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Paper 6

NHS Board Meeting Monday 7 December 2015

Scottish Patient Safety Programme – Maternity & Children Quality Improvement Collaborative (MCQIC) Authors: Angela Cunningham, Associate Nurse Director – Women and Children’s Services Jacky Williams, Head of Quality

Sponsoring Director: Ann Gow, Nurse Director (Interim)

Date: 2 November 2015

Recommendation The NHS Board is asked to:

Acknowledge the ongoing work of clinical improvement in the Maternity, Neonatal and Paediatric services.

Acknowledge the Healthcare Improvement Scotland visit which complimented the service by commenting the improvement work being undertaken was world class.

Acknowledge the work undertaken in and across the services to improve Culture and Team Work utilising the Compassionate Connections Toolkit.

Summary The Maternity & Children Quality Improvement Collaborative programme was formally launched in March 2013. The collaborative covers the areas of Maternity, Neonatal and Paediatric safety improvement programme.

All three workstreams have funded National Clinical Leads on a sessional basis. Two of these leads are Ayrshire and Arran based which is helpful in taking work forward in our Board.

The overall aim of the programme is to improve outcomes and reduce inequalities in outcomes by providing a safe, high quality care experience for all women, babies, children and families across all care settings in Scotland. The information included is to provide assurance to the NHS Board of continuous progress towards the programme aims.

A selection of measures being undertaken within the MCQIC programme will be presented within the SBAR reports from the Maternity, Neonatal and Paediatric workstreams. The MCQIC Team in Women and Children’s Services are well engaged and have undertaken significant work to take the programme to this stage across all departments.

The staff within the Directorate take every opportunity to engage with the national team and colleagues across Scotland to improve learning and form informal support network.

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Key Messages:

The MCQIC programme is well embedded into practice in Women & Children’s Services, the teams are working towards implementing all the measures, moving to spread those with sustained improvement in the pilot areas, as per the improvement methodology. The methodology is used to test changes outwith the National programme; it has become “how we do things”.

In areas of sustained improvement we have been looking at plans for a step down approach to reporting. This work has not progressed over the summer and will be picked up in the next quarter (rationale for non progression ie pressure on service etc).

Each of the workstreams have multidisciplinary meetings on a regular basis to discuss/monitor progress against the programme aims.

All three workstreams have individual reporting toolkits which provide a challenge for collecting data when national measures have been spread beyond pilot reporting sites. Clinical areas have created shared drives to collect data but technical support is required for the creation and annotation of run charts. The lack of access to the Clinical Portal for the national measures for Maternity, Neonates and Paediatrics continues to be a problem.

The maternity workstream has the support of a Maternity Champion funded nationally to co-ordinate improvement project activity and to populate the national reporting toolkit. The Neonatal and Paediatric workstreams have identified non-funded local clinicians to facilitate improvement projects and reporting. Support is also provided by the Quality Improvement Department. Sustaining this is difficult in the current financial climate however staff are very flexible and committed to the work.

Glossary of Terms AMU CDC CO CRBSI ECDC MCQIC MEWS MOPs NHSA&A PAWS PEWS PDSA PICU PPH PVC SBAR SPSP SPSPP SSE

Ayrshire Maternity Unit Centre for Disease Control Carbon Monoxide Catheter Related Blood Stream Infection European Centre for Disease Control Maternity & Children Quality Improvement Collaborative Modified Early Warning Score Maternity Out-patients Department NHS Ayrshire and Arran Paediatric Advanced Warning Score Paediatric Early Warning Score Plan Do Study Act Paediatric Intensive Care Unit Post Partum Haemorrhage Peripheral Vascular Cannula Situation, Background, Assessment, Recommendation Scottish Patient Safety Programme Scottish Patient Safety Programme Paediatrics Serious Safety Events

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1. Maternity Workstream 1.1 Situation The Maternity workstream is currently reporting nationally on 24 agreed measures within the Maternity Care Measurement matrix. The measure of women who are satisfied with the care they received commenced in April 2015, to date the returned questionnaires have demonstrated 100% overall satisfaction with the care episode with AMU Inpatient Ward. One further measure being tested at the time of the last report is detailed later in the report:

The percentage of women who continue to smoke and who are provided with a tailored package of care.

The measure still not commenced is the percentage of normothermic newborn babies at the point of discharge from labour suite. Within NHSA&A this is not a reported issue within the AMU and therefore is not a priority measure. Discussions are ongoing nationally with regard to this measure. 1.2 Background The Maternity Care strand aims to support clinical teams in Scotland to improve the quality and safety of maternity healthcare. The overall aims of the Maternity Care strand are to:

increase the percentage of women satisfied with their experience of maternity care to > 95% by December 2015, and

reduce the incidence of avoidable harm in women and babies by 30% by December 2015

MCQIC was launched in March 2013 and is a programme of quality improvement that will now run in its current format until March 2016. The national discussions as to how work will be progressed post this date continue with the Scottish Government Health and Social Care Directorates, Early Years Collaborative, Raising Attainment for All and Healthcare Improvement Scotland. There is a MCQIC Midwifery Champion funded 15 hours per week via the national programme. The funding for the Midwifery Champion will continue until March 2016. This funding greatly assists in the continuing progress of the programme. There are also non funded identified Obstetric Consultant Lead and Consultant Anesthetic Lead. 1.3 Assessment 1.3.1 CO Key Measure Maternal smoking is a well-researched contributory factor in relation to stillbirth, miscarriage and fetal growth restriction. The three community areas are showing improvement in the number of women offered CO monitoring at the first point of contact in pregnancy. Midwives refer women to Fresh Air-shire if the CO level is four or above. South Ayrshire is the pilot site reporting to MCQIC (Figure 1). Since the previous report, the Electronic Patient Records has been rolled out fully now to all the community areas. This has demonstrated a marked improvement in data collection as evidenced below:

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Figure1: CO monitoring compliance South Ayrshire (MCQIC)

Figure 2: CO monitoring East Ayrshire

Figure 3: CO monitoring North Ayrshire

It is anticipated that this measure will be stepped down if improvement is sustained.

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1.3.2 Referral to Fresh Air Women who have a CO reading of four and above or who smoke are referred to Fresh Air-Shire at the first point of contact with the midwife. The referral process has now progressed to an electronic referral to Fresh Air-Shire across all three community areas and it is now expected that there will be a significant improvement in the number of referrals made (Figure 4). Figure 4 Referral to smoking cessation services

1.3.3 Tailored Package of Care – Key Measure North Ayrshire is testing the Tailored Package of Care which includes offering CO monitoring to appropriate women at each antenatal visit with women who continue to smoke eleven cigarettes or more being offered serial scans in the third trimester. Progress against this measure will be updated in a future report. (Figure 5). Work is ongoing in the Directorate to assess the impact of increased scanning requirements; this is of particular concern as there is a national shortage of sonographers. To date we have recruited one of our sexual health nurses with scanning skills in early pregnancy to undertake a session in Day Ward, this has released a sonographer to support the main department. Figure 5: Percentage of current smokers smoking 11 or more cigarettes per day

Median 64

All Community areas moving to electronic refferal

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% of Women audited that have a CO level ≥ 4ppm & % of compliance for referral to Fresh Air -shire.

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There are various factors that contribute to stillbirth and the MCQIC programme is reporting on measures which are related such as smoking and also a reduction in fetal movements. There is a link between fetal movement and fetal wellbeing, and a decrease or cessation of fetal movement may be associated with the risk of stillbirth. Work continues to progress in this area and will be reported in the next paper. 1.3.4 AMU safety brief The AMU safety brief which is a whole unit huddle involves representation from all clinical areas of the maternity unit to ensure effective communication and planning within the clinical teams. Compliance has been maintained at 100% since August 2014. Safety brief within AMU has also achieved 100% compliance across all inpatient areas. A step down measurement plan for assurance purposes requires to be developed and was planned to be implemented by July 2015. It is anticipated that this work will be completed by January 2016. 1.3.5 MEWS The scoring system supports staff to identify when a woman’s condition is deteriorating and requires escalation for treatment. Compliance is reported on a monthly basis with information shared with staff. The MOPs is the pilot reporting site for the national measures. This measure is reported by all clinical areas into the Clinical Portal. Escalation of women who require treatment is 100%. Observations are reliably undertaken and escalated, however there is variability in the associated care planning. MEWS reviews have been undertaken to provide ‘hot feedback’ to staff for learning. Within MOPs work is being undertaken to develop plans of care for identified conditions. Progress against this will be reported in the next paper. 1.3.6 PPH PPH is a serious and life threatening event following the delivery of a baby. Speedy and effective management is essential to achieve the best possible result. To support the achievement of this as well as the accurate recording of the event PPH prevention and management bundles have been agreed nationally and data is now being reported with the testing elements of these. A scribe sheet for the management of PPH and a dedicated PPH trolley has been identified in labour ward. Nationally progress against this measure has been slow therefore this was a key agenda item at the learning session held in June 2015. Work continues nationally against this measure. 1.3.7 Sepsis Six In previous National enquiries into Maternal Death sepsis has been found to be a leading cause. Accurate and effective management of sepsis which includes delivery of the elements of the Sepsis Six bundle within one hour of suspicion of sepsis is known to reduce mortality and morbidity. The measure for this is an ‘all or nothing’ measure, all six elements of the bundle must be met to attain compliance.

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This work was initially piloted in MOPs. The data involves small numbers and there may be no women presenting with sepsis in each reporting month. Data shows 100% compliance. This measure has been spread to all five clinical areas within the AMU. Data will be presented within the next report. 1.3.8 Safety Culture Work There is a requirement to develop monthly Leadership Walkrounds within the MCQIC programme which will incorporate the existing walkrounds that are established within the organisation. This is the early stages of development within maternity service and progress has been delayed due to clinical pressures over the last couple of months. Informal walkrounds have commenced however we have not commenced reporting on these through the national programme. Corporate Leadership Walkrounds continue within Women and Children’s Services’s with positive feedback being received.

“Compassionate Connections” continues to be delivered to staff groups within the Directorate. This programme promotes the delivery of compassionate person centred maternity care through fictionalised drama in a virtual learning environment which supports learners to understand person-centred approaches to maternity care. Four members of staff attended “train the trainers” sessions in Glasgow September 2014. This is offered to all staff across Women and Children’s Services, uptake mostly Nursing, Midwifery and Health Support Workers, staff have talked at national Conference on our approach. Plan to check attendance numbers in December and then plan for next year’s requirements based on that. The culture work will also include review of the staff survey results. Staff from the Directorate presented our work at the national conference in Edinburgh and are also supporting the person centred care team in an Ayrshire and Arran event on 6 November 2015. The Associate Nurse Director for Women and Children’s Services reconvened the local partnership group and will in future remit the culture work to this group. Workshops and action learning sets continue to be facilitated to support staff in the change process. These will also be used to embed the organisations culture and values into practice. 1.3.9 Risk Assessment & Mitigation Information received from Scottish Government recently advised that funding for the Maternity Champion will be allocated to cover the 2015/16 financial year. Plans require to be put in place in relation to pace and scale of implementation of the programme following this date. The Quality Improvement Team will provide support to increase improvement capacity and capability to try to mitigate this risk. 1.4 Recommendation The NHS Board are asked to acknowledge the ongoing work of clinical Improvement in Maternity services.

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2. SBAR Neonatal Workstream 2.1 Situation The National Neonatal Programme continues to undergo co-ordinated testing across all the units in Scotland with individual Neonatal Units selecting specific measures to test. Ayrshire and Arran were previously collecting data in relation to six elements of the National Data Collection Tool. This included PVC and Gentamicin bundles which are detailed below. We have moved to collecting data on 14 elements of the National Data collection tool including CVC insertion and care bundles. 2.2 Background The key objective of the Neonatal Care strand is to achieve a 30% reduction in avoidable harm in Neonatal Services by December 2015 by seeking to reduce:

harm from mechanical ventilation

harm from invasive lines

high risk medicines

harm from transitions of care, and

undetected deterioration and also to:

increase natural feeding, and

ensure service user engagement The Neonatal Quality Improvement Group formed in March 2014 continues to meet on a regular basis as a multidisciplinary team with service user involvement via a representative from Baby Life Support Services, a UK charity which supports families with premature and sick babies. The MCQIC champion and a representative from the paediatric quality improvement have a standing invitation to attend. Given the benefits of these meetings, our aim is to try and sustain the momentum in driving forward patient safety and improvement work within Neonatal Services. 2.3 Assessment 2.3.1 PVC Care Bundle Following a rise in nosocomial infections detected during the collection of blood cultures, the team created a bundle and insertion sticker, in an effort to minimise the risk of avoidable harm or complications in infants from PVC. Utilising improvement methodology work is continuing to achieve sustainability. (Figure 6)

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Figure 6: PVC insertion bundle; Overall Compliance

This improvement work is supported by a prompt to staff during our safety briefs on maintaining compliance with the PVC insertion and care bundles. 2.3.2 Gentamicin Bundle Gentamicin is a high risk medicine which can cause harm. There are four elements within the Gentamicin bundle which is an all or nothing bundle so all elements must be achieved to be overall compliant. Compliance with the bundle is not sustained and the team drilled down into the specific elements to identify the components causing difficulty in achieving and seek solutions against these components (Figure 7) We are now achieving 100% compliance in three areas of the bundle, the exception being on the administration of medication within the hour of it being prescribed. It is important to note that on these instances the delay has been on the initial prescription in which case the prescription should be re-prescribed. (Aim is to give the dose prescribed within one hour of the time prescribed. Eg a baby is admitted a prescription is written by the Medical staff, the nursing staff are busy admitting the baby and by the time they are ready to administer the medication it is outwith the one hour time therefore medical staff need to prescribe again.)

Figure 7: Gentamicin bundle: overall compliance

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2.3.3 Neonatal Resuscitation Team Huddle A “Neonatal Resuscitation Team Huddle” has now been implemented, the purpose is that all the team members meet at the beginning of each shift and ensure clarity of roles. This has been based on the adult model in use in NHSA&A and is an example of cross specialty working. This should provide the structure to good communication, teamwork and leadership which are key to a well organised and efficient resuscitation.

Huddle was implemented using the PDSA tool and has been in use now for five months.

The initial collection tool designed to monitor its compliance proved ineffective, which was frustrating as it was obvious the huddle was being used following the 0900hr and 2100hr Medical handovers. However, a second draft has been successful and we can now evidence our data. So far in the month of September we have achieved 100% compliance.

A questionnaire to assess staff confidence and understanding of roles within the team was also used and feedback showed staff felt more confident and had a better understanding of the roles involved following the introduction of the huddle. There has also been very positive feedback from Medical Staff who have felt that any emergency resuscitations they have attended now using the ‘huddle’ are 'calmer', 'better organised', 'run smoothly' and they felt more at ease as 'everyone knew what they were doing'.

Plan to use feedback from de-briefing to improve our practice. We are presently pursuing guidance on formal de-brief training ensuring best practice is used.

2.3.4 Safety Brief A step down measurement plan for assurance purposes will be implemented by January 2016 as we continue to maintain 100% compliance of reporting the neonatal unit safety brief. 2.3.5 CVC Bundles We have recently introduced our new CVC insertion and care bundle. Figure 8 CVC Maintenance Bundle Compliance

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2.3.6 Vancomycin prompt Following a change in practice, with the introduction of vancomycin is now being prescribed as our second line antibiotic cover and this being identified as a high risk medicine, we want to ensure we have a safe and reliable system in place to provide best practice in reducing any risk of errors. We have observed the success of the gentamicin prompt and designed a similar tool which will guide and assist staff in the preparation and administration of vancomycin. The tool itself can be used to collect data in monitoring its impact. This data is also one of the elements of the National data Collection tool. We are now in the process of introducing the prompt initially using the PDSA tool. A monograph extension has also been implemented to assist staff when using the pre-filled vancomycin syringe to prepare the loading dose of vancomycin, as well as the maintenance dose. A pre-registration pharmacist is aiming to measure the compliance to monograph initial dosing and subsequent dose adjustment. Progress on this measure will be contained within a future paper. 2.4 Recommendation The NHS Board are asked to acknowledge the ongoing work of quality improvement in the Neonatal Services. 3. Paediatric Workstream 3.1 Situation The paediatric workstream continues to report measures in relation to the nationally agreed Serious Harm Index. NHSA&A is now collecting data on four measures, having added CVC bloodstream infections to SSE, Unplanned admission to Paediatric Intensive Care Unit, and Medicines Harm. The National Reporting Toolkit was launched mid October 2014, however we have populated some of the measures within the toolkit back to January 2014. Currently around 15 hours per month are used to complete audits as it is essential that the National Data toolkit is completed as well as many of the same audits on our NHSA&A Quality Improvement Portal. 3.2 Background The key objective of the Paediatric Care strand is to reduce avoidable harm by 30% by December 2015. One of the mechanisms used to demonstrate this is the Paediatric Serious Harm Key Indicators 1-6. The infrastructure to support this has been established in NHS boards and data reporting has commenced.

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The areas of focus for paediatric care are:

SSE Ventilator associated pneumonia Central venous catheter blood stream infection Unplanned admission to intensive care Medicines harm, and Child protection harm.

3.3 Assessment 3.3.1 SSE Operational definition – A SSE is any event which is recorded in the board using risk management tools and is determined to be “high” or “very high”. There have been three reported and recorded SSEs in the last 19 months. There have been three post operative bleeds, one has been subject to local review, the other two are awaiting review. These have been reviewed by the service and where appropriate action plans put in place. 3.3.2 Unplanned admission to PICU Operational definition – An unplanned admission to PICU is defined as any admission which is not considered to be part of the natural in-patient journey. i.e. 24 hour observation post appendicectomy. Since January 2014, PICU transfers have ranged from 0-3 children per month for figures ending August 2015. The majority of these transfers have been children with respiratory issues requiring invasive ventilation within a tertiary children’s hospital. From October 2015 until March 2016 there is planned to be an ongoing measurement package that will be reported nationally through the Paediatric Critical Care Managed Clinical network. 3.3.3 Medicines Harm Operational definition – A Medicines Harm is any event which is recorded in the board using risk management tools and is determined to be “high” or “very high.” This will be a sub-set of the number reported in SSE (3.3.1). There has been no recorded medicine harm meeting for this criterion since January 2014. However there has been one incident of a patient requiring additional blood tests following administration of intravenous antibiotics twice in one day rather than just once. This is classed as avoidable harm. There is ongoing discussion with pharmacist re Hempa system and anomalies. 3.3.4 Central venous CRBSIs Operational definition – A central venous CRBSI is a septicaemia which occurs in patients who are receiving therapy via a central venous catheter. Recognised diagnosis definitions are provided by CDC 2 and ECDC 3.

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There have been no reported cases since January 2014. Two measures are not being reported on:

The ventilator associated infection measure is not applicable in NHSA&A.

Child Protection Harm definition for reporting to the national team has yet to be agreed. A Paediatric Quality Improvement Steering Group has been convened with the first meeting having taken place in February 2015. The project group will review the National Reporting Toolkit and subsequent measures to be reported on. Currently the national Paediatric Sepsis Six bundle is being implemented within the Children’s Unit, however already there are areas that have been identified that are not meeting national guidance:

High flow oxygen administration

Documented consideration of inotropes

This is currently being discussed with the national Paediatric work stream team, an update will be reported in a future paper.

Senior staff within the Children’s Unit are members of the SPSPP National Clinical Reference Group and attend meetings throughout the year. This provides us with the most up-to-date information and supports us influencing the National picture. 3.3.5 Within the toolkit there are a number of other areas that measurements are

being collated for, including: PEWS (locally called PAWS) Jan 2014 to August 2015 Figure 9

Compliance has dropped slightly since combining the audit results from ward 1A and 1B. Work is ongoing within both areas to improve this. Percentage of at-risk observations identified that are acted upon and have appropriate interventions undertaken in terms of their management as identified by PEWS.

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Figure 10

There is a National PEWS short life working group and outputs are awaited. Local PAWS data is collated within the Quality Improvement Portal. Compliance is reviewed and discussed within the unit. Compliance has been sustained therefore a step down measurement plan for assurance purposes requires to be implemented. Progress towards this will be reported at a subsequent meeting. 3.3.6 SBAR This measure is embedded in the culture of the paediatric unit, both in verbal and written formats. Staff convene regularly throughout a shift to ensure significant information is discussed; a morning Safety Brief is conducted, with watchers identified and a midday Safety Huddle is attended by staff from across the hospital and any children of concern are highlighted to the hospital co-ordinator. A ‘watcher’ is a child with a PAWS score at three or above or a child without a PAWS score but is identified as a concern by nursing or medical staff. Compliance has been sustained therefore a step down measurement plan for assurance purposes requires to be implemented. Figure 11

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3.3.7 SEPSIS Significant work has taken place in an effort to improve the identification and management of Sepsis. In addition to the development of a Sepsis Pathway and Mapping Exercise, the team has worked closely with Emergency Department colleagues and conducted simulation training in both Emergency Department and the Paediatric Unit. Testing of the Sepsis Bundle has commenced in the Children’s Assessment Unit (Ward 1A). Progress will be monitored by the Paediatric Improvement Group and an update will be provided in future papers. 3.3.8 Person Centred Care- What matters to me? Children and parents complete this on a handheld whiteboard in the assessment unit, or with play staff in the inpatient unit. This has been well received within the wards and data collection commenced in March 2015. Within the inpatient ward all children are given the opportunity to write/draw ‘what matters to them’. Currently we only have a response of approx 20%, however the anecdotal feedback from the children and their parents is that there is so much else within the ward to occupy their time that this is not a priority for them. Figure 12

Figure 13

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The number of ward staff contributing to quality improvement work is slowly but steadily increasing. 4. Recommendation The NHS Board are asked to acknowledge the ongoing work of quality improvement in the Paediatric Services.

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Monitoring Form

Policy/Strategy Implications

This initiative links to the Boards SPSP/Quality Strategy.

Workforce Implications

This may have implications for workforce moving forward to maintain the rate of progress across all three workstreams.

Financial Implications

There may be financial implications identified as new National Standards of care are identified. These will be discussed as the programmes progress.

Consultation (including Professional Committees)

There is no requirement to involve professional committees as this work forms part of the SPSP process. Service users are informed of progress via user links established in the services and notice boards in clinical areas.

Risk Assessment

Delivery of the programme is aimed at reducing harm within the Maternity & Children’s services. Non delivery of the programme could impact on the provision of a safe service and reputation of the organisation if timely effective implementation does not happen.

Best Value - Vision and leadership - Effective partnerships - Governance and

accountability - Use of resources - Performance management

This programme encompasses all of the best value standards. The delivery of the elements contained within the MCQIC programme will support the Boards commitment to safe, effective and person centred care.

Compliance with Corporate Objectives

Quality and Safety

Single Outcome Agreement (SOA)

Not required

Impact Assessment Impact Assessment is not required as this is an internal document.