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Reducing Harm and Mortality in Hywel Dda Health Board May 11 th 2010.

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Presentation on theme: "Reducing Harm and Mortality in Hywel Dda Health Board May 11 th 2010."— Presentation transcript:

1 Reducing Harm and Mortality in Hywel Dda Health Board May 11 th 2010

2 Reducing Harm and Mortality in Hywel Dda Health Board Reducing Harm & Mortality in Hywel Dda - Our Main Aims Reduce RAMI to below 100 in 2 years Reduce episodes of harm by 25% in 2 years

3 Reducing Harm and Mortality in Hywel Dda Health Board Executive Leads Janet Wilkinson:- Leadership Dr Simon Mahon Medical Director:- Critical Care& Rapid Response to Acute Illness Bernadine Rees:- Medicines Management Tony Chambers:- Healthcare Associated Infections

4 Reducing Harm and Mortality in Hywel Dda Health Board Executive Leads Caroline Oakley Director of Nursing:- Hospital Acquired Pressure Ulcers Chris Wright:- Surgical Complications Kathryn Davies:- Hospital Acquired Thrombosis Dr Sue Fish Medical Director:- Acute Stroke

5 Reducing Harm and Mortality in Hywel Dda Health Board RAMI 2010 Our aim is to reduce the RAMI to below 100 and also to reduce the variation in our monthly RAMI scores

6 Reducing Harm and Mortality in Hywel Dda Health Board How We are going To Achieve Our Aims By Using Continuous Quality Improvement Methodology

7 Reducing Harm and Mortality in Hywel Dda Health Board How We are going To Achieve Our Aims

8 Reducing Harm and Mortality in Hywel Dda Health Board How We are going To Achieve Our Aims Each ward/department required to sign up to at least one quality Improvement project inline with the requirements of the Health Board Quality Improvement strategy and 1000 Lives+ content areas

9 Reducing Harm and Mortality in Hywel Dda Health Board How We are going To Achieve Our Aims Each ward/department has to complete quality improvement project notification and approval form Page 1 of form

10 Reducing Harm and Mortality in Hywel Dda Health Board How We are going To Achieve Our Aims These forms will be used to track the quality improvement projects and ensures that each project has a sponsor and has been agreed They will also set out the reporting arrangements for the project

11 Reducing Harm and Mortality in Hywel Dda Health Board Quality Improvement Project Feedback/Communication form Each ward/department will be required to provide updates on progress on to the 1000 Lives+ teams monthly

12 Reducing Harm and Mortality in Hywel Dda Health Board Driver Diagram

13 Reducing Harm and Mortality in Hywel Dda Health Board Reduction of RAMI and Harm Primary Drivers Reduce Mortality Levels –Weekly Review of all Deaths in Secondary Care –First review meeting held (Execs & AMD’s in attendance). –39 Deaths reviewed Implementation of Quality Improvement and Patient Safety Strategy –How to Guide for Health Board staff being written Reduce episodes of harm to our patients –This will be achieved by ensuring all elements of the 1000 Lives+ are implemented along with achieving the aims of the Quality Improvement Strategy

14 Reducing Harm and Mortality in Hywel Dda Health Board Reduction of RAMI and Harm Secondary Drivers Analysis of CHKS data to identify areas of potential concern –This work has already started Address data quality issues –Reduce backlog of un-coded notes 6000 sets of un-coded notes coded in 6 weeks –Improve systems for coding of patients notes Discharge summaries/letters being revised

15 Reducing Harm and Mortality in Hywel Dda Health Board Reduction of RAMI and Harm Secondary Drivers Improve systems for undertaking GTT audits in 4 main hospitals –10 sets every two weeks –Train more staff to undertake GTT audits –Improve system for obtaining patients details and retrieval of notes

16 Reducing Harm and Mortality in Hywel Dda Health Board Reduction of RAMI and Harm Secondary Drivers Executive lead for each content area tasked with driving forward the initiatives helping to ensure that harm and mortality reduction targets are met Quality and Safety teams to be set up in each county

17 Reducing Harm and Mortality in Hywel Dda Health Board Clinician Engagement Mortality and Morbidity meetings to be rolled out across the Health Board Standard Agenda to include –Mortality Review –CHKS validation –Unexpected admissions to ITU –Cardiac Arrest Qualitative audits –Adverse Incident –Infection control issues –GTT

18 Reducing Harm and Mortality in Hywel Dda Health Board Key Quality Issues Currently Being Addressed Standardised Handover (SBAR) Clerking Performa Track and Trigger Improved discharge/death documentation Clinicians engagement with clinical coding DNAR

19 Reducing Harm and Mortality in Hywel Dda Health Board Driver Diagram

20 Reducing Harm and Mortality in Hywel Dda Health Board General Ward Primary Drivers Develop an infrastructure that promotes quality care (Transformational Leadership) Provide an environment that has efficient and organised systems in place (Releasing Time to Care) Provide appropriate, reliable and safe care to patients using evidence-based therapies (Safety & Reliability) Create a highly effective and collaborative multidisciplinary team and safety culture (Teamwork & Vitality) Ensure patient and family centred care

21 Reducing Harm and Mortality in Hywel Dda Health Board General Ward Secondary Drivers (Transformational Leadership) Continue to implement the ‘Empowering Ward Sisters’ principles for leadership & development in all areas Establish integrated multi-disciplinary teams supported by the ward/ department Leader Ensure patient care & ward objectives are measurable & aligned to the Health Board priorities

22 Reducing Harm and Mortality in Hywel Dda Health Board General Ward Secondary Drivers (Releasing Time to Care) Establish open and accessible processes to report outcome measures ‘Knowing How We Are Doing Boards’ are creating opportunities for staff, patients & public to understand the information and it’s implications for practice. Create efficient sustainable working environments and systems of work 5’s principles are one example being used to achieve sustainable changes with staff commitment Develop visual information/ communication systems to convey patient information ‘Patent Status At A Glance’ Boards are being developed to support this, with some areas investing in white board technology

23 Reducing Harm and Mortality in Hywel Dda Health Board General Ward Secondary Drivers (Safety & Reliability) Reduce Pressure Ulcers by 50% (See separate driver diagram) Reduce Patient Falls by 50% (See separate driver diagram) Reduce HAI infections by targets within the Quality strategy and AOF

24 Reducing Harm and Mortality in Hywel Dda Health Board General Ward Secondary Drivers (Safety & Reliability) Modified early warning system (MEWS) to identify patient deterioration –Currently 3 different systems in use –Scoring systems being aligned to ensure consistency –Health Board wide system being developed

25 Reducing Harm and Mortality in Hywel Dda Health Board General Ward Secondary Drivers (Teamwork & Vitality) Establish accurate & accountable MDT care planning Ensure all MDT communication / handover processes apply the principles of SBAR some areas have linked the handover to the Patient Status At A Glance board, improving accuracy of information, patient safety and effective use of staff time

26 Reducing Harm and Mortality in Hywel Dda Health Board General Ward Secondary Drivers (Patient & Family Care) Ensure patients physical comfort Involve patients & family with care planning goal setting and discharge planning National Fundamentals of Care Audit provides information regarding the patients’ perception annually to all wards, additional short stay areas to be included. Communicate openly and effectively amongst the MDT, Patient & Family Ensure Patients wishes are respected within end of life care planning –End of life care pathway provides auditable information

27 Reducing Harm and Mortality in Hywel Dda Health Board Driver Diagram

28 Reducing Harm and Mortality in Hywel Dda Health Board Falls Primary Drivers Identification of Risks Multifactorial risk assessment Multifactorial interventions Communication of falls risk status Education of staff, patient and family carer

29 Reducing Harm and Mortality in Hywel Dda Health Board Falls Secondary Drivers Each area to assess their local falls risk- – analysis of falls on units by: time of day, patient’s age range, type of patients, condition. Utilisation of warning cards (above patients head) for patient with a history of falls

30 Reducing Harm and Mortality in Hywel Dda Health Board Falls Secondary Drivers Each ward/Department to work with allied health colleagues to assess –Falls History/ Medication review –Gait Balance, mobility, muscle weakness –Osteoporosis risk –Functional ability –Visual & Cognitive impairment –Urinary incontinence –Cardiovascular assessment - Hazards

31 Reducing Harm and Mortality in Hywel Dda Health Board Falls Secondary Drivers Involvement of patient & family –Include falls status in ward handovers and safety briefings –Develop a Falls prevention information pack for patients, families and caregivers –Develop a Falls education pack and Falls preventions program for staff

32 Reducing Harm and Mortality in Hywel Dda Health Board Driver Diagram

33 Reducing Harm and Mortality in Hywel Dda Health Board Pressure Sores Baseline data for pressure sores within the Health Board Data is from CHKS

34 Reducing Harm and Mortality in Hywel Dda Health Board Pressure Sores Primary Drivers Risk Identification Risk Assessment Implementation of the SKIN bundle Identification, grading of pressure ulcers existing on admission/transfer & appropriate intervention Education

35 Reducing Harm and Mortality in Hywel Dda Health Board Pressure Sores Secondary Drivers All staff to be able to understand the risk factors for acquiring pressure ulcers Understand the local context & analyse local data to assess patients on ward/unit most at risk Utilisation of patient ‘At risk’ cards to quickly identify those at increased risk

36 Reducing Harm and Mortality in Hywel Dda Health Board Pressure Sores Secondary Drivers All patients to have their pressure ulcer risk assessed on admission Re-assess skin every 8 hours Initiate and maintain correct and suitable preventative measures when needed

37 Reducing Harm and Mortality in Hywel Dda Health Board Pressure Sores Secondary Drivers All wards/Departments to implement the SKIN bundle which aaddresses these areas: –Surface –Keep Turning –Incontinence –Nutrition

38 Reducing Harm and Mortality in Hywel Dda Health Board Time Scales May 11 th 2010 Health Board Executives and others attend 1000 Lives+ launch May 12 th 2010 Aims of 1000 lives+ conveyed to all Health Board Staff End of May/Beginning of June ward/department sign up to at least one intervention The Transforming Care initiative to be implemented into all ward/in-patient areas by the end of 2012

39 Reducing Harm and Mortality in Hywel Dda Health Board Thank You

40 Reducing Harm and Mortality in Hywel Dda Health Board May 11 th 2010 Presenter: Dr Simon Mahon Medical Director

41 Reducing Harm and Mortality in Hywel Dda Health Board Reducing Harm & Mortality in Hywel Dda - Our Main Aims Reduce RAMI to below 100 in 2 years Reduce episodes of harm by 25% in 2 years

42 Reducing Harm and Mortality in Hywel Dda Health Board Executive Leads Janet Wilkinson:- Leadership Dr Simon Mahon:- Critical care& Rapid Response to acute illness Bernadine Rees:- Medicines management Tony Chambers:- Healthcare Associated Infections Caroline Oakley:- Hospital Acquired Pressure Ulcers Chris Wright:- Surgical Complications Kathryn Davies:- Hospital Acquired Thrombosis Dr Sue Fish Acute Stroke

43 Reducing Harm and Mortality in Hywel Dda Health Board RAMI 2010 Our aim is to reduce the amount of variation in our monthly RAMI (2010) scores and make it more consistent

44 Reducing Harm and Mortality in Hywel Dda Health Board By reducing the amount of variation in the RAMI will improve the predictability of patient outcomes and will help to reduce the frequency of poor results.

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