1. Aneurin Bevan Health Board 11 May 2010 Reducing Mortality and Harm

2. Aneurin Bevan Health Board Primary Drivers in the Mortality Driver Diagram Reacting to Deteriorating Patients Preventing Hospital Acquired Thrombosis Management of High Risk Medications Prevent HCAI Teamworking Management of Chronic conditions

3. ABHB MORTALITY DRIVER DIAGRAM ObjectivePrimary Drivers (What)Secondary Drivers (How) Action Reduce Unexpected Deaths * Prevent Deterioration of Patients (RRAILLS) * Prevent HCAI MRSA C Diff VAP CLC SSI * Prevent Hospital Acquired Thrombosis * Improve Management of High Risk Medications Insulin Warfarin Improve Team Working CHF Stroke Appropriate Response to MEWs Triggering Appropriate DNARs in Place Recognition and Management of SEPSIS Hand Hygiene Environmental Measures Antibiotic Stewardship VAP Bundle CLC Initiation and Maintenance Bundles Normothermia Glycaemic Control Antibiotic Prophylaxis Appropriate Hair Removal DVT Risk Assessment and Appropriate DVT Prophylaxis * Improve Management of Chronic Conditions Monitoring and Intervention for high INRS Warfarin Chart and Risk Assessment Safety Briefings SBAR WHO Checklist One MEWS Chart MEWS Chart signed by trained staff Observation Policy Appropriate handover/SBAR Outreach Team Hospital at Night SEPSIS 6 SEPSIS Resus Bundle SEPSIS Management Bundle CHF: 6 Campaign Interventions Timely Management of TIA Acute Stroke Care – First Week Early Recovery and Rehabilitation Priority for ABHB * 1000 Lives Plus MEWs (and MEOWs and Community Hospitals)

4. Aneurin Bevan Health Board Primary Drivers in the Harm Driver Diagram Reduce Patient Falls Reduce Pressure Damage Reduce Medication Errors Reduce HCAI

5. *Reduce Patient Falls in Hospital and Intermediate Care *Reduce Pressure Damage *Reduce Medication Errors Risk Assessment TCAB *Reduce HCAI Risk Assessment TCAB Medicine Reconciliation Missed Doses Positive Patient ID Peripheral Lines Bundle CAUTI Initiation and Maintenance Bundles SA UTIs Falls Bundle Hourly Rounds Skin Bundle Hourly Rounds Reduce harm to < 10 events/1000 patient days Priority for ABHB * 1000 Lives Plus ABHB HARM DRIVER DIAGRAM Objective Location Primary Drivers Secondary Drivers Action

6. OutcomesPrimary DriversSecondary Drivers Aneurin Bevan Health Board GTT Driver Diagram Reliable measure that demonstrates improved patient safety over time & provides qualitative data on types of incidents Ensure GTT Audit Measurement Consistency & Reliability Increase Profile/Gain Will for GTT Audit as 1000 Lives Campaign/SPN Measure Use of Qualitative Information Gain Leadership Commitment – Explain GTT Measure, high level feedback to exec team Gain divisional/frontline staff understanding – Explain GTT audit measure, feedback of quantitative/qualitative data split by domain Checklist for auditors including issues highlighted and clarifying basic methodology Clean data of basic errors on GTT audit spreadsheet – ensure consistent sampling Audit of high category graded events ie. G, H & I events Involvement of all auditors, eg. Pharmacy in RGH, Medical input, Nursing input Clarify included events or triggers eg. at home, in hosp, blame? Ensure correct tool is being used at both sites – add to GTT tool month/year, auditor name, question re. patient admitted with event Write a brief protocol for GTT Audit at GHNT/ABHB including roles, support, methodology, sampling, definitions, feedback/use information, mechanism for learning from audit. Time for systematic analysis of data using GTT Spreadsheet including evaluation of overall GTT scores, trends for triggers/events, trends for different domains. Turning data into info. Engage Medical staff - feedback of data such as readmissions, surgical complications Strategy for learning from GTT data – discuss with stakeholders Feedback any system-wide issues identified to Trust Learning Committee Feedback of events related to individual areas/divisions GTT Audit training for auditors and for staff supporting GTT audit Ward level feedback – regular feedback to ward areas

7. Aneurin Bevan Health Board Preventing CLC infections – process measure

8. Aneurin Bevan Health Board Reacting to Deterioration of Patients – process measure

9. Aneurin Bevan Health Board Preventing Hospital Acquired Thrombosis – process measure

10. Aneurin Bevan Health Board Work in Localities/Primary Care The PCTT will be piloted in primary care in Gwent over the next 6 months Leadership walkarounds have spread to Community Hospitals and Mental Health and will spread to Primary Care in the next month