What is risk management?
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Transcript of What is risk management?
‘Active Risk Management at Rotherham’
Rotherham NHS FTQUEST presentation
24th June 2011
Dr Trisha Bain
What is risk management?
‘Risk management is the identification, assessment, and prioritisation of risks followed by coordinated and economical application of resources to minimise, monitor, and control the probability and/or impact of negative events or to maximize the realisation of opportunities’
QUEST topicsVTE
Falls, Pressure Ulcers, UTIs• Falls care pathway
assessments• Pressure ulcer
assessment , including MUST
• UTIs – blood sampling method to accurately identify catheter related UTIs
Identification of risks • Web Datix Incident • Web Risk registers • Serious Incident process• Mortality reviews (Trust and CSU MDT)• Global Trigger• NICE/NCEPOD, National Audits • CHKS :national and peer benchmarking
Monitoring and prioritisation of risks
Assessment and management of risk across pathways: Falls • A&E: Falls and Fracture pathway (50-75yrs)• Referral Osteoporosis and Bone Health Clinic• Referral to community: home safety
assessment, falls management• FNOF pathway were appropriate• Ward Falls assessment and MDT Action Plan• Discharge forms to the community team
Community to BoardMonitoring and ImprovementProgrammes
• SNAP electronic data collection tool• All wards, community sampling• Automated ‘real-time’ feedback reports• Linked to quality accounts programmes
% Patient assessment completion
Hospital Acquired Pressure Ulcers by Month and Grade
PATIENT SAFETY & EXPERIENCE% Patient assessment completion
PATIENT SAFETY & EXPERIENCENumber of incidents per month by type
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110Bed railsassessmentcompleted
Bed railassessmentactioned
Falls assessmentcompleted
Falls assessmentactioned
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Falls
Medicationerrors
All Incidents
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Nutritionalassessmentcompleted onadmission
Smoking statusdocumented
Smoking cessationrecorded in nursingnotes
% Patient assessment completion
Hospital Acquired Pressure Ulcers by Month and Grade
PATIENT SAFETY & EXPERIENCE% Patient assessment completion
PATIENT SAFETY & EXPERIENCENumber of incidents per month by type
0
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110Bed railsassessmentcompleted
Bed railassessmentactioned
Falls assessmentcompleted
Falls assessmentactioned
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40
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Falls
Medicationerrors
All Incidents
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Grade 1 Grade 2 Grade 3 Grade 4
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Qtr 2
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110Nutritionalassessmentcompleted onadmission
Smoking statusdocumented
Smoking cessationrecorded in nursingnotes
B3 Ward Quality Indicators
B2 Ward Quality Indicators
Local level monitoring
Falls from height: April 2009 – March 2011
Falls same level April 2009 – March 2011
Trust wide monitoring
National benchmarks of reported slips, trips and falls in acute (NPSA 2010)
hospitals
VTE90% target metevidence ofactions
Proxy measures
Linked to improvement programmes: Quality Accounts
•Linked to Improvement programmes
•On-going : Mortality. Fluid balance and MUST tool
• CQUINs, National Priorities
• Reducing 30day re-admission rates for Falls, Diabetes,
COPD•Continue to achieve month on month 90% VTE risk assessment
•Ensure 90% of VTE prophylaxis prescribed as per national guidance
• Increasing responsiveness to our patients needs on composite indicator (PET)
• Increasing compliance to 95% of key measures of End of Life care pathway
• 95% high risk prescriptions, opiates, anticoagulants, antibiotics prescribed as per protocol
• Reduce number of communication incidents : handover/hand-off
• Continue to have zero Never Events
Patient Safety
Patient Experience
KPIsClinically Effective
Continuous improvementand management of risks
1 Quality Account indicators at a glance
Baseline type
Baseline period
Baseline Value Target QTR 1 QTR 2 QTR 3 QTR 4 Year to
DateQTR
ChangeYTD
RatingData
Rating
Employee sickness rates (unplanned) Quarter Qtr 4 2009/10 4.8% 3% 4.0% 3.9% 4.3% 4.4% 4.2%
National Inpatient Survey - % of questions where the trust's performance is in the top 20% of trusts nationally Year 2009/10 16.9% Increase 23.4% 23.4% -Staff satisfaction survey - number of key findings in the top 20 percent of 40 domains Year 2009/10 11 Increase 13 13 -Increased IR1 reporting (Datix) Year 2009/10 6555 Increase 1799 2065 1968 1920 7752
All applicable staff to have in year PDR Snapshot Qtr 4 2009/10 69% 100% 61.9% 57.8% 44.1% 56.2% n/a -All staff receive mandatory and statutory training (data quality issues are significant)
Reduction in hospital acquired UTIs (related to catheterisation) per 1,000 occupied bed days 2 Qtrs Qtrs 3/4 2009/10 0.12 50% baseline 0.14 -
Reduction in intrapartum stillbirth rates Year 2009/10 0.0% Reduce 0.0% 0.1% 0.0% 0.0% 0.0%
Reduction in unexpected neonatal admissions (babies over 2.5Kg) Year 2009/10 8.7% Reduce 9.9% 10.1% 4.9% 6.6% 7.9%
Reduction in Caesarian Section rates Year 2009/10 22.0% Reduce 18.4% 21.3% 16.3% 20.7% 19.2%
Number of patients with hospital acquired MRSA Year 2009/10 5 3 0 0 0 0 0
Patients with hospital acquired Claustridium Difficile Year 2009/10 43 Reduce 22 5 7 16 50
Inpatient falls (from height) per 1,000 inpatient admissions Year 2009/10 4.4 Reduce 4.6 4.0 4.7 5.9 4.8
Inpatient falls (same level - SLIP) per 1,000 inpatient admissions Year 2009/10 5.7 Reduce 5.6 6.3 6.6 5.8 6.1
Patient medication errors per 1,000 dispensed item episodes Year 2009/10 1.1 Reduce 1.6 1.7 1.6 1.6 1.6
'Never' events that occur within the hospital Year 2009/10 0 0 0 0 0 0 0
Reduction in the number of complaints from baseline Quarter 4 Qtr 4 2009/10 171 Reduce 168 140 162 181 651
Increase in the number of patients on the end of life care pathway Year 2009/10 28.7% Increase 33.6% 43.9% 42.9% 45.7% 41.6%
Increase in the number of patients assessed using the MUST nutritional tool on admission (SNAP) Quarter 1 2010/11 89.2% 100% 89.2% 93.0% 89.0% 92.6% 91.1%
Reduction in hospital acquired pressure ulcers grade 2 and above (Datix) Year 2009/10 267 Reduce 66 43 58 51 218
Increase in the number of patients undergoing VTE assessments from baseline Month Jun-10 53.2% 90% 53.2% 57.7% 66.8% 88.5% 64.9%
Increase in patients on Hip & Knee replacement bundle (calculated on combined raw data from 3 indicators) Quarter 1 2010/11 96.3% Increase 96.3% 96.4% 96.9% 94.3% 95.9%
Appropriate reduction in LoS for patients following (EL & NEL) surgical intervention (CHKS) Quarter 4 2009/10 1.4 Reduce 1.5 1.3 1.2 1.2 1.3
Reduction in 'Risk Adjusted Mortality Indicator' (RAMI 2010 by CHKS) Year 2009/10 93.6 80.0 76.7 73.9 88.8 79.3 79.7
Reduction in unplanned readmission rates within 28 days (CHKS) Year 2009/10 7.5% Reduce 8.4% 8.3% 7.9% 6.4% 7.7%
Reduction in unplanned readmission rates within 14 days (CHKS) Year 2009/10 5.4% Reduce 6.1% 6.0% 5.8% 5.0% 5.7%
Increase in depth of coding - Average diagnosis per coded episode (CHKS) Year 2009/10 2.6 Increase 2.9 3.0 3.1 3.1 3.0
Clinical Quality
Data Quality
Culture
Annual survey
Annual snapshot audit
Annual survey
Insufficient data quality to report
Patient safety
Patient Experience
Any Questions