer for UHL between April and June 2012. Figure 1: Source: NHS Safety Thermometer (July 2012)
5.4. Figure 2 provides the proportion of patients with a new pressure ulcer for LPT during the same time frame. Figure 2: Source: NHS Safety Thermometer (July 2012) 5.5. The NHS safety Thermometer also provides the ability to analyse by the number of cases, specified age groups (<18; 18-70; and >70), and by gender. 5.6. In addition to the information available via the NHS Safety Thermometer the NHS Quality Observatories have produced a Safety Thermometer Dashboard 1 which provides regional and organisational level data. National comparisons are also provided although these come with a heavy caveat as not all Trusts are submitting data and the national average is calculated using data from all types of providers (Acute, MH, Community and integrated). 5.7. What the Safety Thermometer Dashboard provides is the percentage of harm free care being provided by each organisation (based on the four harms included in the NHS safety thermometer) and the percentage of patients suffering one or more harms. Table 2 shows the % of harm free care provided by UHL and LPT. Table 2: % of Harm Free Care Mar-12 Apr-12 May-12 Jun-12 Jun-12 National Average LPT No Data 89.49% 91.34% 90.38% UHL 88.06% 88.65% 89.11% 91.46% 90.38%* 5.8. Table 3 provides the number of patients surveyed each month by UHL, the number of patients who received harm free care and the numbers that suffered harm. 1 NHS Quality Observatories Safety Thermometer Dashboard (July 2011), http://nww.qualityobservatory.nhs.uk/index.php?option=com_cat&view=item&itemid=2&cat_id=588 * National figure includes data from all types of providers (Acute, MH, Community and Nursing Home)
Table 3: UHL breakdown of harm free care Number of patients surveyed 1441 1533 1570 1593 Harm free care and number of harms Mar-12 Apr-12 May-12 Jun-12 Number of patients with harm free care 1269 1359 1399 1457 Number of patients with 1 harm 163 159 159 131 Number of patients with 2 harms 9 15 12 5 Number of patients with 3 harms 0 0 0 0 Number of patients with 4 harms 0 0 0 0 Total patients harmed 172 174 171 136 Source: NHS Quality Observatories (July 2011) 5.9. Table 4 provides the number of patients surveyed each month by LPT, the number of patients who received harm free care and the numbers that suffered harm. Table 4 LPT breakdown of harm free care Number of patients surveyed 2467 2367 2278 Harm free care and number of harms Apr-12 May-12 Jun-12 Number of patients with harm free care 2176 2162 2088 Number of patients with 1 harm 273 201 182 Number of patients with 2 harms 18 3 8 Number of patients with 3 harms 0 1 0 Number of patients with 4 harms 0 0 0 Total patients harmed 291 205 190 Source: NHS Quality Observatories (July 2011) 5.10. Initial observations of this information would indicate an improving position overall, however it is to be noted that data collection and therefore comparisons, are at an early stage and will need to be monitored closely to understand any true trend. 5.11. Information from the NHS Safety Thermometer and the NHS Quality Observatories dashboard will continue to be monitored by the PCT Cluster/CCG patient safety and contract teams to oversee compliance with the regional CQUIN regarding data collection and progress against the SHA ambition relating to pressure ulcers. 6. Pressure Ulcer Ambition Strategic Group 6.1. Commissioners have convened a LLR pressure ulcer ambition strategic group (PUASG). This group will be the principle group that oversees delivery of the SHA ambition to eliminate all avoidable grade 2, 3 and 4 pressure ulcers by December 2012. The PUASG is directly accountable for all decisions that impact on delivery of the ambition.
6.2. The PUASG will meet each month and will be responsible for identifying areas for targeted work and providing strategic direction to the Pressure Ulcer Ambition Operational Group. The PUASG will review pressure ulcer data each month, utilising data from the NHS safety thermometer; STEIS; and provider reported to ensure organisational learning and sharing of best practice; the group will review performance against the ambition and will assess the implications of any external arrangements that may impact on the successful delivery of the ambition and agree appropriate actions as required. 6.3. The key roles of the PUASG will be: To identify areas for targeted work and provide strategic direction to the Pressure Ulcer Ambition Operational Group. The forum where provider pressure ulcer data will be reviewed and sharing of organisational learning and best practice. The PUASG will agree appropriate actions to be taken to ensure delivery of the SHA ambition including actions required by other agencies/providers (e.g. community equipment) The PUASG will report progress and any performance issues to the LLR PCT Cluster and Clinical Commissioning Group s Quality & Clinical Governance Committees. 6.4. The first meeting of the PUASG took place on 16 July 2012, Terms of Reference were agreed by the group and the commissioner plan was discussed. UHL and LPT provided a verbal update regarding their corporate action plans which will be submitted via the CQRG s for each provider. 6.5. The group agreed trajectories would be set from baseline positions in July for UHL and August for LPT. On receipt of the providers corporate action plans and the agreement of trajectories commissioners would close down all outstanding pressure ulcer RCAs to allow providers to spend time undertaking the work at point of care delivery and to prevent detraction from doing what needs to be done for patients. This approach was agreed with the SHA at one of the informal SHA reviews. 6.6. The group recognised the need to establish a link with the integrated equipment contract monitoring process. This link has been established and initial issues have been identified and actions are being progressed. 6.7. It was agreed that there needs to be a targeted approach to media campaigns for both patients and staff and the commissioner communication lead would scope with LPT and UHL regarding what a communication and media plan could look like for both patients and staff. This plan will be discussed by the PUASG in August. 6.8. In addition to the strategic group an operational group will be established to include members from providers and commissioners to ensure delivery of the actions identified by the strategic group. Individual representatives have been identified from provider and commissioner and the first meeting will take place in August 2012. The operational group will meet at least monthly with updates provided to the PUASG.
7. Provider Baselines and Trajectories 7.1. Baseline position in relation to the number of avoidable pressure ulcers has been established for UHL and LPT. For grade 3 and 4 pressure ulcers April data was used as this information was already available via the existing serious incident reporting process. For grade 2 pressure ulcers July data was used to establish a baseline position. 7.2. Reduction trajectories have been agreed with both providers to enable performance monitoring against the ambition. Tables 5 and 6 provide the baseline and trajectories agreed with LPT. Table 5: LPT Grade 2 PU Baseline and Trajectory LPT Grade 2 Avoidable PU Trajectory Jul Aug Sep Oct Nov Dec Jan Feb Mar 35 29 23 17 11 5 0 0 0 Table 6: LPT Grade 3 & 4 PU Baseline and Trajectory LPT Grade 3&4 Avoidable PU Trajectory April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 11 9 7 6 5 4 3 2 1 0 0 0 7.3. Tables 7 and 8 provide the baseline and trajectories agreed with UHL. Table 7: UHL Grade 2 PU Baseline and Trajectory UHL Grade 2 Avoidable PU Trajectory Jul Aug Sep Oct Nov Dec Jan Feb Mar 15 12 9 6 3 1 0 0 0 Table 8: UHL Grade 3 & 4 PU Baseline and Trajectory UHL Grade 3&4 Avoidable PU Trajectory April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 7 6 5 4 3 2 1 0 0 0 0 0 7.4. Progress against these trajectories will be monitored via the monthly PUAOG and the contractual clinical quality review groups for each provider. 8. Commissioner Operational Plan 8.1. Commissioners have identified a lead to drive delivery of the ambition. A Commissioner specific operational plan has been developed stating the desired outcomes and the actions that are required in order to achieve the stated outcomes. The full plan is attached as Appendix 1. 8.2. Progress against this plan will be monitored continuously by the commissioner lead. Updates will be provided to the PUASG and the PCT Cluster and CCG quality and clinical governance committees at regular intervals.
RECOMMENDATIONS: The PCT Cluster Board is requested to: note the content of the report suggest further actions as necessary
APPENDIX 1 Leicester, Leicestershire and Rutland Commissioners Operational Plan to support the SHA Ambition 1 Eliminate all avoidable Grades 2, 3 and 4 Pressure Ulcers by December 2012 Outcome/Aim 1. To establish an LLR wide Strategic Group to drive the ambition Current Position Meetings schedule throughout 2012. 1 st meeting taking place 16 th July 2012 Action Required Inform all relevant attendees of meeting dates Draft Terms of Reference for the group Responsible Officer Lisa March / Sue Hucknall Lisa March Timescale 18 th June 2012 (continuous review) 9 th July 2012 Terms of Reference to be signed off by the group All members 31 st July 2012 2. To establish an LLR wide Operational Group to ensure specific projects are delivered No established group To discuss at 1 st Strategic Group meeting on the 16 th July 2012 and agree membership of operational group All members of strategic group 16 th July 2012 3. Each provider to have a clear strategy to achieve the ambition (must include actions in relation to the recommendations from the IST visit) LPT Draft strategy/corporate action plan in place LPT - Need to incorporate recommendations from the IST visit Di Postle 31 st July 2012 UHL Old strategy in place UHL - Need to refresh to reflect the ambition and the recommendations from the IST visit Eleanor Meldrum
Outcome/Aim 4. Commissioners will have an agreed process in place to receive Grade 2 Pressure Ulcer data from providers Current Position Commissioners do not currently receive Grade 2 PU data Action Required Commissioner and Provider leads to meet to agree the process for receiving the Grade 2 PU data (split by avoidable/unavoidable) Responsible Timescale Officer Lisa March 30 th June 2012 5. Commissioners and Providers to agree monthly reduction trajectories for all grade 2, 3 & 4 avoidable Pressure Ulcers No monthly trajectories in place (zero by end of December 2012) Obtain quarter 1 baseline data for avoidable grade 2,3 & 4 PU s Commissioner and Provider Leads meet to discuss and agree a monthly reduction trajectory Lisa March Lisa March, Di Postle, Eleanor Meldrum 16 th July 2012 31 st July 2012 6. To have a streamlined Root Cause Analysis tool for providers to utilise Current RCA process is laborious and is not adding value. Commissioner and Provider Lead discussion - RCA tool needs to be streamlined to provide sufficient information for providers and commissioners to assess avoidable/ unavoidable Lisa March, Di Postle, Eleanor Meldrum 20 th June 2012 New tool to be agreed by Commissioners and Providers Lisa March, Di Postle, Eleanor Meldrum 13 th July 2012
Outcome/Aim 7. To have a Communication Campaign for Patients/Carers and Staff Current Position No clear communication campaign in place Action Required Commissioner Lead to establish what Providers already have in place / planned Responsible Officer Lisa March Timescale 20 th June 2012 Agree whether Providers will have an individual or joint Comms approach Lisa March, Di Postle, Eleanor Meldrum 16 th July 2012 Identify Comms Leads for Providers and Commissioner Lisa March, Di Postle, Eleanor Meldrum 16 th July 2012 8. To have an established link to the Integrated Equipment Contract monitoring process 9. To ensure Care Homes are supported to reduce the number of Pressure Ulcers acquired in the Community 10. To have a process for on-going monitoring of compliance with the Ambition No clear link or process in place Funding identified for provision of training Existing process in place via the contractual quality schedules Agree/share communication literature and roll-out plan with Strategic Group Commissioner Lead to obtain audit data re: timeliness of equipment from contract/quality leads To discuss training plan at 1 st operational group meeting Strategic group to receive updates from Commissioner and Provider Leads Progress will be monitored via the existing contractual quality schedule Communications Leads from Providers and Commissioners 31 st July 2012 Lisa March 31 st July 2012 Di Postle Lisa March, Di Postle, Eleanor Meldrum Lisa March, Pat Fathers 31 st August 2012 16 th July 2012 Complete (Continuous review)