Insert name of presentation on Master Slide

Making Quality Everyday Business Cardiff & Vale University Health Board

National Learning Event – 11th May 2012

The Faculty

Launched in November 2011, The Faculty will

• Support staff, giving them confidence and practical advice, enabling them to test their ideas and turn them into action.

• Develop training programmes in improvement techniques to enable staff to develop skills in improvement science.

• Harness the expertise of academic partners, including Cardiff University, to ensure staff at all levels have access to leading edge thinking and support

• Work with research and academic partners to “bridge the gap” between academic and NHS services

• Ensure public health issues are central to the work of the Faculty through close links with the Welsh Branch of Public Health Research

Eliminate harm, variation and waste

Develop a culture of continuous improvement and capacity building

Increase quality reliability and effectiveness of care

Collaborative and partnership relationships, to advance and promote innovation

Best for Patients

& Citizens

Best

health

Best

care

Best

value

Best place to work

Adapted from AQuA Alliance 2010

The Faculty

1. Common and Consistent approach to Improvement

• UHB has a strong track record in QI language as evidenced in the 1000

Lives + collaborative; Transforming Care; Transforming Theatres; and improvement programmes adopt the model for improvement and PDSA approach as well as LEAN and DMAIC.

• Faculty will support the QI training of 1000 practitioners over the next 2 year period to include Yellow belt and Green belt practitioners.

• Faculty is supporting QI skills training as part of the Junior Doctors Leading Change Programme and discussions are under way to develop an Advanced Training Programme for senior clinicians in the future.

The Faculty

2. A patient driven NHS Wales

• Building on the Safer Patient Initiative the UHB has striven to ensure that

patients are at the heart of its QI agenda:

• Patient Safety Walk arounds

• Patient Stories at the centre of the Board meetings

• Development of a Resource Centre at UHL/UHW

• Making Good Decisions in Collaboration – MAGIC

• The UHB in collaboration with Cardiff University is embarking on MAGIC phase 11 – this pioneering programme supports delivery of ‘ASK 3’ which is based on

‘no decision about ME, without ME’

The Faculty

3. Developing capacity and capability now – and in the future

• 1000 Lives Plus programme and its role in the UHB

UHB actively engages and participates in 1000 Lives plus collaborative and Learning sets

• UHB is keen to work with 1000 Lives Plus to:

Ensure that the UHB strategy is aligned to the business methods of NHS Wales and the improvement agenda.

Develop a QI training plan

Participate in the ‘Measurement for Managers’ training programme

Ensure that the UHB improvement database is aligns to the Improvement on Line Resource

Continue to participate and hopefully win NHS Awards

The Faculty

Perfectly aligned to:

• Put quality and safety above all else

• Invest in our staff through training and development to make sure they have the right tools to do their jobs well

• Always look at ways of improving services, getting rid of waste, harm and variation (evidence based/PDSA)

• Focusing on prevention, improving health, addressing inequality and making wellness and well-being priorities

• Work collaboratively with all our partners and stakeholders, including staff, patients, their carers and families

Eliminate harm, variation and waste

Develop a culture of continuous improvement and capacity building

Increase quality reliability and effectiveness of care

Collaborative and partnership relationships, to advance and promote innovation

Best for Patients

& Citizens

Best

health

Best

care

Best

value

Best place to work

Adapted from AQuA Alliance 2010

• 75% of inpatient areas in Cardiff and Vale UHB have

completed the facilitated phase of the Transforming Care Programme

• The next phase of roll out to the remaining 23 inpatient areas commences in May 2012 with a final inpatient cohort in September 2012 for any outstanding areas.

• Transforming Theatres and Transforming Maternity Theatres has been running alongside the Inpatient programme and facilitated by the Innovation and Improvement Team

Transforming Care

Releasing

Time To Care KHWD

Safety and Reliability

Patient and

Family Centred Care

Teamwork

and Vitality

Transformational Leadership and

Preparation

Format of delivery framework

Roll out of the Transforming Care programme will be accompanied by workshops which will provide module

details and also act as learning and support forums

Releasing Time

To Care WOW

Releasing Time

To Care PSAG/Process

Workshop 1

5- 6 weeks 3-4 weeks

Revisit and Sustaining

Improvement

6 weeks 7-8 weeks 8- 10 weeks

Timeframes indicate the number of weeks between each training workshop.

Following the final workshop there will a Celebration Storyboard event 8-10 weeks later (2 hours)

which will be an opportunity to share progress and innovation with colleagues/managers and stakeholders.

Workshop 2 Workshop 3 Workshop 4 Workshop 5

PATIENT OBSERVATIONS

•(RRAILS) Rapid response to

acute illness

NURSING

PROCEDURES

•SKIN BUNDLE

• CAUTI Bundle

•PVC Bundle

MEALTIMES

•Improving Nutrition &

Protected Mealtimes

MAKING THE LINKS TO

QUALITY & SAFETY!

ADMISSIONS &

PLANNED DISCHARGES

•Falls

•Butterfly Scheme

•Dementia Pathway

Wards Before After Increase

Delyth Gynaecology 35.8% 50.4% 14%

West 3 Llandough 41.1 % 79.7% 39%

Newid Ward 31% 59% 28%

B4 Haematology 45% 61% 16%

East 4 47% 72% 25%

Lansdowne Ward 53% 75% 22%

Cardiff and Vale UHB Direct Care Results

TRANSFORMING CARE

TRANSFORMING CARE

Cardiff and Vale UHB

HEADLINE RESULTS

East 8 saw 73% reduction in the incidence of C Diff in 2010 with a

further 41% in the 6 months to June 2011.

200+ days without pressure damage in Orthopaedics

449 days without pressure damage in Gynaecology

A3L identified cost savings by looking at Ward Processes in

relation to Pharmacy returns. In one month Pharmacy refunded the

ward:-

£5697 (including £288 of POM’s medication- which could have

gone straight back into our cupboards)

Celebrating Success

Celebrating Success

Transforming Maternity

Services

Multi-disciplinary 1000 lives Directorate working group set up in Cardiff and Vale UHB Includes, Midwives, Obstetrician, Anaesthetist and Haematologist. This team have taken the mini-collaborative work forward.

Progress to date:

4 care bundles have been introduced:

• Admissions Bundle

• Recognition Bundle

• Response Bundle

• Sepsis Six bundle

Data Collection of Bundle Compliance

• ‘Patient Status at a Glance Boards’ are used to record the bundle data.

• Staff training has been key to ensuring accuracy of data collection, staff have undergone one to one training from the Directorate 1000 Lives Plus team to assist them in collecting the data at the end of each shift.

• Data collection was commenced on the antenatal ward which has 10 inpatient beds. Lessons learnt from this service development will inform the introduction of data collection on the 44 bed maternity ward for all postnatal admissions. Plan to implement this in April 2012.

• A reliable outcome measure of compliance with the bundles is the number of women transferred to critical care for on-going care. This outcome is reported on the Maternity dashboard and a decrease in the number has been noted.

PSAG Board

Admissions Bundle • All pregnant women admitted in

pregnancy have a full set of observations on admission and a plan for the frequency of observations is made and communicated to all clinical staff via the patient status at a glance board (PSAG). A booking BMI is recorded in the woman’s handheld notes and a DVT risk assessment is recorded on the PSAG board.

Recognition Bundle

• The MEWS chart was implemented following the CEMACH report 2007 ‘Saving Mother lives’. It was initially used only in the CLU for inpatients. In 2009 the MEWS chart was introduced for use through pregnancy, labour and postnatal which is unique to this Health Board.

• Cardiff and Vale UHB staff introduced an Obstetric Alert course in 2008 to aid maternity staff in the recognition of the critically ill woman and deteriorating condition. Winners of a National Safety Award in 2010.

• The benefits of this initiative have reduced clinical incidents relating to the non-recognition of the critically ill woman and improved outcomes for mother and baby

Response Bundle

• The Maternity Early Warning Score (MEWS) chart was introduced in Cardiff and Vale UHB in 2007 and is used throughout all stages of pregnancy, which is unique to this Health Board. The benefits of this initiative have reduced clinical incidents relating to the non-recognition of the critically ill woman and improved outcomes for mother and baby

• DVT risk assessment for use in childbirth has been developed by Cardiff and Vale staff and has been adopted across Wales for use.

Insert Title here

Sepsis Six Bundle

Increased rate of maternal deaths relating to sepsis from the general population to the maternity population

Systemic Inflammatory Response Syndrome (SIRS) – ACCP/SCCM consensus conference 1992

• Two or more of the following:-

• Temperature > 38 or < 36 C

• Heart rate > 90 beats/minute

• Respiratory rate > 20/minute, or PaCO2 < 4.3 kPa

• White blood cell count > 12 x 109/l, < 4 x 109/l, or > 10% immature forms

Implement sepsis bundle.

Perform a lactate > 4mmol/l

Consider diagnosis of severe sepsis

Sepsis Six Bundle All consecutive women delivering in MLU or CLU over 12 random days July-Aug 2011 225 were

analysed

Patients with >= 2 SIRS criteria: 51 (23%)

33/51 (65%) of those with SIRS received some form of further sepsis screening

10 cases of culture positive sepsis

12.4: Temp > 38 degrees p=0.001

6.8: Resp rate > 20 p=0.007

5.0: Pulse > 100 p=0.01

5.4: WBC>20 p=0.004

12.4: Temp < 35.5 p=0.001

Transforming Maternity

Services – next steps • Repeat audit larger number of patients

• Confirm previous finding and use new pregnancy/labour SIRS criteria

• Early use of lactate to improve positive predictive value of screening tool to reduce over treatment with antibiotics

DVT risk assessment – Antenatal Inpatient

Ward

• Introduced in Sept 2011.

• DVT risk assessment part of the admission bundle for all CLC women admitted to the antenatal ward.

• Team Briefings • Vision = PERFECT Preparation

Equipment

Resources

Familiar team

Effective and efficient

Communication

Time management Sharing Information

-weekly theatre utilisation reports

displayed in theatres/suites

Automated daily list summary to

surgeons

Weekly elective UHB theatre

performance reports

• WHO Checklist

• 5 Steps to Safer Surgery

• Checklists

Foundation and enablers • Workshops; Vision, Knowing How We Are Doing, WOT (Well

Organised Theatres) & OSAG (Operational Status at a Glance) and Team working

• Linking to the clinical audit agenda

• Executive Lead: Medical Director

• Monthly Steering Group

Transforming

Theatres in the Short

Stay Surgical Unit

• In February 2012 an audit of staff attitudes towards Transforming Theatres was carried out in SSSU

• 75% of staff involved in the programme felt their practice had improved

• 70% believed there had been a reduction in glitches during lists

• 70% believed that care had been improved by being able to meet patient needs more effectively

• Communication increased

• No episodes of wrong site surgery in SSSU since the programme commenced

Concerns raised by theatre staff regarding details included in lists

Local audit of pre-operative details

showed 22% of “side specific” procedures had no side listed on TCI sheet

3 inconsistencies between handwritten patient details and information on patient ID labels

Information sheet created to aid juniors completing theatre lists

Re-audit;

100% compliance with use of patient identifier labels on theatre lists

100% of side specific procedures clearly identified on theatre lists – all TCI “side omissions” rectified

Design incorporated in IT Theatre system

Promoting better team working through briefings

- Understanding through Human Factors training

- Enabling better communication

- Introducing and using national and local Checklists

Sharing information

Tripartite review; Theatre staff, Anaesthetist, Surgeon

Commence in 8 theatres, across 3 suites and 2 sites

Supported and reviewed by

Transforming Theatres Steering Group monthly

Early Results Of 187 completed Team Briefing forms

82% indicated that a briefing took place

Did a briefing take place?

0

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A B C D E F G H

Theatre

No. of lists

N

Y

Using process to prevent delays / errors

SITUATION

• Requirement to implement NEWS across the UHB.

• Resuscitation Service is the lead for the education and implementation of NEWS across the UHB.

BACKGROUND

• EWS insitu since Sept 2008.

• Medical Rapid Response Team (MRRT) insitu.

• Referral to MRRT using SBAR format.

• Requirement to develop a response following the identification of acutely ill patients across the UHB.

NEWS

ASSESSMENT

• Standardised education package developed.

• Gantt charts completed to enable sustainable spread across the Organisation – spread aligned to: EWS and incidence of cardiac arrest.

• Audit tool developed.

RECOMMENDATIONS

• Continue with implementation of NEWS at a sustainable rate.

• Wider awareness and utilisation of the Sepsis Screening tool.

• Audit data disseminated throughout the UHB.

NEWS

Agreed chart for the UHB. Responses to

identification of acutely ill patients are

speciality specific.

Insert Title here Carbonated SBAR form to

aid handover and

escalation of care. One

copy is filed in the patients

notes, the other copy is

retained for audit

purposes.

Falls - Community

• Since October 2010, the team have been working on three Care Bundles but are not undertaking Care Bundle 4 (Monitoring).

• The team provides patient information and informs the GP of the screening, assessing and interventions undertaken.

• Significant achievement is that CELT has had only 2 re-referrals for falls in the 12 month since commencing the care bundle approach. (1% of total).

• Total patients on CELT database – 198 (Oct 2010 – Nov 2011)

• Consent forms show that all patients have agreed to participate in the programme

• 73% of patients referred to CELT for Falls Prevention received a full assessment (27% declined or were admitted to hospital etc).

• 11 patients have died in this time (not community falls-related) and one patient has not wished to comply with falls interventions.

Falls - Community % patients who receive the full Assessment Bundle

Falls

from Nov 2010 to Nov 2011

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% patients who complete the initial screening using an

agreed tool

Falls

from Nov 2010 to Nov 2011

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Falls – Community

Next Steps:

• Questionnaire for Monitoring Bundle ready to be sent out to patients for completion, with HIPO Project to be asked to manage the questionnaire.

• The nurse practitioner has become more adept at data entry and about to spread the work between other team members.

• Data Warehouse to be asked if information could be interrogated to identify repeat attendances at EU by patients.

• The team continues the excellent work.

Falls – Day Hospitals

• The DHs are working together on the Specialist Intervention Bundle; component parts and outcomes.

• PDSA cycles and discussion in MDT meetings used to finalise agreed evidenced based tools for outcome measures to use in the data collection by medical, nursing, physiotherapy & occupational therapy.

• The provision of falls prevention services throughout Cardiff and Vale is now aligned.

• The database is agreed and comprises of different colours to represent input from the different disciplines. The spreadsheet can be accessed and completed by different professionals at the same time.

Falls – Day Hospitals

• The Monitoring Bundle is integral to the database.

• JPDH will join the Collaborative and commence entering data when the database is up and running.

• UHL DH is likely to wait until the new DH is open due to limited space at present.

• Otago exercises are being introduced into the DHs.

• Public Health Wales is funding an Otago course for P/Ts and Technicians to increase availability of programmes in the home and community.

Falls – Day Hospitals

Next steps:

• The DHs join the Collaborative and enter data onto the 1000 Lives database.

• Fallers not suited to the group will be included into audit after an initial introductory period.

• Qualified Physiotherapists and Physiotherapy Technicians attend the Otago Training Course to learn the programme (training includes Extend Instructors and National Exercise Referral Scheme trainers).

• Extend the Otago programme into the community for up to 12 months, requiring support of Band 4 physiotherapy technicians.

• Physiotherapy Department to sell ankle weights to Patients due to purchasing difficulties.

Falls – Unscheduled

Care to Primary Care • Unscheduled Care Services: Emergency Unit in University Hospital of Wales; Barry

Minor Injuries Unit and Medical Assessment Unit in University Hospital Llandough.

• Linked with Welsh Ambulance Service Trust pathway – not integrated with 1000 Lives.

• Personnel involved: Consultant Nurse for Unscheduled Care with nursing staff; Consultant Physician with Clinical Lead for Falls and Programme Manager for Falls and Bone Health.

• The Falls and Bone Health Programme has a remit of partnership working and service improvement. It sits under the Integrated Health and Social Care Programme Board (The Wyn Campaign), working across all sectors. The Consultant Physician also leads the 1000 Lives Community Falls Collaborative.

• Unscheduled Care Services are busy units working under pressure.

Falls – Unscheduled

Care to Primary Care • Rationale for the service improvement:

– Nearly 4000 attendances at USC with a fall by older people with 530 repeat fallers. 30% repeat fallers return within a week (stats 2010).

– Exponential population corrected curve for > 75 years old fallers: agreed age for intervention.

– UHB not compliant with recommendations of Royal College of Physicians to assess fallers in USC and provide written patient information.

• The Consultant Physician met with and gained agreement from the Community Directors in March 2010 that Primary Care is the appropriate sector to care for people who fall.

• Work began on a pathway to complete an initial screen in Unscheduled Care Services (USC) indicating the on-going falls risk for patients attending with a fall, but not admitted.

• Meetings held with USC to determine level of assessment that busy units could complete.

• UHB joined the 1000 Lives Falls Collaborative. An appropriate validated Trigger Bundle tool was identified using PDSDA cycles (within community by Cardiff East Locality Team; Integrated Teams in the Vale; Clinical Case Managers and community physiotherapists).

• Cardiff East Locality Team joined Falls Collaborative and began testing three bundles in October 2010, trail-blazing the pathway for the UHB.

Falls – Unscheduled

Care to Primary Care • Improved compliance with RCP National Audit recommendations – screening of patients in

USC and patient information provided from November 2011.

• Engagement with Primary Care commenced with lead GP for falls and attendances at Community Director meetings to agree incentivised voluntary pathway; assessment tools.

• Primary Care not agreeable to enter data onto 1000 Lives database.

• On-going risk of falls: stratified by Trigger tool and low risk managed within USC – non-medicalisation of person.

• On-going risk of falls communicated to Primary Care via Communications Hub for further falls and bone health assessment.

• Trigger bundle tool score: input via Communications Hub to the 1000 Lives database.

• Development of information included patient public consultation on Care and Repair Home safety Checker leaflet.

• USC attendance for falls: improved partnership working with Primary Care.

• Safe discharge for non Cardiff and Vale Patients considered and actioned via letter to Primary Care.

• Staff Resource: ‘Red Files’ to guide admission avoidance and visual display board developed in USC.

• Link to in-patient falls risk assessment from USC.

Falls – Unscheduled

Care to Primary Care • To date: 68 referrals from USC.

• Numbers smaller than expected: issues within USC relate to pressure of work and competing priorities.

• Information and pathway for Primary Care on clinical portal.

• Primary Care engagement relate to issues about screening and assessment of housebound and vulnerable patients.

• Also issues with WAST limited engagement with agreed pathway (not part of 1000 Lives).

• Referrals to Day Hospital falls services targeted at those at highest risk.

Month Total Low risk Higher risk

November 34 17 18

December 8 2 6

January 16 6 10

February 11 1 10

March 10 2 8

April 7 2 5

November 9

December 18

January 11

February 15

March 9

April 5

Falls Risk Older People – Community (FROP-

Com) scores completed in the Emergency Unit

WAST – referrals to Primary Care

Adverse events - UHW Adverse event rate per 1000 patient days

Cardiff and Vale University Health Board - UHW

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Number of adverse events

Cardiff and Vale University Health Board - UHW

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Number of adverse events

Cardiff and Vale University Health Board - Llandough and other

hospitals

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Cardiff and Vale University Health Board - Llandough and other

hospitals

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Adverse events – UHL & others

Patient Safety WalkRounds

142 WalkRounds have taken place to date, visiting 133 different teams/areas, including 9 return visits, across 27 different sites, including schools, HMP Cardiff and nursing homes, with Board members discussing patient safety issues with over 350 members of staff. 217 Executive actions have been recorded as completed.

Patient Safety WalkRounds WalkRounds by

Month

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Nov-09Dec-09Jan-10Feb-10Mar-10

Apr-10May-10Jun-10Jul-10

Aug-10Sep-10Oct-10Nov-10Dec-10

Jan-11Feb-11Mar-11Apr-11May-11Jun-11Jul-11

Aug-11Sep-11Oct-11

Nov-11Dec-11Jan-12Feb-12Mar-12

Children & Women: 13

Clinical Diagnostics & Therapeutics: 16

Dental Services: 2

Medicine: 22

Mental Health: 23

Primary, Community & Intermediate Care: 23

Specialist Services: 18

Surgical Services: 19

Other: 6

WalkRounds by

DivisionWalkRounds by

Location

UHW: 67

UHL: 26

PCIC/Community Settings 8

Whitchurch: 7

St David's: 7

Mental Health Community Services:7

CRI/West Wing: 6

Rookw ood: 4

Barry Hospital: 4

Lansdow ne: 2

Schools: 1

Nursing Homes: 1

Cardiff Locality Office: 1

HMP Cardiff: 1

Patient Safety WalkRounds

Review of WalkRounds by Board Members held in April 2012.

• Executive and Independent Members asked to form “couplets”, carefully paired around skills

• Two WalkRounds to take place each week, including evening and weekend visits

• Briefing provided for Board Members ahead of visits detailing incidents, concerns, FOC audit outcomes

• Structure of visits reviewed to include capture of patient experience

• Continue to focus on organisational safety priorities

• Continue with visits to specialist, support and Primary Care services in addition to wards

Stories for Improvement - Success To Date (1)

Organisational Awareness – embedding stories

– Standardised ethical guidelines and governance structures in place

– Stories are an integral part of the patient feedback framework

– Board meetings and Board and Divisional Quality and Safety meetings start with a patient, carer or staff story

Building Capacity – collection and analysis

– Embedded in RCN Clinical Leadership Programme

– Over 150 staff trained

– Training available for all other staff groups

– Training for medical and other students

Stories for Improvement - Success To Date (2)

Demonstrating the impact – collection and analysis

– Data base of stories established

– Stories used to identify, influence and assess service improvements

– Stories at Board level linked to agenda items

Stories for Improvement - Future Focus (1)

Organisational Awareness

– Increased use of stories as part of patient experience feedback reports

– Increase the range of methods used to present and share stories

– Embed the use of stories in Operational and Service planning

Building Capacity

– Continue to train staff, as part of RCN programme and through internal training

– Expand the story database, improve “theming” and improve utilisation

– Increase the range of staff trained, including administrative and facilities staff

Stories for Improvement - Future Focus (2)

Demonstrating the impact – targeting priority areas

– Carers stories

– Patient Information services – patients with cancer

– Patient Environment, including food and cleanliness

– Shared Decision Making – involving patients in decisions about their care

Eating Disorders

Drivers:

• Tier 2 to improve specialist advice and support to primary care, including

pre-referral advice and shared care arrangements.

• Improved assessment care co-ordination and interventions across Tier 2

mental health services for CAMHS and CMHTs.

• Improved provision of Tier 3 Specialist Eating Disorder Services (SEDS) to

local communities.

• Improved acute medical in-patient care for patients with anorexia nervosa.

Eating Disorders

Achievements to date

• Establishment of data collection processes for monthly monitoring of 4 Drivers in key clinical areas of the UHB

• Regular review of auditing processes with key stakeholders within clinical services

• Training events within Tier 2 services, Tier 3 services and medical services established to support Drivers

Next steps….

• Establishment of individual clinician feedback mechanisms to enhance Driver implementation

• Increase access to, and familiarity with, resources to support liaison between Tiers 2 and 3 in line with Driver 1

• Participation in national review of delivery models for refeeding of severe eating disorders with medical ward environments

Medicines management

Medicines reconciliation • Note peaks every sixth entry – correspond to Mondays (reduced opening

hours over week-end.)

• Development of “joined up approach” via targeted medicine use reviews post

discharge. Supports reconciliation in primary care.

Medicines management

MSc work analysing warfarin associated major

bleeds and influence of 1,000 lives

Patient commenced on warfarin in December 2010 roughly 30% less likely to suffer warfarin associated major

bleed compared to January 2005.

Note improvement appearing to coincide with 1,000 lives campaign.

Further work to confirm cluster of low results early 2010 indicative of a sustainable trend.

Warfarin associated major bleeds per 1,000 Warfarin packs issued (with polynomial trendline)

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Key contacts for

Cardiff & Vale University Health Board

Joy Whitlock, Quality & Safety Improvement Manager

(Key Contact)

Ruth Walker, Executive Director of Nursing

(Executive Lead)

Dr Graham Shortland, Executive Medical Director (Executive Lead)

Fiona Jenkins, Executive Director of Therapies & Health Science (Executive Lead)

Dr Sharon Hopkins, Executive Director of Public Health, (also

covering Mental Health and Primary, Community & Intermediate Care) (Executive Lead)

Robert Williams, Assistant Director Patient Safety & Quality