Leadership in Clinical PracticeQuality of Care Rounds
Improving Quality Programme and Ward Accreditations
Deborah CarterDeputy Director of Nursing (Quality)
What did we want to achieve?
• Improve our patients experience
• Empower ward leaders to gather their own data about the environment of care
• Ward teams able to directly influence the quality of care and the environment
• Patients and staff giving direct feedback
• Board level assurance on the quality of patient care
Where Did We Start?
• In 2008 ~ no Trust wide approach to data collection on the environment of care or patients view of this
• Review of results from 5 years inpatient survey
• Analysis of complaints feedback
• Understanding the national picture
• Choosing which aspects to measure
Understanding What Matters
• Environment of Care• Privacy and Dignity• Clean• Infection control• Communication• Food• Pain
Quality Care Dashboard
Presenting the
Quality of Care For
Ward Part of the
PatientExperienceMetricsQualityCampaign.co.uk Reported Distributed on 16/01/2011 December 2011
Providing Good Nutrition
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Ensuring Patient Safety
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Ensuring Patient Satisfaction
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Achieving Good Communication
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Ensuring Pain is Managed
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Respecting Privacy & Dignity
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Achieving a Clean Environment
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Ensuring Infections are Controlled
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Involving Patients & Carers
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
KEY: Scored by… Blue - Patients via Tracker Turquoise - Ward Managers via MWR/QCR (New QCR started April 2011)
Overall Quality
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Meeting Equality & Diversity Needs
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
Meeting Personal Hygiene & Care Needs
40%
50%
60%
70%
80%
90%
100%
12
/10
01
/11
02
/11
03
/11
04
/11
05
/11
06
/11
07
/11
08
/11
09
/11
10
/11
11
/11
12
/11
85% Lower Threshold - 95% Upper Threshold
Quality Care Dashboard
Delivering the Best Patient Experience in the NHSCentral Manchester University Hospitals NHS Foundation Trust.
Brown - Safeguarding IncidentsGreen - PALS Compliments, Blue - PALS Complaints and Red - ComplaintsBlack - MRSAGreen - Median Length of Stay Purple - CDIFF
Monitoring Medication Errors
0
5
10
15
20
25
30
35
40
12/1
0
01/1
1
02/1
1
03/1
1
04/1
1
05/1
1
06/1
1
07/1
1
08/1
1
09/1
1
10/1
1
11/1
1
12/1
1
Total Reported Incidents
0
10
20
30
40
50
60
70
80
90
100
12/1
0
01/1
1
02/1
1
03/1
1
04/1
1
05/1
1
06/1
1
07/1
1
08/1
1
09/1
1
10/1
1
11/1
1
12/1
1
Monitoring Patient Falls
0
5
10
15
20
25
30
35
4012
/10
01/1
1
02/1
1
03/1
1
04/1
1
05/1
1
06/1
1
07/1
1
08/1
1
09/1
1
10/1
1
11/1
1
12/1
1
Monitoring Pressure Sores
0
2
4
6
8
10
12
14
16
18
20
12/1
0
01/1
1
02/1
1
03/1
1
04/1
1
05/1
1
06/1
1
07/1
1
08/1
1
09/1
1
10/1
1
11/1
1
12/1
1
Average Length of Stay
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
12/1
0
01/1
1
02/1
1
03/1
1
04/1
1
05/1
1
06/1
1
07/1
1
08/1
1
09/1
1
10/1
1
11/1
1
12/1
1
Reducing Complaints
0
2
4
6
8
10
12
14
16
18
20
12/1
0
01/1
1
02/1
1
03/1
1
04/1
1
05/1
1
06/1
1
07/1
1
08/1
1
09/1
1
10/1
1
11/1
1
12/1
1
Monitoring Infection Rates
0
2
4
12/1
0
01/1
1
02/1
1
03/1
1
04/1
1
05/1
1
06/1
1
07/1
1
08/1
1
09/1
1
10/1
1
11/1
1
12/1
1
Safeguarding Patients
0
2
4
12/1
0
01/1
1
02/1
1
03/1
1
04/1
1
05/1
1
06/1
1
07/1
1
08/1
1
09/1
1
10/1
1
11/1
1
12/1
1
KEY: By Severity…Teal - Low/Grade 1 Green - Minor/Grade 2 Yellow - Moderate/Grade 3 Orange - Major/Grade 4 Red - Catastrophic (L5) *Grades refer to Pressure Sores only
For
Trust
Part of the
PatientExperienceMetrics Showing data for Number of Audit taken place:
Report Produced byColin HunterInformation AnalystQuality Campaign Team (Analysis)
Patient Experience Tracker DashboardAll Categories
940December 2011
Central Manchester University Hospitals NHS Foundation Trust.Delivering the Best Patient Experience in the NHS
75.0%
89.4%
82.8%
82.2%
73.7%
75.5%
81.5%
80.9%
78.4%
74.0%
79.7%
80.3%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95%
How Clean is your Environment
Are we doing our best to Control Infections
How Safe do you feel in this Environment
How Effective is our Communication
Are we Offering Good Nutrition
Are we Managing your Pain Levels
Do we give you Privacy & Dignity
How Aware of Equality & Diversity
Did we Involve You and/or your Carer
How Satisfied are you
National NHS CQUIN Measures
Overall Patient Experience Score
Lower Threshold UpperThreshold
Monthly Snap Shot
For
Trust
Part of the
PatientExperienceMetrics Showing data for
IP Quality Care Round DashboardAll Categories
December 2011
Central Manchester University Hospitals NHS Foundation Trust.Delivering the Best Patient Experience in the NHS
96.0%
97.8%
96.6%
98.0%
93.8%
93.3%
95.5%
91.0%
96.1%
85.5%
94.8%
95.4%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95%
How Clean is your Environment
Are we doing our best to Control Infections
How Safe do you feel in this Environment
How Effective is our Communication
Are we Offering Good Nutrition & Hydration
Are we Managing your Pain Levels
Do we give you Privacy & Dignity
Are you Satisfied with our Service
Did we Involve You and/or your Carer
Have we met your Equality & Diversity requirements
Are we meeting your Personal Hygiene needs
Overall Quality Score
Lower Threshold UpperThreshold
Continuous improvement
• Review of process with matrons and ward managers
• Understand what adds value to the patient experience
• Improve report functions
• Spread to non-ward areas
• Developed the tool further
• Board Assurance
Improving Quality Programme
• NHSi Productive Ward – whole hospital roll out pilot site 2007-2010
• Recognised some good ideas started but not spread– Lacked standardisation
• Not embedded as a culture– Seen as a project
• Had become another performance measure– Rated red, amber or green
• Reviewed sustainability– What did we want to sustain?
Key Elements
• Well organised environment (WOW)
• Improving Quality data board
• Patient Status at a Glance (PSAG)
• Shift Handover
Key Elements
Shift Handover
To include patient details e.g. location, name, age, gender andto provide summary of current admission e.g. current diagnosis and management plan / interventions.
To include requests for next shift related to patient care needs, management plan or any outstanding tasks.
To include an overview of patient care during your shift, e.g. relevent observations /monitoring, EWS etc., any 'risks', MDT involvement
To include relevent past medical history and social circumstances.
ecommendation
ssessment
ackground
ituationS
B
A
R
Verbal Prompt for Shift HandoverWard Area Date Time of Handover
No. Alert Specific requirements Report Details
1Patients with similar
namesList all patients names and
Hospital Numbers
2Deteriorating patients with
EWS above 3List all patients names and
Hospital Numbers
3Safeguarding / Vulnerable
patient issuesList all patients names and
Hospital Numbers
4 Falls risks Confirm completed assessments, actions, traffic lights
5 Infection Control Issues check screening, pathways, VIP charts, any barrier nursing
6 Absent Patientsinclude names of patients not on ward, current location if known
and last time seen
7Patients on Liverpool Care
PathwayList all patients names and
Hospital Numbers
8 Patients with DNR order List all patients names and Hospital Numbers
9Confused / Wandering
PatientsList all patients names and
Hospital Numbers
12Relatives / Carers resident
on wardGive details
10 Incidents or Complaints Details of significant clinical incidents or complaints
11 Staffing Issues Off duty checked and NHSP booking made / outstanding
12 Cleaning Matters discuss with H.S.A any issues affecting cleaning schedule
Handover to………………………………
Shift Handover - Core Huddle
Handover from……………………………………
ONCE DATA COLLECTION COMPLETED OPEN A3 REPORT IN SHIFT HANDOVER AND CLICK ON THE PALE BLUE TAB TO FIND CORRECT PAGE TO INPUT DATA
No
Yes
1 23 45 6
7 8 9 10 11 1213 14 15 16 17 1819 20 21 22 23 24
25 2627 28
29 30 31
1 23 45 6
7 8 9 10 11 1213 14 15 16 17 1819 20 21 22 23 24
25 2627 28
29 30 31
Was S.B.A.R. used for all patient handovers?
Was a core huddle completed?
1 23 45 6
7 8 9 10 11 1213 14 15 16 17 1819 20 21 22 23 24
25 2627 28
29 30 31
1 23 45 6
7 8 9 10 11 1213 14 15 16 17 1819 20 21 22 23 24
25 2627 28
29 30 31
Day to Night - Shift Handover Monthly Audit - August
No Date this month
Improving Quality ProgrammeSet minimum standards with flexibility to apply in all areasDeveloped agreed Trust wide ‘gold standards’
Provide teaching in methods:Provided a 14 week programme of master classes andfacilitation to all wards
Provide resources:Provided handbooks, data collection tools and electronicresource files
Establish 30 day project mentality:Feedback sessions after 30 days with expectation of further learning and improvements
Create motivation:Assessments to achieve Bronze, Silver or Gold
Layered Approach
Standardisation
Align to normal business
Embed knowledge
Layered Assessments
Wards are assessed and rated as:• White• Bronze• Silver or • Gold
Standardisation: At end of 14 weeks assessing successful implementation of standards (withfacilitation)
Embedding knowledge: 12 weeks laterassess ability to apply methods to issues identified in data(without facilitation)
Align to normal business: 12 weeks later comprehensive ward accreditation process
Clinical Leadership
In wards that were successful in achieving and
maintaining silver or gold:
• Leaders with clear vision and good communication
• High level of staff involvement and engagement in IQP work
• Good understanding of data and methodology
Ward Accreditation Process• Data review• Observation
• Culture of continuous improvement• Environment of care• Communication about and with patients• Nursing processes
• Discuss findings of observation and review in context of data
• Score standards as White, Bronze, Silver or Gold
• Overall score validated at panel review
Aims to…
Support ward leaders and their staff in….
• achieving the best patient experienceon their ward through continuousimprovement work
• thus provide a level of assurance to theboard about the quality of care on wardsand departments
As measured by…
• Number of wards assessed and rated
• Improvements in Quality Care Dashboard data
• Findings of external assessors including CQC
• Staff and Patient survey results
How are we doing?
Number of wards achieving overall results as Gold, Silver, Bronze or White
0
5
10
15
20
25
30
GOLD SILVER BRONZE WHITE number tocomplete
Achieving Good Standards
% of wards acheiving silver or gold for each category
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Culture ofcontinuous
improvement
Environment of care Communication aboutand w ith patients
Medicines - process Meals - process
Communication About Patients
Using Standardised Communication Tools
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11
CoreHuddle
Status ata GlanceBoards
90%target line
Improving Risk Assessments
Documentation - Risk Assesments Completed Within Timescale
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11
Falls
Bed rails
PressureulcersNutrition(adult)Continence
90% targetline
Medications - Ensure Drugs Fridge Locked
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11
Focus on Process
Meals - Offering Hand Wipes With Meals
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11
Supporting White Wards
• Understanding that areas are safe
• Diagnostic assessment
• Individual support for ward manager
• Blended approach to providing support to ward team to achieve improvement
Celebrating Gold
“Never tell people how to do things. Tell them what to do and they will surprise you with their ingenuity”
George S Patton