1

Pennine Acute Hospitals NHS

Trust:

Improvement Journey

2

Nursing establishments increased by circa

20 wte (£682k) – full by end Sep 17 – FGH

FGH Consultant Medical staff full, 4

remaining middle grades recruited -await

start date

UCC – RN vacancy reduced 30% to 8%

AMU skill mix review – vacancies decreased

from circa 45% to less than 5% (RN)

AMU redesign plus further 10 beds Q3

17/18

Zero 12 hour ED waits since 02.17

Sepsis training above 95%

Medicine Workforce - £1.3 m 17/18 –

additional 14 RNs & 30 HCAs

FGH/RI – ED/Medicine

Site based

leadership

TROH Urgent Care

• Only ED with Green NAAS

• Investment in 25wte nurses and

additional Band 6 posts in ED/AMU

to strengthen leadership

• Expansion of Ambulatory

Care

• Additional CT scanner

• Frailty model expanded to ED/AEC

Primary care Streaming gaining

traction

Speciality response to

ED improving

Increasing use of AEC

4

Improvements on 4 hr performance

trajectory - ahead of STP agreed

trajectory by 1.22%

Significant reduction/elimination of 12

trolley waits

Escalation policy established and in place.

Moving towards recognised OPEL

ACU: National award for ambulatory care

service from NHS England

Ambulance arrivals to assess 14%

improvement, 24% improvement in time to

treatment

Quality Improvement strategy: PDSA

ongoing: See and treat in ED/ 2 hourly

Quality rounds

Unstable and unsafe

system stabilised and

improving NMGH - ED

5

AMU redesign

• Additional 8 beds opened July

2017

• Full expansion to 50 beds October

2017

• Pathway redesign based on SAM

guidance with focus on frailty and

full MDT working

• Improvements in LOS

• 94% compliance with mandatory

training

Fragile Service - AMU

6

£1.2m investment in midwives to achieve Birth rate +

9 consultants recruited with clinical directors in post

at both NMGH and ROH

Bi- weekly practice review meetings in place

Increased incident reporting

Improved Governance processes

- improved culture of incident reporting

- managing incidents in real time

- weekly complaints an incidents meeting to identify learning

93% Mandatory training compliance

84% Essential training compliance

Maternity services

Maternity services

• CTG central monitoring now live and working well with a clear reduction in CTG related incidence upon audit

• CTG training at 94%

• 50% reduction general anaesthetic at non-elective caesarian section

• Significant reduction in blood loss during post-partum haemorrhage

• Reduction seen in trauma post C Section and general anaesthetic emergency section down from 30% to 15%

• Early warning score assessment for mothers significantly improved and a reduction in critical care admissions

• Trust part of wave 1 for the NHSI maternity and neonatal safety collaborative

7

Paediatrics

• Strengthened clinical leadership

teams – consultants, ward

leaders, matrons

• 26 new nurse starters

• Attention to risk and governance

systems with weekly review

meetings, joint boards rounds,

annual education programmes,

risk register reviews.

• Reliably staffing HDU beds and

sustained reduction in transfers

out of area

• Training to support identification

and support of the unwell child

• Paed O&A expansion to create

additional capacity and reduce

LOS

8

9

C&YP Experience

0%20%40%60%80%

100%

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17 -

Friends & Family Test

Friends & Family Test Negative

Feedback Cloud Where word occurrs at least 10 times

Critical Care

• ROH HDU rota – increased from 5

hours a day of a consultant Intensivist

and a speciality doctor, progressing to

10 hours a day 7 days a week.

• Speciality Doctors - 3 wte overseas

recruits with a further 2 to join the

service by the end of the year.

• Advanced Critical Care Practitioner

(ACCP) training commenced in

February 2017 – two underway and two

further trainees from February 2018.

• An ICM trainee has started with the

Trust based at ROH

• Supernumerary shift leader recruitment

is on-going, with steady improvement

• Recorded handover from ROH HDU

to parent teams with a structured

ward round document with safety

checklist

• Daily joint multidisciplinary handover

of the unit at the ROH in the morning

• Ventilator Acquired and Associated

Pneumonia (VAP) screening done

daily process for recording rates

under development

• Procedural checklists introduced –

CVC, tracheostomy, bronchoscopy,

intubation

• Monthly joint M&M/MDT between

ROH/FGH meetings and bi weekly

M&M/MDT at the ROH

10

11

Quality Improvement Strategy

Quality improvement strategy

launched mid 2017

Staffing investment has allowed

greater involvement and

engagement in projects

Expansion of QI team enables

facilitation of collaborative events

and greater focus on

improvement

12

AIM: To reduce the cardiac arrest rate (per 1000 admissions) by 50% on

collaborative wards by 31st November 2017

Deteriorating Patient Collaborative

For collaborative wards, the chart

is within statistical control. If you

compare baseline with

intervention period then there has

been a 14% decrease.

For collaborative wards,

the chart is within

statistical control. If you

compare baseline with

intervention period then

there has been a 9%

decrease.

Highlighting sick patients at

the start of each shift

Trust-wide roll out of NEWS observation

chart

Roll-out of Patientrack e-

obs system commenced

Cardiac arrest role allocation

Using manual observations

for more accurate

identification of

deterioration

Code red- escalating

clinical intuition and

empowering staff

Weekend plan/escalation

stamp

13

AIM: To ensure 90% of all Red Flag Sepsis patients to receive antibiotics within 1

hour of arrival (in A&E) or within 1 hour of sepsis screening (inpatients) by 31st

March 2018

Sepsis

CQC MD 12: Ensure that staff are always escalating patients who

trigger the sepsis pathway for immediate medical review

In-Patient Sepsis Screening and Action Tool launched 10th

April with NEWS Observation Chart across all sites

‘Screen for Sepsis’ visual prompt included in NEWS

Observation Chart to ensure staff complete the Sepsis

Screening Tool if any Sepsis triggers are identified

If staff identify ‘Red Flag Sepsis’ using the Sepsis Screening

and Action Tool, then the ‘Sepsis Six’ pathway is available to

follow immediately

CQC MD 41: Ensure that staff complete training in ‘Sepsis six’ so

staff are aware of the process to follow when a patient is put on a

‘Sepsis six’ treatment pathway

Adult Sepsis E-Learning Module now included within Essential

Job Related Training for all nursing, midwifery and medical

staff working with adults

Clinical microsystems established for each Care

Organisation to focus improvement work locally

within all A&E departments with the aim of improvement the

early identification and timely management of sepsis.

13

14

NAAS

30%

49%

21%

Across all 4 sites 50 areas in total to be

assessed 47 undertaken 3 outstanding

Red wards Amber wards

Green wards

45%

33%

22%

NMGH 18 areas in total to be

assessed 18 undertaken 0 outstanding

Red wards Amber wards Green wards

22%

64%

14%

TROH 16 areas in total to be

assessed 14 undertaken 2 outstanding

Red ward Amber ward Green ward

13%

54%

33%

FGH / RI 16 areas in total to be

assessed 15 undertaken 1 outstanding

Red ward Amber ward

Green ward

Investment in 3 corporate quality

Matrons ( introduced June 2017

Still significant work to be done

but steady improvements in

outcomes

Far greater visibility of ward

quality and performance

November 2017 roll out of

paediatric NAAS

70% of all wards

assessed at Green or

Amber. 21% at Green

15

Actions and initiatives implemented to support

improvement to Trustwide Falls are as follows;

The roll out Pennine wide of the RCP bundle

Introduction of Falls Steering Group

Intensive training for areas with high falls levels

Introduction of falls panel which looks at learning from

falls across Pennine

Introduction of a distinct falls team

Collaboration with Alliance colleagues at Salford

Harm Free Care - Falls

16

Pennine Acute per 1000 bed days

There are 8 points below the mean from Sept 2017 which indicates special

cause. There are an average of 5.34 falls per 1000 bed days per month

across Pennine Acute.

Statistically

significant

improvement

correlates with the

introduction of the

RCP bundle

17

Pennine Acute Count of Falls

There is an astronomical data point in January 2016 with the rest of the data

points in statistical control. There are an average of 187.97 falls per month

at Pennine Acute.

18

The Infection Prevention Improvement plan 2017/18.

90 Quality Improvement programme completed for an innovative

patient hand hygiene project and adoption now in progress across

Pennine Care Organisations

NE sector collaborative E.Coli improvement programme initiated

with CCGs

“SIGHT “ CDI educational video completed

Implementation of both Care Organisation and Group Infection

Prevention Committee chaired by each Care Organisation DIPC.

Re-launch of IP Link Nurses programme with 2 successful study

days completed

Hand hygiene mandatory annual assessment compliance above

90% for all Care Organisations .

Harm Free Care – Infection Prevention

19

CDI: The Trust position compared to monthly reported cases in

2016/17, has improved and is in a position to meet the annual

objectives.

CDI Rate per 100,000 bed days has reduced from 14.31 in 2016/17 to

13.89 in first quarter of 2017/18.

The graphs below highlight post 48hr MSSA rate per 100,000 bed days

benchmarked with North of England Trusts. Pennine Acute continues to

report low a rate of 2.9. The majority of cases relate to soft tissue

infection and cellulitis.

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

E.Coli bacteraemias (Trust apportioned) rate per 100,000 Bed days Benchmark data for North England Trusts: Apr to Jun 2017

REN

RFF

RBS

RP5

RTX

RNL

RWY

RXL

RFR

RAE

RM2

RRF

RXP

RR7

RVY

RE9

RCF

23

A review of the Thromboprophylaxis policy is underway and following a pilot

on F11 at ROH VTE assessments. The prescription of thromboprophylaxis

will be linked via the EPMA from October 2017 to improve the compliance of

assessment and prescription for all new admissions.

Following the pilot 91% of newly admitted adults had VTE risk assessments

completed.

A check list has been introduced to all the wards at TROH for the ward

rounds, as a reminder to assess a patient’s VTE need. It will be monitored

by undertaking an audit of this from November 17 onwards This will help in

reducing the incidents of hospital associated VTE.

NMGH are looking at processes to increase compliance with risk

assessment as part of their MAU redesign work. The learning from this work

will be spread to other care organisation as part of their MAU redesign work

A group HA-VTE project is to be established as part of the Pennine QI

strategy.

Harm Free Care – VTE

24

VTE Assessment Compliance within 24

hours NMGH

25

Pressure Ulcers Collaborative

The aims of this

collaborative are: • A 30% reduction of Stage 2

Pressure Ulcers in pilot areas

by 1st April 2018

• Zero tolerance of Stage 3&4

(including unstageable pressure

ulcers) Pressure Ulcers in pilot

areas by 1st April 2018

• A 20% reduction in pressure

ulcers in the community pilot

areas by 1st April 2018.

Driver Diagram

26

Pressure Ulcers - Pilot Areas

27

Pressure Ulcers - Tests of change

Designed a flow chart explaining

what to do/next steps for pressure

ulcer care as a hand held pocket

device

Protected time for skin checks

and equipment checks

Standardised handover with

designated section for skin care,

skin check frequency, equipment

and mobility.

Body maps as part of intentional

rounding tool

Qualified staff aim to complete

skin inspections on AMU within

4 hours of arrival.

Welcome pack at every

bedside to educate patients on

pressure ulcer prevention.

End of bed handover on the

late/night shifts.

Bedside checklists as a visual

prompt on the bay for pressure

relieving equipment.

Review of fractured neck of

femur pathway from A&E and

focus on pressure ulcer

prevention earlier on.

To complete hourly

assessment of all medical

devices which risk damage to

skin

Education leaflets around skin

integrity handed out at pre-op

Educate and update staff on

correct use of slide sheet

CCU SKIN Bundle

Body maps as part of

intentional rounding tool

FGH/RI Pilot TROH Pilot NMGH Pilot

Supported with

• Site based learning sets throughout August & September

• Pressure Ulcer Pledge – to highlight importance

• NHS Model for Improvement

• Quality Improvement Team

End Of Life & Bereavement

• EOL Resource boxes on all wards and departments

• Dedicated Bereavement Offices with Bereavement Clerks, separate to General Office

• SWAN bereavement suites on all sites & in A&E

• celebration packs, comfort packs and z-beds for relatives staying overnight with loved ones.

• Tissue Donation process improved

• 3 Dedicated Bereavement Nurses, EOL Support Volunteers and investment in training and education days

29

February 2016

Monthly Mortality Case reviews were – under resourced, with delays

in analysis and reports

Speciality M&M reviews – Meetings not multi-disciplinary for

richness of feedback

Speciality M&M reviews - No formal agreed structure for

implementing and monitoring improvement actions from learning

Mortality Performance Report HSMR/SHMI and Dr Foster analysis -

Mortality performance and Mortality review findings reported via

different routes

Coding and Mortality validation - Variable practice of mortality

validation tool

The Hospital Standardised Mortality Ratio (HSMR) performance for

the Trust for the period June 2015 to May 2016 at 102.47

Morbidity & Mortality

30

Reliable system for multidisciplinary M&M reviews,

engaging Ward staff, Bereavement Nurses and EOL and

palliative care teams.

Adapting the SRFT Mortality Review Policy to provide a

standardised review process and governance structure for

escalation and reporting by the Care Organisations

Moving to a 3 step process to align with SRFT policy with

the creation of a new electronic Death Summary and

Coding form

Structured Judgement Review adopted as corporate review

methodology with overlap period during training.

Focus on learning with robust collation, communication and

education process being developed to provide assurance

around learning from avoidable factors. (incl. M&M, Clinical

Audit reports, Dr Foster, Grand Rounds, Coroners, themed

harms data, SI’s, Claims, Complaints etc.)

On-going data analysis and review of Dr Foster intelligence

to determine improvement actions within areas Trustwide

and at Care Organisation level.

Bereavement teams involved in liaising with relatives of

patients to support their involvement with mortality case

reviews, and investigations, and to keep informed of

progress and outcomes.

Morbidity & Mortality

31

The Trusts HSMR has

continued to reduce,

against a rolling 12

month trend, to the

period June 16 to May

17. HSMR is now

statistically less than

expected at 95.3.

The improved position,

against the risk

adjusted mortality

indictors is multi

faceted; reduction in in-

hospital deaths and

crude rate; increase in

the expected number

of deaths due to

improvements in

documentation, coding

and the introduction of

new coding guidance

for Septicaemia.

Morbidity & Mortality

Dr Foster Mortality Dashboard Period Jun-16 - May-17

32

Morbidity & Mortality

The Trusts HSMR has

continued to reduce,

against a rolling 12

month trend, to the

period June 16 to May

17. HSMR is now

statistically less than

expected at 95.3.

The improved position,

against the risk

adjusted mortality

indictors is multi

faceted; reduction in in-

hospital deaths and

crude rate; increase in

the expected number

of deaths due to

improvements in

documentation, coding

and the introduction of

new coding guidance

for Septicaemia.

Complaints

33

Complaints reduction and earlier response

rate less dissatisfied complainants with

introduction of new head of complaints and

investment in 4 Complaints handlers posts

and administration support

Eradication of +100 days open

complaints

Incidents, Claims and Coroners

• Care Organisation incident

reporting increased by 10%

• Serious Untoward Incident

investigation backlog reduced

from 102 to 4

• Reduction in SUI related

deaths

• Duty of Candour for Serious

Untoward Incidents –

increased from 20% to 100%

(Director or Deputy led

process)

• Coronial information request

data backlog Aug 2016 n=1000

– Aug 2017

• Prevention of Future deaths

notices reduced

• Legal representation at

inquests reduced from 44% to

5%

34

Claims

The Trust has been notified of 163 claims within the last year. There has been an decline in the

number of claims received. (caveat - claimant’s have three years from the date of incident or the

date of knowledge

Improvements to continue the reduction of claims include; changing Trust solicitors to Hill Dickinson;

a claims focus at meetings; training sessions to promote expedited processes.

Two new permanent members of staff within the department and a legal assistant who handles the

release of medical records.

Non clinical claims

Detailed analysis of EL/PL claims presented to H&S Committee to inform plans for targeted training

• Needlestick

• Slips/trips/falls

• Manual handling

0

2

4

6

8

10

12

14

16

18

20

Claims Received

Linear (Claims Received)

Claims

The above graph highlights the specialities of those claims which we have been notified of within the

last year, confirming hot-spots within: A&E, General Medicine, Obstetrics and Orthopaedic Surgery.

Regular meetings with the Governance Managers for Women & Children’s to investigate how we can

attempt to decrease the number of claims; often with the highest damages payments.

Further clinical training sessions are to take place following feedback to Orthopaedic Surgery due to the

high number of claims relating to missed fractures.

Clinical Negligence Claims

Analysis of NHSR scorecard to inform a planned programme of review with MD/CD's for each Care

Organisation and Division

Detailed review of high cost/high volume claims to support targeted training of clinicians

Further consideration to establish a clinically led Litigation Review Group. ( Group wide), to review new

claims received, to assess risk, lessons learned and potential early settlement.

0

5

10

15

20

25

30

Delays and Outliers

Medical outliers reduced from peak of 50 in Feb 2016 to

less than 10

MOATs and DTOCs still largely

unchanged

90 improvement cycles and clinical microsystem

coaching

38

Data Quality - ED

Point prevalence analysis of clock

stops between 3hour 30 and 3

hours 59.

• Auditors independent of the site

analysed, were trained in the

methodology for validation.

• Clinical input was provided by an

ED Consultant and information

support from the Divisional

Information Manager.

39

Data Quality - RTT

Phase 1 – removing data no longer accurate, timely or up-to date

- 174 specialities removed from consultant masterfile

- cleanse of cancellation reason masterfile (21 codes deleted)

- 35 unused specialities deleted

- admissions and referrals - all entries mapped to data dictionary and cleansed , so

meaningful to end users

Phase 2 – Autoclosure

- 170,00+ pathways closed safely, remaining 56,000+ by Oct

- monthly automation of auto closure with SOPs in place to maintain cleansed system

- new Patient Tracking Lists currently being tested for go line Oct

Phase 3 – Training

- 379 staff via face to face training and passed RTT e-learning

Phase 4 – PAS Upgrade and Patient Centre Roll-out - TBC

New Workforce Strategy - Aims

40

Hig

h s

tan

dar

ds

of

care

, del

iver

ed r

elia

bly

an

d

pro

du

ctiv

ely

highly motivated people

highly competent people, working at the "top of their

licence"

A workforce of sufficent numbers

A workforce of sufficient

numbers

41

More work to be done on Medical

recruitment

104 RNs and 37 Midwives started Sept

A workforce of sufficient numbers

Key changes • Significant investment in recruitment activities • Leveraging of SRFT brand • Part way through implementing radical transformation of

recruitment activity from administration to assertive management

• Starting journey to develop and embed new employee value proposition

• Implementing NHSP across all functions (medical implemented in Nov 17)

• Revision to workforce planning – first phase medical rotas • HRD business partner model

Results • Overall most measures have improved significantly over the last twelve months. • The overall engagement score for the Trust has increased to 3.91 from 3.77.

• 63.92% of staff would recommend the Trust for care or treatment compared to 52.88% in

March 2016

• 56.36% would recommend it as a place to work compared to 45.51% in March 2016.

• Measure of Staff confidence in the future of the organisation increased (3.08 from 2.58)

• Staff feeling able to achieve their work objectives increased to 3.63

• Sickness absence reduced by one percentage point in year 2016/17 • Staff turnover rate stabilised

43

Highly motivated people – May 2017

results

Key Changes • CO Director leadership

– Shop floor presence

– 1000 voices

– Comms

• Increased appraisal coverage

• Roll out of Pioneer (Go Engage) programme

• Revision of grievance & disciplinary practice

• Revision of sickness management practice

• Revision of L&D and OD practice and leadership

• Launch of MES programme

• HRD Business Partner Model (inc changes to contracting out model)

44

Highly motivated people

45

Highly Competent People

Key Changes

• Launch of clinical leaders programme

• Prioritisation and review of clinical development programmes

• Working up new LNA aligned with Trust priorities and staff aspirations

• L&D & OD functions with new operating models

• Revision of Contribution Framework

A workforce of sufficient

numbers Key changes

• Significant investment in recruitment activities

• Leveraging of SRFT brand

• Part way through implementing radical transformation of recruitment activity from administration to assertive management

• Starting journey to develop and embed new employee value proposition

• Implementing NHSP across all functions (medical implemented in Nov 17)

• Revision to workforce planning – first phase medical rotas

• HRD business partner model

Results • Overall most measures have improved

significantly over the last twelve months.

• The overall engagement score for the Trust has increased to 3.91 from 3.77.

• 63.92% of staff would recommend the Trust for care or treatment compared to 52.88% in March 2016

• 56.36% would recommend it as a place to work compared to 45.51% in March 2016.

• Measure of Staff confidence in the future of the organisation increased (3.08 from 2.58)

• Staff feeling able to achieve their work objectives increased to 3.63

• Sickness absence reduced by one percentage point in year 2016/17

• Staff turnover rate stabilised

Highly Motivated & Competent

People Key Changes

• CO Director leadership – Shop floor presence

– 1000 voices

– Comms

• Increased appraisal coverage

• Roll out of Pioneer (Go Engage) programme

• Revision of grievance & disciplinary practice

• Revision of sickness management practice

• Revision of L&D and OD practice and leadership

• Launch of MES programme

• HRD Business Partner Model (inc changes to contracting out model)

Key Changes • Launch of clinical leaders

programme

• Prioritisation and review of clinical development programmes

• Working up new LNA aligned with Trust priorities and staff aspirations

• L&D & OD functions with new operating models

• Revision of Contribution Framework

47

Looking Ahead

• Reliable process to maintain fundamental

clinical & operational standards;

• Scale up and spread of QI change

packages and launch of QPID methods

• Establish robust and reliable learning

Framework

• Enhanced observation – appropriate use

of staff and interventions

• Workforce; alternative roles and reducing

reliance on agency staff

• A&E and UCC – maintaining progress

and maximising winter resilience

• Reducing harm caused by pressure

ulcers , falls and C-Diff

• Continue to be key stakeholder in

development of LCOs

• Engagement, Engagement, Engagement

48