Pa#ent  Safety  Academy    Chief  Opera#ng  Officer:  Dr  Paul  Durrands  

Introduction to safety

culture

AHSN  core  purpose  –  health  and  wealth  •  Licensed by NHS England for 5 years to deliver four

objectives: •  Focus on the needs of patients and local populations:

support and work in partnership with commissioners and public health bodies to identify and address unmet health and social care needs, whilst promoting health equality and best practice.

•  Speed up adoption of innovation into practice to improve clinical outcomes and patient experience - support the identification and more rapid uptake and spread of research evidence and innovation at pace and scale to improve patient care and local population health.

•  Build a culture of partnership and collaboration: promote inclusivity, partnership and collaboration to consider and address local, regional and national priorities.

•  Create wealth through co-development, testing, evaluation and early adoption and spread of new products and services.

Oxford  AHSN  Governance  Structure  

(1)  Best  Care  Programme  –  Clinical  Networks  incorporates  Sustainability,  Popula>on  Healthcare  and  the  Con>nuous  Learning  programme  (including  the  Pa>ent  Safety  Academy  and  Evidence  Based  Healthcare  MSc  Fellowships)  

Oxford AHSN Board

Programme Office

Oversight Group

Best Care Programme

(1)

Clinical Networks

Oversight Group

R & D Programme

Projects

Oversight Group

Wealth Creation

Programme

Projects

Oversight Group

Informatics Theme

Projects

Oversight Group

PPIEE Theme

Projects

AHSN Partnership Council

AHSN Partnership

Board

Oversight Group

Clinical Innovation Adoption

Projects

Pa#ent  Safety  in  Oxford  AHSN  •  Best Care – Patient Safety Academy (with HETV) •  Best Care Clinical Networks

•  Reducing unwarranted variation (eg improving immunisation coverage, tackling variation in diabetes care)

•  Medicines information on discharge •  Clinical Innovation Adoption – safety focus, eg

•  Reducing UTIs – bladder scanner •  Electronic blood transfusion

•  Patient Safety Collaborative – Charles Vincent •  15 Collaboratives based on AHSN geographies •  Build on existing work including the Patient Safety Academy •  Locally lead engagement and prioritisation •  Capability to be built on transparency, continuous learning, prevention,

reliability, leadership, improvement and measurement, accountability, team work and communication, negotiation (ie Berwick)

•  Next steps to October 2014 •  Engagement of providers and commissioners •  Identify priorities and baselining •  Develop work plan  

Peter  McCulloch  Director  of  QRSTU  Director,  Pa>ent  Safety  Academy  

Pa>ent  Safety  Academy  Why,  What  and  How?  

Why  do  we  need  the  PSA?  "  Scien>fic  evidence  of  

frequent  unintended  harms  in  modern  healthcare  

"  Serious  poli>cal  and  public  concern  

"  Willingness,  effort  but  lack  of  exper>se,  co-­‐ordina>on  and  resource  in  NHS  efforts  to  improve  

What  will  the  PSA  do?  

"  Develop  Regional  programmes  for  improving  safety  and  support  these  with  training,  measurement  and  advice  

"  Supply  specific  safety  and  quality  training  needs  for  NHS  organisa>ons  in  the  Region  and  Na>onally  

Regional  Programmes  2014-­‐6  "   Improving  Emergency  

Surgery:  management  of  suspected  appendici>s  

"  Senior  Leaders  programme:  improving  Acute  Trust  safety  management  infrastructure  

"   Improving  the  safety  of  Primary  Care:  iden>fying  key  dangers  in  general  prac>ce  

"   Improving  safety  in  Mental  Health  services  

Bespoke  training  and  advice:  examples  

"  Training  course  on  Human  Factors  for  CORESS  Board  members  

"  Assistance  to    OUH  Trust  on  new  Handover  process  development  

"  External  expert  review  of  SIRI  at  a  London  Teaching  Hospital    

How  do  we  work?    "  Exper>se  &  experience  

"  QRSTU  –  Research  group  in  NDS  since  2006  

" OxStaR  –  training  and  simula>on  centre  in  NDA  

"  Mul>disciplinary  faculty  and  links  

"  Underpinning  research  base  "  Studies  of  CRM-­‐based  

teamwork  training  "  Studies  of  “lean”  based  

systems  improvement  "  Demonstra>on  of  synergy  

using  a  combined  approach  (S3  research  programme)  

How  do  we  work?    Implementa>on  

 "  Training  local  team  of  Champions  and  

suppor>ng  them  via:  "  “Playbook”  to  help  guide  development  of  local  

programme  "  E-­‐mail  and  telephone  advice  "  Facilita>on  and  liaison  with  Trust  management  "  Advice  and  assistance  with  measurement  

Thank  you  

QIPP team update

What does QI mean at RBFT? July 2014

“A trust wide alignment of effort to continually improve quality in all that we do”

“A trust wide alignment of effort to continually improve quality in all that we do”

By year end 2012/13, the Trust achieved £49m in cost & income efficiencies over the last 3 years

Of this, £33m has been savings in cost (29% in pay & 71% in non pay)

Year Target Actual CIP  £000's CIP  %Income  £000's

Income  %Cost  

Avoidance  /  Other  £000's

Cost  Avoidance  /  Other  %

FY  10/11 20,400 13,855 10,186 73.52% 2,838 20.48% 831 6.00%FY11/12 21,300 18,287 12,997 71.07% 1,247 6.82% 4,043 22.11%FY12/13 12,200 16,935 9,927 58.62% 7,003 41.35% 0 0.00%FYs  10-­‐13 53,900 49,077 33,110 67.47% 11,088 22.59% 4,874 9.93%

Reduction in corporate spend

= £4m Reduction in agency / nursing spend = £5m

Reduction in clinical admin = £1m

Reduction in procurement spend = £9.4m

Reduction in drug spend = £1.5m

Efficiencies in estates & facilities = £1.9m

Achievement of stretch CQUIN targets = £5.7m

Quality Improvement Programme (QIPPs) By year end 2012/13, the Trust will have achieved £49m in cost & income efficiencies over the last 3 years

Of this, £33m has been savings in cost (29% in pay & 71% in non pay)

Year Target Actual CIP  £000's CIP  %Income  £000's

Income  %Cost  

Avoidance  /  Other  £000's

Cost  Avoidance  /  Other  %

FY  10/11 20,400 13,855 10,186 73.52% 2,838 20.48% 831 6.00%FY11/12 21,300 18,287 12,997 71.07% 1,247 6.82% 4,043 22.11%FY12/13 12,200 16,935 9,927 58.62% 7,003 41.35% 0 0.00%FYs  10-­‐13 53,900 49,077 33,110 67.47% 11,088 22.59% 4,874 9.93%

Reduction in corporate spend = £4m

Reduction in agency / nursing spend = £5m

Reduction in clinical admin = £1m

Reduction in procurement spend = £9.4m

Reduction in drug spend = £1.5m

Efficiencies in estates & facilities = £1.9m

Achievement of stretch CQUIN targets = £5.7m

But…..only 1-2% identified

• ‘Low hanging fruit’ already delivered • Capacity within day job to deliver

• Affordability of CCGs • More of the same won’t do it

-  ‘Insanity: Doing the same thing over and over again and expecting different results’ Albert Einstein/Benjamin Franklin/Anon

- Work harder!

- Waste!

- Asking the Why?

- Fresh eyes

- Everyone’s responsibility

Think differently! Do differently!

Quality Improvement Doing the right thing for the right patient in the right way every time Reliability, get rid of waste, test out change in a safe way Drive up quality; drive down cost

-  Bring together all elements needed to make an (improvement) change work

-  Structure

-  Explicit what need to consider and be mindful of

-  From the Big to the small

The Approach

Service Improvement Winner 2011

Making  Every  Moment  Count

45 trainees completed 27 projects

“Igood  QI  is  ….it  is  relevant  to  day-­‐to-­‐day  prac7ce…it’s  simple  …..makes  a  big  difference  to  our  pa7ents………  It  is  worth  giving  it  high  priority  in  our  clinical  du7es.”    

“Igood  QI  is  ….it  is  relevant  to  day-­‐to-­‐day  prac7ce…it’s  simple  …..makes  a  big  difference  to  our  pa7ents………  It  is  worth  giving  it  high  priority  in  our  clinical  du7es.”    

“Igood  QI  is  ….it  is  relevant  to  day-­‐to-­‐day  prac7ce…it’s  simple  …..makes  a  big  difference  to  our  pa7ents………  It  is  worth  giving  it  high  priority  in  our  clinical  du7es.”    

“Igood  QI  is  ….it  is  relevant  to  day-­‐to-­‐day  prac7ce…it’s  simple  …..makes  a  big  difference  to  our  pa7ents………  It  is  worth  giving  it  high  priority  in  our  clinical  du7es.”    

“The  magic  is  in  seeing  a  trainee  iden7fy  a  problem  they  encounter  and  feel  empowered  to  make  a  change”      Hospital  Board  member  

“This  has  been  a  very  valuable  learning  experience  into  clinical  quality  improvement  as  well  as  being  brilliant  for  my  CV”  

“This  has  been  a  very  valuable  learning  experience  into  clinical  quality  improvement  as  well  as  being  brilliant  for  my  CV”  

Examples of projects - Improved experience of children with cystic fibrosis - Use of longterm peritioneal drains changed the lives of 12 patients - Patient guided DVD to reduce anxiety prior to anaesthesia

“My whole outlook has changed…I now look for situations to improve…” Trainee

•  Quality improvement as usual practice

•  High quality training

•  Supporting resources

RBFT QIPP

Programme

An approach to delivering Quality Improvement

Shared  Vision

The  vision  should  

answer  the  question  ‘where  do  we  want  to  get  to?’ and  should  be  

the  inspiration  

and  framework  for  planning

Assurance

CQIU  involvement:

-­‐Involvement  in  completion  &  challenge  of  Quality  Impact  Assessments

-­‐ Monitoring  of  balancing  measures

-­‐ Research  capability

SMART  Aims

The  aims  set  should  be:

Specific  

Measurable

Achievable

Realistic

Timeframe

The  Quality  Improvement  Approach

Improve  it!

Improvement  opportunities

Measure

Plan

RoI

Outcomes

Vital  behaviours

Evaluate

Vital  Behaviours

Desirable – what’s  in  it  for  them?

Enable – provide  information  and  skills  /  deliberate  practice

Stakeholders  – crucial  conversations  – team  and  beyond

Influencers – senior  engagement  and  support;  opinion  leaders

Rewards – what  are  the  incentives?

Environment  –providing  the  physical  means  to  achieve  the  outcome

Governance

Project  Management  Office  (PMO)  involvement:

-­‐Projects  grouped  by  value  (P1-­‐P3)

-­‐Tracking  &  monitoring

-­‐Project  documents

-­‐Risk  assessments

-­‐QIPP  Reports  -­‐Programme  Board

Outcomes

What  are  the  Process  measures?

What  are  the  Outcome  Measures?

Sustainability

To  sustain  the  improvement    requires:

-­‐Patient  &  staff  engagement

-­‐Alignment  with  goals  &  structures

-­‐Infrastructure

-­‐Credible  evidence

-­‐Adaptability

-­‐Continual  monitoring  of  progress

Shared  Learning,  show  casing  of  examples  such  as  MEMC,  clinical  leadership  programme  etcRBFT  Quality  Improvement  Training  Programme  (training,  master  classes,  visits  to  centres  of  excellence)Communication  Strategy  –sharing  plans,  outcomes  &  celebrating  success  

Quality Improvement Framework: Our journey towards excellence

Shared  Vision

The  vision  should  

answer  the  question  ‘where  do  we  want  to  get  to?’ and  should  be  

the  inspiration  

and  framework  for  planning

Assurance

CQIU  involvement:

-­‐Involvement  in  completion  &  challenge  of  Quality  Impact  Assessments

-­‐ Monitoring  of  balancing  measures

-­‐ Research  capability

SMART  Aims

The  aims  set  should  be:

Specific  

Measurable

Achievable

Realistic

Timeframe

The  Quality  Improvement  Approach

Improve  it!

Improvement  opportunities

Measure

Plan

RoI

Outcomes

Vital  behaviours

Evaluate

Vital  Behaviours

Desirable – what’s  in  it  for  them?

Enable – provide  information  and  skills  /  deliberate  practice

Stakeholders  – crucial  conversations  – team  and  beyond

Influencers – senior  engagement  and  support;  opinion  leaders

Rewards – what  are  the  incentives?

Environment  –providing  the  physical  means  to  achieve  the  outcome

Governance

Project  Management  Office  (PMO)  involvement:

-­‐Projects  grouped  by  value  (P1-­‐P3)

-­‐Tracking  &  monitoring

-­‐Project  documents

-­‐Risk  assessments

-­‐QIPP  Reports  -­‐Programme  Board

Outcomes

What  are  the  Process  measures?

What  are  the  Outcome  Measures?

Sustainability

To  sustain  the  improvement    requires:

-­‐Patient  &  staff  engagement

-­‐Alignment  with  goals  &  structures

-­‐Infrastructure

-­‐Credible  evidence

-­‐Adaptability

-­‐Continual  monitoring  of  progress

Shared  Learning,  show  casing  of  examples  such  as  MEMC,  clinical  leadership  programme  etcRBFT  Quality  Improvement  Training  Programme  (training,  master  classes,  visits  to  centres  of  excellence)Communication  Strategy  –sharing  plans,  outcomes  &  celebrating  success  

Quality Improvement Framework: Our journey towards excellence

RBFT QIPP

Programme

A template to delivering QI Projects

Improvement  opportunity

Measure Plan RoI Outcomes Vital  Behaviours

Evaluate

How…

Metho

dology

… do  we  want  to  improve?

….  do  we  generate  ideas?

… good  are  we  and  how  do  we  know?

… do  we  make  the  changes?

… do  we  prioritise?

…timescale?

… do  we  demonstrate  it’s  worth  it

…are  things  different  

from  before?

… will  our  behaviours  support  the  change

… will  we  know  we  

have  made  a  difference,  and  how  do  we  keep  

improving?

Brainstorm

P&L

Process  Map

Model  for  Improvement

Spaghetti  Diagram

RAG  Study

Benchmark

Audit

Historical  analysis

Baselines

Lean

Pareto

Staff  +Patient  

Engagement

5  D’s

PDSA

PMO  Docs

Human  /  Financial  cost  and  saving

SPC

Business  Cases

Project  Plan

Owners

Timescales

Rapid  Improvement  Events

Six  Sigma

Open  to  change

See  the  benefit  or  bigger  picture

Engagement

Review  performance

Communicate  change

Ensure  sustainability

Celebrate  Success

The Quality Improvement Approach: IMPROVE

Improvement  opportunity

Measure Plan RoI Outcomes Vital  Behaviours

Evaluate

How…

Metho

dology

… do  we  want  to  improve?

….  do  we  generate  ideas?

… good  are  we  and  how  do  we  know?

… do  we  make  the  changes?

… do  we  prioritise?

…timescale?

… do  we  demonstrate  it’s  worth  it

…are  things  different  

from  before?

… will  our  behaviours  support  the  change

… will  we  know  we  

have  made  a  difference,  and  how  do  we  keep  

improving?

Brainstorm

P&L

Process  Map

Model  for  Improvement

Spaghetti  Diagram

RAG  Study

Benchmark

Audit

Historical  analysis

Baselines

Lean

Pareto

Staff  +Patient  

Engagement

5  D’s

PDSA

PMO  Docs

Human  /  Financial  cost  and  saving

SPC

Business  Cases

Project  Plan

Owners

Timescales

Rapid  Improvement  Events

Six  Sigma

Open  to  change

See  the  benefit  or  bigger  picture

Engagement

Review  performance

Communicate  change

Ensure  sustainability

Celebrate  Success

The Quality Improvement Approach: IMPROVE

Improvement  opportunity

Measure Plan RoI Outcomes Vital  Behaviours

Evaluate

How…

Metho

dology

… do  we  want  to  improve?

….  do  we  generate  ideas?

… good  are  we  and  how  do  we  know?

… do  we  make  the  changes?

… do  we  prioritise?

…timescale?

… do  we  demonstrate  it’s  worth  it

…are  things  different  

from  before?

… will  our  behaviours  support  the  change

… will  we  know  we  

have  made  a  difference,  and  how  do  we  keep  

improving?

Brainstorm

P&L

Process  Map

Model  for  Improvement

Spaghetti  Diagram

RAG  Study

Benchmark

Audit

Historical  analysis

Baselines

Lean

Pareto

Staff  +Patient  

Engagement

5  D’s

PDSA

PMO  Docs

Human  /  Financial  cost  and  saving

SPC

Business  Cases

Project  Plan

Owners

Timescales

Rapid  Improvement  Events

Six  Sigma

Open  to  change

See  the  benefit  or  bigger  picture

Engagement

Review  performance

Communicate  change

Ensure  sustainability

Celebrate  Success

The Quality Improvement Approach: IMPROVE

Improvement  opportunity

Measure Plan RoI Outcomes Vital  Behaviours

Evaluate

How…

Metho

dology

… do  we  want  to  improve?

….  do  we  generate  ideas?

… good  are  we  and  how  do  we  know?

… do  we  make  the  changes?

… do  we  prioritise?

…timescale?

… do  we  demonstrate  it’s  worth  it

…are  things  different  

from  before?

… will  our  behaviours  support  the  change

… will  we  know  we  

have  made  a  difference,  and  how  do  we  keep  

improving?

Brainstorm

P&L

Process  Map

Model  for  Improvement

Spaghetti  Diagram

RAG  Study

Benchmark

Audit

Historical  analysis

Baselines

Lean

Pareto

Staff  +Patient  

Engagement

5  D’s

PDSA

PMO  Docs

Human  /  Financial  cost  and  saving

SPC

Business  Cases

Project  Plan

Owners

Timescales

Rapid  Improvement  Events

Six  Sigma

Open  to  change

See  the  benefit  or  bigger  picture

Engagement

Review  performance

Communicate  change

Ensure  sustainability

Celebrate  Success

The Quality Improvement Approach: IMPROVE

Mortality

Data quality, outliers & review group -  Dr Foster, CHKS, SHMI

-  Use data to inform areas of concern and priorities to improve -  Prioritised areas: HSMR weekend, pneumonia, palliative care codes

R  codes  (including  uncoded)  by  Month

238

400

93 83 71 84 83 90 79111

85116

0

50

100

150

200

250

300

350

400

450

Feb-­‐13

Mar-­‐13

Apr-­‐13

May-­‐13

Jun-­‐13

Jul-­‐13 Aug-­‐13

Sep-­‐13

Oct-­‐13

Nov-­‐13

Dec-­‐13

Jan-­‐14

No  of  sp

ells

Mortality reviews & actions

Spread of learning

Care bundles

Junior doctor alerts

All deaths reviewed with coding Action plan to address R codes

Prevention of hospital acquired pneumonia

Prevention of aspiration pneumonia

Stroke unit MDT working

Next steps: sustainability of approach on ASU Spread to other wards where enteral feeding taking place

Next steps: Spread to all other wards beyond the 8 pilot wards

• Successful QIP 2010-11: reduction in 9 HAP cases per week to median 3 cases per week • Sustainability issues saw rise in number of cases of HAP to median 4- 6 cases per week • Successful relaunch on 8 pilot wards – reduction to median 2 per week Drug chart changed Concentration on mouthcare

• % feeds being done at the correct position improving from 63% to 89% • Rates of pneumonia reducing from 60% to 0%

2012 Prevalence audits on 4 wards

012345

1 2 3 4

2013 HAP prevalence 8 wards

0123456789

10

1 2 3 4 5 6

Week

Stroke Unit – Shared Ways of Working

Improvement: Stroke patents go through 3 separate phases – Hyper-Acute Phase (0-72hrs), Acute Phase (72hrs-14 days), and Rehabilitation Phase (14+days). The ASU and CASU wards are split over two floors within the RBH with the Hyper-Acute and Acute Units located on Level 2 whilst Acute and Rehabilitation Units are located on Level 1. Patients perceive this as being treated by different units and different teams of staff.

QIPP Improve Template for: Stroke Unit – Shared Ways of Working Project Ref: QI-2013-08-02 Workshop Dates:

Vision & Vital Behaviours: To establish one team across ASU and CASU creating a consistent quality of care for the patient though efficient and effective working. The key output for this Structured Improvement Activity will be to develop an Operational Framework for ASU & CASU which includes operational plans, policies and procedures.

Opportunity: This improvement activity will be delivered over a series of 5 workshops: Workshop 1 – All staff groupings, Outputs to include Requirements, Risks & Issues, Opportunities & Benefits, and Ways of Working Workshops 2–4 Outputs to include capturing current ways of working for each staff grouping. Workshop 5 – All staff groupings, Proposed Shared Ways of Working, agreed Operational Framework

Care Group / Area: Urgent Care

Executive Sponsor: Mandy Claridge

Ward / Dept: ASU / CASU Team Leader: Ian Waddell QIPP Lead: Julie Huish

Plan (Resource): All staff from all groupings listed working with the ASU and CASU Units. • Nurses & All Ward Staff (Matrons, Specialist Stroke Nurses, HCA’s, Ward Clerks,

etc) • Doctors (Stroke, Rehabilitation, Neurologists, etc) • Therapies (OT, Physiotherapy, Speech & Therapy, Dieticians, etc) • Patient Representative – Gary Jopling, Stroke Association

RoI: Goal Financial

Cashable Non Cashable Financial

Non Cashable

1 More efficient ways of working

2 Quality of service to patients

Measure: Evaluate

Goal Metric Target Current

1 Operational Framework for ASU & CASU

2

Achieved

Document Ref: QI/TEM/13/07/101 © 2013, Royal Berkshire NHS Foundation Trust All Rights Reserved

“The project is now closed as the 12 Stroke beds that were on Caversham are now not designated Stroke Beds. However the work we completed was very positive and did help strengthen ASU” Ian Waddell

STROKE UNIT- PICK CHART

Patient Engagement

IMPLEMENTATIO

NHARD

EASY

Inter Working

Shared Training

Joint ASU Development

Meeting

Shared Paperwork

Better Comms

Board Round

Patient Care Pathway

Consistent Decision Making MDT Meeting

Staff Model

California Best Practice

Stroke Co-ordinator -

Beds High Up

Location

Care Group

BENEFITSSMALL BIG

Work stream Outcome Patient Engagement Ongoing Consistent Decision Making/MDT meeting Complete for ASU Shared Training (Stars) Complete Joint ASU Development Meeting Not applicable now Patient Care Pathway Complete Board Round Complete Staff Model Complete for both wards Care Group Changes Complete Location Complete Unit Communication Complete but now not

applicable

STROKE UNIT - Shared Ways of WorkingForce Field Analysis

F O R SHARED

WAYS

OF

WORKING

A G A I N S T

MDT Stroke Notes

Access to Stroke Rehab

Specialist Staf f

8am Board Round MDT

Long Term Goal Setting &

Continuity

Continuity of Care

Discharge Planning

Continuation of Stroke Pathway

Access to Early Supported

Discharge Team

Direct Access HASU <4hrs

In-Pts Cont Need SU and

Prov Time

Stroke / Medical

Mix

Spare Beds Dumping Ground

Communication of Transition to

CASU

2 x Dif ferent Care

Groups

Selection of Patients

Location of ASU & CASU

Bed Management

Issues

x 1 Assisted Shower

Single Sex

Pts Awaitint

NE & Care

Junior Medical

Cover CSU

Fluctuating Demand -

Accomm Flex

Big Impact

Small Impact

The objective for this event was to establish one team across ASU and CASU creating a consistent quality of care for the patient through efficient and effective working.

Improvement: The Specialist Commissioners have set best practice targets for Arterio-Venous Fistulae prevalence in HD stock population. Targets for 2013-2014 are set at 80%, whilst targets for 2015 are set at 85%. Within RBFT the current rate of achievement is between 70-75%. Factors contributory to this include radiology waiting times, patient compatibility, availability of theatres, failed treatment, and refusal of treatment. Key areas for improvement are Senior Decision Making, Failing PD and Radiology Waitlists. Areas for review include:

• Senior decision making in ‘Acutes’ patients • Senior decision making in PD patients transferring to HD (inadequate peritonitis takes) • Acute PD service • Fast track service for AVF in acute patients (instant needling grafts) • Surgery – operating lists at RBH • Radiology waitlists • Transplant patients (inadequate, acute rejection, PD) • Transfer-ins – (Hammersmith, previous access history, previous PD decisions)

QIPP Improvement Charter for: Renal AVF Project Ref: QI-2013-07-01

Workshop Dates:

Vision & Vital Behaviours: To review & develop standardised processes in order to improve quality and achieve best practice target rate of 80% for 2013-2014, and subsequent BPT rate of 85% for 2015. The two main areas for improvement opportunities are: 1. Improve the process for patients diagnosed with CKD/5 waiting to have AVF 2. Patients who have had an AVF and are waiting to mature (Time of op to time of use)

a. Patient choice b. Needling – self needling / Windsor needling practice c. Radiology – new ultra sound machine d. Nurse influences e. Time of use f. Line removal g. Signed form for refusals h. CV5 options i. Vascular access ¼ meetings

Opportunity: This event focuses on developing a single way of working by increasing process flow and reducing variation. Key outputs include – • SIPOC to define project boundaries • Documented As-Is Process Map • Documented To-Be Process Map with key decision points identified • Develop a single access Data Plan / Handover Process • RACI including patient accountability

Care Group / Area: Networked Care

Executive Sponsor: Dr Emma Vaux – Consultant Nephrologist

Ward / Dept: Renal

Team Leader: QIPP Lead: Julie Huish

Plan: (Resource) Emma Vaux Claire Orme Cian Chan Oliver Flossmann Bassam Alchi Lloyd Swee Leo Bailey Jane Moore Theresa Matthews Gill Downs Julia Smith Madeleine Wallis Joy Stringer Barbara Dollery Angela Clarke Mary Wyman Moses Amao Alison Swain Katy Priddis Alison Galer

RoI: Goal Financial

Cashable Non Cashable Financial

Non Cashable

1 CQUINS To meet national BPT standards

2 Collaborative working, efficient use of resource

Measure: Evaluate

Goal Metric Target Current

1 Increase target rate in line with Best Practice Target rates

80-85% 70-75%

2 Develop a single access Data Plan & Handover Process

Achieved

© 2013, Royal Berkshire NHS Foundation Trust All Rights Reserved Document Ref: QI/TEM/13/07/101

Renal AVF Process Improvement

QI Project Action Plan for: Renal AVF Project Ref: QI-2013-07-01  

No. Action Owner Target Date

RAG status

(Red / Amber / Green)

Progress Update

1 Design an A0 size poster to detail the Pros and Cons of Fistulae Jane Jan 2014 End of January

2 Develop a staff booklet – A Guide to Fistulae Access Jane / Angela Jan 2014 Date in diary by end January, complete 14/02/14

3 Develop a flow chart for the referral process Cian Jan 2014   Remind Cian

4 Develop a Trigger List for each area PD – Barbara/Ollie, LCC – Ollie/Julia, TX – TX Nurse

+, HD – Bassam/Swee

Jan 2014  

5 Setting up Acute PD Service Leo / Barbara Jan 2014   Diary date

6 Develop an education process of an acute Cian / Jill Jan 2014  

7 LCC has to happen within 4 weeks of referral Madelaine Jan 2014   Complete

8 Standard Operating Procedure for Fastrack Jane Jan 2014   In progress

9 *Vascular Access Service 8am till 8pm Mon to Fri Leo/Jane/Emma Jan 2014   By March

10 Educational Link Nurse for each unit Angela Jan 2014  

11 Agenda for holistic meetings for all units inc vascular Jane/Emma Jan 2014   By end of February

12 Wednesday MDT – rag rate patients regarding access Jane/Emma Jan 2014   By end of February

13 Weekly Theatre List Leo/Jane/Emma Jan 2014  

Vascular meeting being set up to combine weekly theatre and clinic lists – dates to be confirmed

14 Weekly Clinic List Leo/Jane/Emma Jan 2014   As above

15 2 x Monthly Arm Block List Jane Jan 2014   Jane to follow up

16 *Day Surgery Unit Leo Jan 2014   *Feed into VA nurse and consultants

17 Identify why patients sit with lines for a long time Jane/Emma Jan 2014  

Baseline Rate - Achieving 70% Current Target Rate Achieved 80%

Set - National Target Rates 80 - 85% The objective for this event was to review & develop standardised processes for Arterio-Venous

Fistulae prevalence in HD stock population, in order to improve quality and to achieve best practice target rates as set by the Specialist Commissioners

Length of Stay

* = QI Team involvement

*

*

*

*

*

QI Team also support weekly LOS meetings

Respiratory and Sleep Clinics The objective for this event was to develop and improve the departments

effectiveness and identify optimum ways of working.

Measure: Evaluate: RoI:

Goal Metric Current Target Achieved Goal Financial Cashable

Financial Non Cashable Non Cashable

1 Produce an Operational Framework Document

1

Efficient and effective ways of working

2 2

Quality of service to patients

3 3

Improvement: Over the past few years the Respiratory and Sleep Clinics have grown in an unstructured way. There are inefficiencies within the admin processes that provide support to clinicians. In order to provide structure and develop more efficient ways of working, processes and procedures within these departments need to be revisited.

QIPP Improve Template for: Respiratory & Sleep Clinics Project Ref: QI-2013-09-01 Workshop Dates: 26/09/13

Vision & Vital Behaviours: • To develop and improve the departments effectiveness and identify optimum ways

of working. • To ensure roles & responsibilities are fit for purpose, and increase better utilization

of resource • To ensure the patient is at the heart of the service and processes are lean behind

the patient journey.

Plan: Key outputs from this workshop to include- • SIPOC-high level process map to define project boundaries and identify critical

elements within the processes • Documented As-Is Process Map with issues and concerns identified. • Documented To-Be Process Map including Responsibilities, Accountabilities, who

to Consult and Inform, including patient accountability

Care Group / Area: Urgent Care

Sponsor: Mandy Claridge

Ward / Dept: Respiratory & Sleep Clinics Team Leader: Ian Waddell QIPP Lead: Julie Huish

Organise: Team members from the following areas will support this improvement opportunity: Admin staff Nurses and HCA’s Consultants Medical Secretaries AHP’s

Document Ref: QI/TEM/13/07/101 © 2013, Royal Berkshire NHS Foundation Trust All Rights Reserved

“Thank you for organising yesterdays event, it was helpful and it will be interesting to see what comes from it. I look forward to working towards a new improved service” -- Karena Cranstone, Respiratory Physiologist

“In my time with the NHS I have been involved with a few of these events and I can say this was one of the best I have attended in terms of engagement from staff meaning we have a good chance to do something good” – Ian Waddell, Directorate Manager, Acute Medicine

“Yes agree, thanks Ian for organising this. It reminded me that once a year team building which we used to organise and pay for should happen again” -- Dr Chris Davis (Consultant)

Work streams: Direct Access Oximeter Diagnostics, new on Choose & Book - In progress Job Plans for all staff - Complete Streamlined booking and Admin - In progress IT Review - Complete Review of Sleep Service Oxford Model - In progress Explore Resmed consumables outsourcing service - In progress Rationalisation of Suppliers - Complete Stock List - Complete Respiratory Clinic - As-IS Process Map

Tele CallsCheck Out

Transport

Letter(s) Maybe

Multiple

Scribe

Pt's Not Getting Letter

Results

Access to Data

Sec's

Phone Calls

Car Park

Staff Levels & capacity

Rooms Lack Of

Clinic Enviro

Admit to Ward

Admission Delays

Other Investigations

Follow Up

Clinic Capacity &

delays

Tests -Maybe

Multiple

*Walk-Ins

Tests Not Booked

Clinic Cancelled

Choose & Book

Contact Centre

Confirmation Letter

Notes & referral Letter

Clinic Appointment

Maybe Cancelled or

Changed

Check-In Front Desk

On Ward Referrals

inc Physio / Other Spec

DrConsultant

Height & Weight

DischargeX-Ray

Treatment

NurseConsultant

2 Week Waits

*DNA's

ERR Training

Wrong Clinics

Appt Changes

Inadaquate Equipment

Capacity for CT etc

Delays

New Appt Changes

Patient Cancels

Conf & Privacy

Wait Times

Notes Don't Arrive or

Taken

IT Issues

Safety Net

Respiratory Clinic - Ideal Process Map

Pat

ient

Inst

ruct

ion

PharmacyGP

PhysiologyRadiology

PathCardiology

Other Depts

A + CClinicianTransport

DoctorNursePhysio

EstatesA + C

CliniciansTrustScas

Volunteers

Reminder Appt

(Improved)

Direct Referral

Pre-Order Tests

ApptBooking +

Clarity - Who, Where etc

< 6/52<4/52

Capacity

TestsNo delay

Book-In- Private

- Confidential- Efficient

- Vent'd Area

S/B Clinician / Nurse etc

Park Transport on Time

GRADING

Seen with notes

FU

Check Out D / C

Tests

Admission -No Delay / Right Ward

Referral

Treatment

Clinic Capacity+ Space

? Generic

DischargeLetter

Timely

Made Same Day Not

by

Cap

acity

Results with Notes

Treatment

Tests Referral

Monitoring

Letter

TRACKING

TRACKING

Tests

Discharge

FU

Letter

Pharmacy

Letter GP

OVERALL PICTURE

A + CClinician

A + C

CliniciansPhysiologyRadiology

A + C

Site Management

& Ward

CliniciansA + C

Cinicians

A + CIT

Out of Control

Out of Control

External Out of

Control

Out of Control

Out of Control M.R.

Out of Control

Out of Control

1 1092

4

83 7

6

5 11 12

13

14

15

16

20

21

22

17

19

18

23

24

25

26

27

28

29

30

“Thanks and thanks for all your hard work in the event” -- Dr Grace Robinson (Consultant)

“From my perspective it was very worthwhile to have most of the department together and discussing the way we work” -- Dr Andy Zurek (Consultant)

34

Quality Improvement Training – 5 levels

2. Introduction to Quality Improvement – 30 mins

-  Introduction to QI methodology

-  IMPROVE framework & templates

-  The journey from ‘idea’ to ‘testing’

-  QI Support available

3. Basic Awareness – 2 hour sessions An interactive session, introducing: -  An awareness of QI tools & techniques

-  Includes soft ‘leadership’ change management skills

-  Brings to life how the tools can be used day to day

4. Intermediate training – 2 x half days Includes: -  Detailed understanding of QI approach

-  Exploration of concepts & tools -  Aimed at staff wishing to make a change / lead a

project in their area of work

5. QI Ambassadors Recruiting QI Ambassadors across the Trust: -  Good understanding of QI approach & use of

tools & techniques

-  Able to lead projects and facilitate others -  Ongoing follow up and development by QI team

1.   Core Induction - 30 minutes every month (for new staff) -  Introducing Trust approach to Quality Improvement , overview of trust QI projects, how staff can get

involved, and how the QI team can offer support, QI training programme.

RBFT Academy Leadership, management and quality improvement skills for Doctors in training Launched November 2013

Next steps: 2014/15 academy recruitment from August intake of trainees. Spread to other staff (band 7+) in development

What is it? RBFT Academy is an intensive annual programme designed for doctors in training. 5 full day workshops and final summit over one year The skills and knowledge learnt would equip participants to lead, manage and contribute to quality improvement within the NHS.

‘Inspirational speakers’

‘Brilliant, wish this was available at other Trusts’

‘Excellent speakers- pitched relevant content at the right level. Thank you for organising such an inspiring course!’

‘I have learnt so so much’

The challenges

-  Senior leadership

-  External consultants

-  CQC & Monitor scrutiny

-  Reviewing priorities to match resource

-  Focus on understanding Return on Investment for QI projects

-  Drive forward QI training trust wide

-  Maximising opportunities to win external funding through bids

-  More collaboration – PSF/Unipart / Salford / NHS Scotland/PSA/AHSN etc

- We know this works!

- Hold our nerve!

- In for the long run!

Caring, safe and excellent

Pa>ent  Safety  Academy  Network  Event  

Oxford  Health  NHS  Founda>on  Trust  Experience  of  Implemen>ng  Harm  Reduc>on  

Approaches    

Jill  Bailey:  Consultant  Nurse  Pa>ent  Safety    

Caring, safe and excellent

The  importance  of  pa#ent  safety  at  Oxford  Health  NHS  Founda#on  Trust  

•  Two  year  membership  of  South  of  England  Mental  Health  and  Integrated  Trusts  Safety  Collabora>ve    

•  Pilot  site  for  MH  ST  •  Pilot  site  for  new  ways  of  repor>ng  restraint  to  NRLS  as  a  ‘harm’  

•  Re-­‐modelling  services  to  create  integrated  pathways  –  Importance  of  safety  in  transi>on  – Recogni>on  that  we  need  to  translate  /  develop  harm  reduc>on  approaches  for  people  at  home  

•  Organisa>onal  >me  and  resources  dedicated  to  recovery  from  failure  (SIRI  inves>ga>on  costs)  

Caring, safe and excellent

The  South  of  England  Mental  Health  and  Integrated  Trust  Safety  Collabora#ve  

! 2  Faculty  members  (Director  of  Nursing  and  Consultant  

Nurse),  IHI  Fellows,  24  staff  par>cipants  ! Quarterly  Steering  Board  !   2  F/T  Pa>ent  Safety  leads  (CN  and  Programme  Manager)  

 –  29  harm  reduc#on  projects  across  3  coun#es  "  Suicide  preven>on,  self-­‐harm,  AWOL,  violence  and  aggression  

"  Restraint  reduc>on  (prone)  "  CAUTIS,  VTE,  Pressure  Ulcers,  Falls,    "  Medica>on  errors  and  medica>on  reconcilia>on  

Caring, safe and excellent

Early  successes:  harm  reduc#on  in  pilot  sites  •  Safe  and  >mely  return  (AWOL  and  missing  pa>ents)  increased  from  baseline  of  30%  to  74%  -­‐  sustained  and  re-­‐tes>ng  interven>ons  

•  Medica>on  errors  (prescribing  and  omissions)  reduced  by  75%  in  acute  adult  ward  

•  Death  by  probable  suicide  in  Oxon  and  Bucks  crisis  teams  increased  from  62  days  between  to  483  between  using    ‘Always  Events’                                                              

Caring, safe and excellent

Harm  reduc#on  work:  our  learning  •  Good  Board  engagement  has  been  cri>cal  to  success  •  Engagement  with  clinical  staff  has  been  rela>vely  easy    

•  Ignore  middle  >ers  (opera>onal  and  professional  at  your  peril)  •  Tempta>on  to  resort  to  problem  solving    •  Focus  on  measurement  for  improvement  

–  Learning  about  measurement  can  be  challenging    –  Staff  who  feel  alienated  from  ‘maths’  following  early  experiences  –  Measurement  for  improvement  is  really  measurement  for  judgement  –  Moving  away  from  tradi#onal  RAG  ra#ngs  –  Determining  own  measures  is  unfamiliar  –  Frequent  and  systema#c  review  of  progress  is  a  new  way  of  working  (audit)    

•  Spread  –  Tempta#on  to  spread  too  quickly.  Avoid  spray  and  pray  –  Consider  carefully  the  condi#ons  and  culture  of  areas  for  re-­‐tes#ng  before  

spread

Caring, safe and excellent

Challenges  for  the  PSA  

•  Be  realis>c  about  the  >me  it  takes  to  bring  about  cultural  change    •  Coaching  approach  has  been  more  successful  –  Resource  intensive  •  Invest  in  specific  Measurement    for  Improvement  training    

•  Clinical  staff  •  Performance  staff  •  Trust  Board  

•  Ensure  clarity  of  Programme  Manager’s  role  in  determining  spread  –  Test,  re-­‐test,  test  again  in  different  wards  and  teams  –  Avoid  staff  tempta>on  to  celebrate  too  early  and  ‘spray  and  pray’  

•  Encourage  work  across  organisa>onal  boundaries  –  Learning  from  falls  work,  AWOL  work  

•  Middle  layer  engagement  is  cri>cal  –  needs  to  be  embraced  at  all  levels  (ownership,  permission  and  unblocking)  

User-Led Quality Improvement in Neurosurgery

Nick de Pennington SpR, Department of Neurosurgery

John Radcliffe Hospital, Oxford

My experience…

User-­‐Led  

Training  &  Support  

Mul>-­‐disciplinary   Outcomes  

nicholas.depennington@ouh.nhs.uk  

Dr Helen Higham Director, OxSTaR Director, Patient Safety Academy    

Working Together  

Building Collaboration

"  Linking with other AHSN Networks "  Linking with existing expertise

"  Identifying and interacting with key players "  Patient Safety Federation "  Mental Health Safety Collaborative "  Simulation Centres "  Others?

"  Developing coherent inclusive strategy "  Identifying stakeholders in priority areas

"  Acute Trusts: Senior Management "  Acute Trusts: Surgery "  Mental Health: which organisations? "  Primary Care: how to relate to frontline GPs?  

 

Involving Everyone

"  Iden>fying  areas  of  need  

"  Engaging  organisa>ons  in  Regional  projects  

"  Sharing  knowledge  and  best  prac>ce  

The PSA Faculty includes… "  Peter McCulloch Surgeon, Safety Researcher

"  Helen Higham Anaesthestist, Safety Trainer, Simulation Expert

"  Lauren Morgan Postdoctoral Human Factors Researcher in Healthcare "  Lorna Flynn Human Factors Researcher in Healthcare

"  Lance Holman Clinical Research Fellow

"  Christopher Pennell Clinical Research Fellow

"  Steve New Operations Management Expert, Said Business School

"  Ken Catchpole Patient Safety Expert, California

"  Charles Vincent Professor of Psychology, Patient Safety Expert

"  Emma Vaux Health Foundation Leader for Patient Safety

"  Jill Bailey Mental Health Nurse, Safer Care Lead, Oxford

"  Claire Merriman Head, Professional Practice Skills, Brookes University

"  David Griffiths General Practitioner

"  Matt Inada-Kim AGM Consultant, Infection Control Specialist

" Rosamund Snow Patient & Public Involvement Expert

"  Marcus Durand Human Factors Practitioner, Clinical Engineering Lead  

Future Plans

"  Develop  a  comprehensive  set  of  improvement  projects  across  the  AHSN  region  

"   Ensure  sustainability  by  developing  a  mixed  funding  model  

"   Iden>fy  and  mee>ng  key  staff  training  needs  in  the  AHSN  

"  Develop  training  for  extra-­‐regional  and  Na>onal  healthcare  organisa>ons?    

"   Link  with  other  AHSNs?  "  Develop  a  strong  collabora>ve  research  programme  

linked  to  training  

?  

Thank  you  for  coming!