Learning Session 7

1. Learning Session 7

2. Core Team Members Leadership: Board Management Team Hazel Borland, Executive Lead (Nurse Director) Maureen Stevenson, Programme Manager (Head of Clinical Governance) Diane Bentley, Patient Safety Co-ordinator General Ward: Wards 4,7,9,10,12,14,15&18, CHD, Alexandra Unit, Kennedy Suite Perioperative: Theatres, Day Surgery, Outpatients, Wards 3,5,6, 16&17, Pre-assessment Critical Care: ICU, SHDU, A&E, Wards 7 & 8 Paediatrics Coronary Heart Failure Mental Health Medicines Management: Pharmacy Team supporting each area HAI – Infection Control Nurses embedded into all workstreams NHS Dumfries & Galloway

3. Our programme goals and process reliability? Mortality: 15% reduction Adverse Events: 30% reduction Ventilator Associated Pneumonia: only 1 VAP diagnosed in the last 8 months Central Line Bloodstream Infection: no central lines in ICU since June 2009 Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range Staph Aureus Bacteraemias: 30% reduction - ICU Crash Calls: 30% reduction Harm from Anti-coagulation: Reduction in INRs > 6 Surgical Site Infections: 50% reduction across 7 sites Reliable process measures: - MEWS - Medicine Reconciliation - SBAR - Safety Briefings - SSI bundle - Hand Hygiene - PVCs

4. Our journey thus far …… Critical Care Current Work: Drivers and Changes Outcomes Secondary Drivers Reduce complications from Ventilators/central venous catheters. Optimal glucose control. Prevent healthcare associated infections and cross contamination. Proper sepsis recognition and treatment. Ensure appropriate infrastructure and leadership to provide consistent, reliable, evidence based care. Improve ICU throughput. Ensure competent staff with knowledge in improvement work. Reliable care planning, communication and collaboration of a multi disciplinary team. Primary Drivers Process Changes • Central lines maintenance bundle • Reducing VAPs – new checklist introduced • Chloroprep in packs • Extended the range of optimal glucose control to 10. • Glucose awareness workshop. • Hand hygiene - Code of Conduct for unit. • Laminated key elements of policies Provide appropriate, reliable and timely care to critically ill patients using evidence-based therapies Improve Critical Care Outcomes (Reduce mortality, infections and other adverse events) Develop an infrastructure that promotes quality care Create a highly effective and collaborative multidisciplinary team and safety culture • Multi disciplinary rounds every day. • Safety briefings carried out by nursing staff.

5. Critical Care Outcome Process CC01a – Days between a VAP CCP2 – Percent compliance with the preventing VAP care bundle Days between VAP - 115 days since last event CC06 – Percent of ICU blood sugar results within range CC04 – SABs per 1000 acute occupied bed days CCP4 – Percent compliance with Hand Hygiene Next steps: Improve process reliability through linkage with daily goal setting.

6. Our Success Critical Care: Maintaining glucose control within Intensive Care (ICU) and High Dependency Units (HDU) has shown significant and sustained improvement above our goal of 80%. Significant progress has been made in reducing VAPs with only one VAP diagnosed in the last eight months. There have been no central line infections in ICU since June 2009. Infection Control: Sustained improvement with only two Staph Aureas Bacteraemias (SABs) in 27 months and no cases of C Difficile in 20 months. We have exceeded our 50% reduction target within ICU and are pursuing a goal of zero infection.

7. Our journey thus far …… General Ward Current Work: Drivers and Changes Primary Drivers Process Changes Outcomes Secondary Drivers • MEWS – implemented and reliable hospital wide • Paediatric Advanced Warning System (PAWS) – now used for all paediatric admissions • Deteriorating patients – Steering Group established. Pilot ward prototyping interventions including wad round checklist. Crash team rebranded as Peri-arrest team. • Successful bid for Pass it On Collaborative with Cardiff/Vale for pressure ulcers. • Wound audit planned for P/Care. Early identification of patient deterioration (EWS) Early response system to respond to deterioration Prevent healthcare associated infections Prevent pressure ulcers Reliable planning, communication and collaboration of multi disciplinary team. Optimise flow and efficiency in admission process, handoffs, discharge process, routine care for high volume clinical conditions (CHF, MI). Provide reliable, timely, care using evidence-based therapies Improved general ward outcomes (Reduced infections, crash calls, pressure ulcers, AE in CHF and AMI patients) Create a collaborative team and safety culture • Reliably implemented PVC bundle in DGRI and Galloway Community Hospital • Reliable hand hygiene and naked from the elbow down, with no hand & wrist jewellery • Safety briefings routinely held within all wards • SBAR handover inter/intra ward reliable • CHF bundle introduced and auditing Develop an infrastructure that promotes quality care • SBAR - implemented and spreading

8. Secondary Drivers: General WardEarly Identification & Response to Patient Deterioration S D A P A P S D P A D S Change 7: In depth review and categorisation of crash calls P A D S Change 6: All wards audit and report on weekly basis > 95% reliable P A D S Change 5: MEWS Educator in post for 9 months to support spread P A D S Change 4: MEWS reliable in pilot spread Change 3: Timing of observation rounds changed Change 2: MEWS audit improvement cycles in pilot ward P A D S Change 1: MEWS introduced hospital wide prior to SPSP

9. General Ward – Deteriorating Patient GW01 – Crash call rate SMEWs reliable hospital wide. Crash calls not decreasing. B No outreach service. Initially crash calls reduced when introduced MEWS. AReliable process for detecting and escalating patients who deteriorate. Reduced ability to respond (MMC). A review of crash calls over the past 12 months demonstrated 50% of crash calls are either peri arrest or pulmonary arrest. RFully understand system of response. Improve effectiveness of escalation system. Test improvements to response system. Deteriorating Patients Steering Group. Prototyping ward based escalation systems. Ensuring patients have DNAR status recorded. GWP1 – Percent compliance with Early Warning Score Assessment (DGRI) Reduction in audit data availability Hospital wide data

10. Our success General Ward: • CHF bundle introduced and auditing – one of the first Board’s in Scotland; • excellent use of SBAR demonstrated with medical engagement; • safety briefings carried out reliably with good engagement in the process; • hand hygiene has demonstrated good compliance with local ownership of the data and process; • local leadership and engagement, enthusiastic staff leading on various process changes and displaying good knowledge and skills in the use of improvement methodology. • integration demonstrated within the General Ward workstream with SPSP and other programmes, ie CQI and RTC; • new web based system developed and being rolled out to all wards to record data – will integrate with CQIs etc; • compliance with PVC bundle throughout DGRI and Galloway Community Hospital.

11. Our journey thus far …… Leadership Current Work: Drivers and Changes Process Changes Outcomes Secondary Drivers Primary Drivers • Patient Safety responsibility of Operational Management Groups. • Walkrounds embedded in senior leaders’ work programme. • BMG view Extranet report monthly. • Senior officers identified for each workstream area. • All wards now reporting – new web based system developed. • Community & Cottage Hospitals now report on a shared drive. Establish an SPSP Implementation Committee. Ensure a feedback mechanism for issues raised in walkrounds. Ensure the development of a measurement system used to understand and drive patient care quality and safety indicators. Assign a senior leader to each improvement area (critical area, general ward, medicines management and peri-operative care). Meet with the Programme Manager – remove barriers. Meet regularly with the SPSP. Implementation Committee to track progress and remove barriers. Display the Gantt chart that depicts progress toward SPSP goals. Ensure that the senior team participates in walkrounds. Place safety an quality issues at the top of senior leader meeting agendas. Add SPSP progress and outcomes to the Board agenda. Develop the infrastructure to support quality and safety improvement. Provide the Leadership System to support the Improvement of Safety and Quality Outcomes in your Board. Provide oversight to programme • Regular meetings with Programme Manager and PCCD, SCNs; QIG and workstream meetings. • Monthly Ward Scorecards • Board Management Group involved in 2-3 walkrounds per month. • Follow up on actions identified. • SPSP standing item on Board agendas. Promote the position of safety and quality in the organisation

12. Secondary Drivers: LeadershipEstablish an SPSP Implementation Committee P P A A D D S S P A D S Change 5: Nurse Manager Quality Groups tracking progress Change 4: LHP and Hospital Management Group now responsible for delivery S D A P Change 3: Patient Safety Delivery Group to co-ordinate A P S D Change 2: Monthly report to and meeting with Executive Lead, Board Management Group, NHS Board Change 1: 5 workstreams established with Executive sponsors

13. Our journey thus far …… Medicines Management Current Work: Drivers and Changes Process Changes Outcomes Primary Drivers Secondary Drivers • Implementing FMEA parenteral medicines and insulin. • On-line parenteral medicine resource is being purchased – to be tested on a PC in treatment area of ward. • ‘Think Glucose’ campaign. • Testing high risk medication processes – anticoagulation. • Admin of Warfarin post-op – new guidelines and Warfarin presc. chart introduced to the organisation. • Getting feedback via questionnaire from GPs as to how they manage their Warfarn patients and those with raised INRs before deciding on intervention. • Standardise time for INR draws/reporting. Use standardised protocols and algorithms for high risk meds Routine and reliable patient and laboratory monitoring Identify high risk areas using FMEA Pharmacy consultation service Identify patients at risk with high-alert medications Standardise recovery protocols (eg opiate over sedation Accuracy of medicines at the interface “One stop” delivery system Reliable in-hospital handoffs Communication with primary care High risk medicines management services Patient and family education Self management protocols Reliable Medicines Management Processes Provide safe and effective medicines management (Reduce adverse drug events: r/t high risk processes and medicines eg medicines at the interface, anticoagulation Co-ordination of care • Medicines Reconciliation completed within 24 hours of admission. • Immediate discharge letter – improved documentation to GPs of alterations to medications. • Redesigned ICU Kardex in Critical Care to include prompts for reasons of starting/stopping drugs. Patient and family involvement • Home medication forms - embedded in OP and Pre-assessment.

14. Secondary Drivers: Medicines Management - spreading hospital wide A A A A P P P P A A A A P P P P S S S S D D D D D D D D S S S S S S S S P P P P A A A A S S S S D D D D 4 – Consultant shares results weekly with Junior medical staff to increase reliability Orthop. 3 – Medical Admissions Unit – incorporate into clerk-in proforma ENT 6 – Spread to surgery – pre-assessment and clerk in 2 – Multi-disciplinary process to establish reliability in pilot ward Gen. Surg. 5 – OP Home Medication List 1 – Test process in Elderly Care ward Pre Assess. Medical OP/Day Patients Surgical

15. MMP1 – Medicines Reconciliation Ward 6 Ward 7 (> or = 1 source) Ward 7 (> or = 2 sources) Ward 18

16. Our Success Medicines Management: • Good team communication when conducting Tests of Change; • excellent clinician engagement in workstream, in particular with the medicines reconciliation process; pilot ward demonstrating multidisciplinary engagement involving medical and nursing staff further supported by the pharmacist; • looking at medicines reconciliation and prescribing on discharge to improve information sent to GPs regarding changes to medicines; • antimicrobial prescribing and management - multi-professional working including the Infection Control Team and Perioperative workstream; • quality aspect of the medicine reconciliation is monitored to ensure not only the process takes place but the quality of the medication information obtained is present. Continued feedback regarding data and compliance with the process is being given to the multidisciplinary team.

17. Our journey thus far …… Peri-operative Current Work: Drivers and Changes Process Changes Secondary Drivers Outcomes Primary Drivers • Reliable administration of appropriate prophylactic antibiotics. • Theatre Integrated Care Pathway (ICP) incorporates WHO checklist. • Pre-assessment issue leaflet issued explaining the risk of SSI and the importance of showering before coming in on the day of surgery and not shaving. • SSI Bundle implemented: • -Razors have been removed from all theatres, small shavers are used • -Periop normothermia process has spread to all surgical wards via theatre ICP. • Successfully implemented the WHO Safety Checklist into surgical pause – reliable for all theatres. • Sustaining diabetic periop blood glucose control. • Prevent Surgical Site Infections: • Ensure proper prescribing and admin of prophylactic antibiotics • -Ensure, if hair removal was required, operation site is clipped, not shaved • -Maintain normal blood glucose level (for known diabetic patients) • -Ensure normal body temperature (excludes cardiac patients) • Use briefings: • -use standard intra-operative procedures to prevent AEs • -Undergo team training • -Maintain team focus during surgery • -Have responses to intra-operative adverse events ready • Identify patients at risk: • -DVT prophylaxis • -Continuation of beta blockers Provide appropriate, reliable and timely care to patients using evidence-based therapies to prevent surgical site infections. Improved peri-operative outcomes (Reduced peri-operative adverse events: infections, cardiovascular events) Create a team culture attuned to detecting and rectifying intraoperative errors • Reliable safety briefings in all theatres. • Team training led by Clinical Lead – Surgery. • SBAR – routinely used. Provide appropriate, reliable and timely care to patients using evidence-based therapies to prevent peri-operative cardiovascular events. • DVT Prophylaxis guidelines being implemented. • Sustaining maintenance of postoperative Beta Blockade

18. Perioperative – Reducing SSI and HAI: Process Outcome SSI POP3 - % of known diabetic surgical patients with periop glucose control 100% POP5 - % of eligible surgical patients with periop normothermia 100% POP6 - % of inpatient surgical patients requiring hair removal for whom the hair at the operation site was clipped 100% POP2 - % on-time prophylactic antibiotics administration GW04 – C. difficile associated disease rate Cephlasporin chart Achieving success: Integrated improvement process - Theatres, Wards, Infection Control and Pharmacy working together

19. Our Success Perioperative: An SSI bundle has been reliably implemented for all Theatres and inpatient wards; excellent work in relation to SSI vascular surgery surveillance programme linking to improvement in patients receiving their prophylactic antibiotic; clinical teams fully engaged in understanding their data and testing process improvements; integrated improvement process ie Theatres, Wards, Infection Control and Pharmacy working together; new Theatre Integrated Care Pathway (ICP) includes prophylactic antibiotic check; excellent compliance with theatre safety briefings.

20. Our 2 Major Challenges Deteriorating patients – early identification and appropriate response; Reducing SABs and meeting HEAT target.

21. Help Needed Please! Critical Care: Sepsis bundle Safety briefings – when is the best time, what is included? General Ward: Escalation and Response System – Deteriorating Patients: ‘Finding an affordable solution’ Medicines Management: Improving the management of anticoagulation therapy in Primary Care to reduce INRs>6 Ensuring patients admitted direct from clinic have Medicine Reconciliation completed Perioperative: Linking Scottish Audit of Surgical Mortality (SASM), Surgical Profiles, SPSP and 18 weeks.

22. And lastly ….. Connecting quality - we are integrating our SPSP work with other national programmes, eg Clinical Quality Indicators and Releasing Time to Care; Our community hospitals have implemented many of the process changes too; Barriers include the need to use different recording systems for each initiative – we are looking at developing an IT system to encompass all.