Pennine Acute Hospitals NHS Trust: Improvement Journey 1 FGH/RI - - PowerPoint PPT Presentation

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Pennine Acute Hospitals NHS Trust: Improvement Journey

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• 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

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• 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
• ngoing: See and treat in ED/ 2 hourly

Quality rounds

Unstable and unsafe system stabilised and improving

NMGH - ED

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• 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

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• £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

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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

• ut of area
• Training to support identification

and support of the unwell child

• Paed O&A expansion to create

additional capacity and reduce LOS

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C&YP Experience

0% 20% 40% 60% 80% 100%

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 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
• f 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

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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

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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

• ut of NEWS
• bservation

chart Roll-out of Patientrack e-

• bs system

commenced Cardiac arrest role allocation Using manual

• bservations

for more accurate identification

• f

deterioration Code red- escalating clinical intuition and empowering staff Weekend plan/escalation stamp

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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.

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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

• utcomes

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

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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

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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

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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.

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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

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CDI: The Trust position compared to monthly reported cases in 2016/17, has improved and is in a position to meet the annual

• bjectives.

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

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

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VTE Assessment Compliance within 24 hours NMGH

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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

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Pressure Ulcers - Pilot Areas

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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

• nes.
• Tissue Donation process improved
• 3 Dedicated Bereavement Nurses, EOL

Support Volunteers and investment in training and education days

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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

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• 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

• f 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

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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

• f deaths due to

improvements in documentation, coding and the introduction of new coding guidance for Septicaemia.

Complaints

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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%

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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

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.

5 10 15 20 25 30

Delays and Outliers

Medical outliers reduced from peak

• f 50 in Feb 2016 to

less than 10

MOATs and DTOCs still largely unchanged

90 improvement cycles and clinical microsystem coaching

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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.

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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

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High standards of care, delivered reliably and productively

highly motivated people highly competent people, working at the "top of their licence" A workforce of sufficent numbers

A workforce of sufficient numbers

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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

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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)

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Highly motivated people

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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
• bjectives 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
• perating models
• Revision of Contribution

Framework

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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
• f 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

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