Cwm Taf Health Board Insert name of presentation on Master Slide
Improvement Programme
Initiatives
Cwm Taf Health Board
May 2013
Cwm Taf Health Board
Leadership – Walkrounds
Improved
Communication Showcase areas
of excellence
Staff Contribution
and Team Working
discussions
Learning
and
Sharing
Staff Comments:-
“ It’s nice to talk and see board level
members really take an interest in what I
had to say”
“Was a lovely visit, it was our chance to
show off our hard work”
“ I felt I could be honest and listened to”
Displays
staff &
patient
relations
Leadership –Walkround findings
Cwm Taf Health Board
Fresh Eyes Buddy System has been successful within the Maternity
Services and is welcomed by staff, it has proven to be effective and is
working extremely well. Improved safety feature and ensuring staff are continuously vigilant, the smallest change in patients statistics are
noted.
As result of the Walkrounds it’s apparent there is a positive
patient care directive amongst all staff. Ensuring a patient-
centred led approach to individual care throughout the
patients journey
The heightened security procedures within the Maternity Service have been noted and
displays of security measures in place were visible for visitors and
patients to be fully informed. This has improved a general
sense of safety amongst visitors, service users and staff
Enhanced Recovery After Surgery (ERAS) Excellent
feedback has been received and noted in relation to the
1000 Lives+ ERAS programme. Patients are informed and less worried
Cwm Taf Health Board
Mortality Review The population of Cwm Taf experience higher than average levels of deprivation:•62% classed as obese•27% are smokers•44% consume greater than the recommended weekly limit for alcohol consumption•23% have high blood pressure (hypertension)•15% have chronic respiratory disease•9% have a chronic cardiac condition
•34.2% live in most deprived areas (this deprivation translates into lower life expectancy and also lower healthy life expectancy as shown by Public Health Wales Observatory). Continued efforts are being made to focus on Clinical Coding of Co-morbidities.
Next Steps
• Continue to identify themes and trends from Mortality Review• Set up activity groups to review and report on specific mortality conditions• Continue to stream-line the review process in its entirety reducing cost and
time to each session without compromising on quality and reporting• Develop standard operating procedures for all stage 2 cases• Promote joint working approach between Concerns, Clinical Coding and Information
Management
Cwm Taf Health Board
Mortality & Harm Review
Process Mortality
Review: Stage 1*
(data recorded by
Clinical Audit
department)
Mortality Review
Stage 2* (data
recorded by
Clinical Audit
department)
**Condition
specific mortality
STROKE
**Condition
specific mortality
#NOF
**Condition
specific mortality
SEPSIS
**Condition
specific mortalityPOST-
OPERATIVE
DEATH
**Condition
specific mortality
OTHERS
No further
review
Death
potentially
amenable
Death
probably not
amenable
All deaths at
both acute
sites
Global Trigger Tool
Cwm Taf Health Board
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Feb
2012
Mar
2012
Apr
2012
May
2012
Jun
2012
Jul
2012
Aug
2012
Sep
2012
Oct
2012
Nu
mb
er
Number of triggers
CTHB - Prince Charles Hospital
Values
Average (5.2)
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Feb 2012 Mar 2012 Apr 2012 May 2012
Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012
Nu
mb
er
Number of triggers
CTHB - Royal Glamorgan Hospital
Values
Average (8.7)
Royal Glamorgan Trigger
EventsPrince Charles
Trigger Events
Findings:- Top 2 triggers routinely identified across both sites are
• Readmission to hospital within 30days
• Lab Test Module
•Further work ongoing via Faculty of Quality and Patient Safety, to explore this in further
depth
Cwm Taf Health Board
Global Trigger ToolProgress
The GTT programme continues to explore and conduct reviews of current practice and triggers for harm.
• Over a one month period 40 cases are reviewed and all findings are incorporated into a 1000Lives Plus database to present data for comparison of activity.
• The findings of GTT currently give us an organisational overview of care and areas of good practice
• GTT review continues to highlight the importance of the quality of documentation
• It is a frequent finding that trigger events are often a result of the disease process, and not a consequence of poor care
Cwm Taf Health Board
Patient StoriesKey Developments & Improvements
• A central stories database has been designed and developed, and is now available on the intranet for staff to search for a story and request its use following confirmation that patient consent has been obtained.• Five digital stories have been developed which will be used by the Directorates to look at the learning, and how the patient’s experience can be improved:
•“This is Me”
•“Tamara’s Story – Our Nightmares & Hopes”•“Tomos Story – The Transition”
•“Vic’s Story”
• Agreement provided by the University of Glamorgan School of Nursing that patient stories will become part of the Student Nursing curriculum. Currently working on a formal structure with the University to take this work forward
• Working with the RCN Clinical Leadership course leaders with a view to introducing the digital story element onto the course
• Cwm Taf recognised as an area of good practice by 1000 Lives Plus
• Seven additional staff have recently been trained in digital story taking
• Occupational Therapy and Facilities Departments are now involved in the workstream
Rapid Response to
Acute Illness (RRAILS)Outcome measures
April 2012 -Implementation of NEWS in all Welsh HospitalsApril 2013 - Achievement of 95% compliance with all four RRAILS bundles in all acute hospital areasApril 2014 -Demonstrable reductions in mortality from Sepsis and Acute deterioration in all Welsh hospitals
Key Developments in RRAILS•The NHS Early Warning Score Wales (NEWS) is used on all wards across all hospitals, since April 2012
• Maintaining compliance with completion of NEWS remains a challenge. It has been identified that the criteria on the form are more sensitive – this leads to increased scoring when observations are recorded and acted upon
•The principles of RRAILS are implemented on both DGH sites and the use of the SBAR handover tool for escalating deteriorating conditions and early intervention has improved
•RRAILS – currently implemented on Ward 4 Prince Charles Hospital (PCH) and Ward 20 Royal Glamorgan Hospital (RGH). Admission bundle, recognition bundle, response bundle, Sepsis 6 and SBAR all in place and working well.
Cwm Taf Health Board IMPROVING ACUTE CARE
SEPSIS SIX - 24hr
Outcomes
Cwm Taf Health Board IMPROVING ACUTE CARE
• On ward improved 51
• On ward triggering 21
• On ICU within 4hr 11
• On ICU > 4hr 6
• DNAR 2
• RIP 1
• No Data 8
• Statistically significant drop in NEWS score.
• Biggest drop -8
Percentage favourable outcomes after 24 hours
Cwm Taf LHB. Sepsis Bag Database.
from May 2012 to Dec 2012
RRAILS – SEPSIS BAG
RESPONSE
Cwm Taf Health Board IMPROVING ACUTE CARE
0
5
10
15
20
1 2 3 4 5 6 7 8 10 12 14 15 19 20 A+E MCDU CMU Blank
• Bags used across wards at The Royal Glamorgan Hospital • Age range 19-91 years, (Mean age 65years)
Reducing Falls in the
Community
Cwm Taf Health Board IMPROVING PRIMARY AND COMMUNITY CARE
Key Developments
• Some key service areas in the Health Board have been engaged, where there are opportunities to identify those who have a falls history.• Tools to use for falls work are being developed and piloted• There is recognition that the tools are appropriate for assessing frailty
• Some staff in Welsh Ambulance Service Trust (WAST) locally, Primary Care, @home services, on wards and in Emergency Care Centre (ECC) and Minor Injuries Unit (MIU) are building competencies in falls work
• Community Integrated Assessment Service (CIAS) will use the falls database to monitor compliance
• The pathway for referring for exercise, gait and balance training is emerging• Local information to give to clients and patients is under development• All Wales networks to share knowledge and skill• The work on reducing falls in the community is cross-referred to reducing inpatient falls
Reducing Falls in the
Community
Cwm Taf Health Board IMPROVING PRIMARY AND COMMUNITY CARE
Next Steps
• Establish fracture liaison services (objective 2)
• Develop capacity within primary care
• Developing a Health Board wide falls database
• Explore capacity to complete the falls database in service areas
•Agreement about where high risk fallers will be referred for further assessment from ECC and MIU if we do screen over 75year olds
•Electronic information sharing and referral from ECC and MIU to primary care and community services through Myrddin
First Episode Psychosis
(FEP) Intelligent Target
Key Developments
• Development of a multiagency steering group for improving services to people in First
Episode Psychosis
• Development of an agreed protocol for reporting FEP cases across Cwm Taf
• Initiatives to promote access to psychological therapy have been developed and
implemented across Cwm Taf such as:-
– Development of a Pilot First Episode service in Merthyr CMHT, to assist to plan a
comprehensive service which will operate across the health board.
– Liaison with established FEP Services elsewhere in Wales which has helped with
planning the service
– Offer of shadowing opportunities for CMHT staff to help with skills development
Cwm Taf Health Board MENTAL HEALTH
First Episode Psychosis
(FEP) Intelligent Target
Cwm Taf Health Board MENTAL HEALTH
0
10
20
30
40
50
2010 2011 2012 so far
FEP Case finding
Reported
Found by detailed search
• Data reporting has improved, particularly in the area of the pilot. Since the process for reporting was agreed at the end of January, we have identified more cases than in the previous 9 months.
• The pilot scheme is well supported within the Merthyr CMHT, and gives us practical opportunities to improve important aspects of service provision.
• We are developing proposals for an invest to save bid, with an initial proposal to provide a dedicated post, as a secondment, to lead these developments across the health board.
Identifying Depression in
Hospital Settings
Cwm Taf Health Board
Progress
• Scoping exercise undertaken
• One area has implemented a pilot – Stoma Care
Background to Implementation• Previously assessments were completed by a Stoma
Care Nurse(SCN) paying specific attention to
physical, social, psychological, sexual needs using a
Dansac Observation Tool (DOT)
• A psychological score identified by the SCN and
appropriate advice offered.
Cwm Taf Health Board
Identifying Depression in
Hospital Settings
Cwm Taf Health Board
Key Developments
• Familiarised with ‘Identifying depression in hospital settings to
improve patient outcomes’.
• CNS Met with Psychologist and Ward Manager in Mental Health
Directorate to provide informal teaching session.
• Developed tool to use within clinic environment.
• Commenced audit for 1 month on ALL patients attending Stoma
Care Clinic.
• SCN assessed patient using Active Listening Skills and scored the
patient as they felt appropriate.
• SCN asked two relevant questions, specific to the above booklet.
If yes to either Question, PHQ 9 Depression Tool Completed.
Cwm Taf Health Board
Identifying Depression
in Hospital Settings
Cwm Taf Health Board
Current Position
• The Stoma Care Team are appropriately assessing patient’s psychological needs.
• The 1000 Lives Plus Depression Tool has its place within the department; the SCN
will identify those patients who would benefit from completion of the tool.
• The tool allows the patient to recognise they have a psychological problem that needs
addressing.
• The tool signposts the patient to seek further support and help e.g. counseling, Book
Prescription Wales.
Next steps:
SCN to continue to collect data using monitoring tool to identify trends and improve
service delivery.
HEALTHCARE ASSOCIATED
INFECTIONS Reducing Catheter Associated Urinary Tract Infections (CAUTI)
KEY OBJECTIVE
• To improve patient care and safety through the implementation of a series of
evidence based interventions in a care bundle format.
PROGRESS/ACHIEVEMENTS TO DATE
• The CAUTI care bundle was originally piloted on three wards in Dewi Sant Hospital and
has since been introduced to:- all community hospitals, all surgical wards at the Royal
Glamorgan Hospital and Prince Charles Hospital, and in theatres at Royal Glamorgan
Hospital.
• Surveillance data is being collected on the surgical wards at Royal Glamorgan Hospital -
data analysis will be performed by a Clinical Audit Facilitator.
Cwm Taf Health Board HEALTHCARE ASSOCIATED INFECTIONS
REDUCING INFECTIONS FROM
PERIPHERAL VASCULAR CATHETERS
Peripheral Vascular Catheters (PVC)
• The PVC bundle was originally piloted on three medical wards and is now being used on:-
all medical wards in the Royal Glamorgan Hospital, all medical and surgical wards at Prince
Charles Hospital, and on the Intensive Care Unit and Endoscopy Unit at Prince Charles
Hospital.
• The original pilot wards have agreed to collect limited surveillance data daily and perform
audits twice monthly to monitor compliance with the care bundles. The Infection Prevention
and Control Team are performing unannounced audits twice per month to monitor
compliance with the care bundle.
• A monthly root cause analysis is performed for all line associated bacteraemias which is
shared with the Directorates.
Cwm Taf Health Board HEALTHCARE ASSOCIATED INFECTIONS
HEALTHCARE ASSOCIATED
INFECTIONS
Cwm Taf Health Board HEALTHCARE ASSOCIATED INFECTIONS
Challenges
• PVC and CAUTI bundles have not been spread to all areas – this work is ongoing
• Surveillance data needs to be collected consistently in all areas
• Analysis needs to be performed on the data received to monitor outcome and process measures
• Medical staff need to be fully engaged and represented at the CAUTI and PVC meetings
• The results of the verification audits performed by the Infection Prevention & Control Team shows poor compliance with the care bundles. Following discussion at the Faculty for Quality and Safety, the process is being reviewed and re-energised to ensure the bundles are applied consistently.
Next steps
• A standardised mechanism for reporting outcome and process measures is being established with the aid of a dedicated Clinical Audit Facilitator
TRANSFORMING CARE
Cwm Taf Health Board TRANSFORMING CARE
Progress/Achievements to Date:
•Average increase of 19% in Direct Care Time - Highest to date 80%
More recently we have seen a decline in Direct Care Time as some
improvements have not been sustained in individual areas. This will now
require a detailed review to determine the issues and identify solutions.
•Average increase of 7% in reported Patient satisfaction - Highest to date
98%
We have recently introduced the use of volunteers to carry out patient
satisfaction surveys. This is to ensure no administrative bias or patients
feeling pressured to give positive responses when surveys are administered
by the same staff who deliver care
•Average increase of 5% in reported Staff Satisfaction - Highest to date
92%
TRANSFORMING CARE
Cwm Taf Health Board TRANSFORMING CARE
• Steady decline in adverse events across all Transforming Care areas demonstrated by
examples of some of the highest ‘days since’:
50% Reduction in time taken for nurse handovers
28% reduction in the time taken to locate equipment
45% reduction in interruptions to nursing staff activity
69% reduction in time spent in medicines administration
Significant improvements in direct care time have allowed staff to re-
direct their time. Examples of the time saved are as follows:
TRANSFORMING MATERNITY
SERVICES
Cwm Taf Health Board TRANSFORMING MATERNITY SERVICES
Progress and Improvement
Introduction of :
•DVT Risk Assessment•MEWS chart introduced across all maternity areas Jan 2012 – to date
•White Boards providing information at a glance•Sepsis guideline agreed•Sepsis boxes placed on obstetric emergency trolleys which are highly visible to staff•Sepsis screening tools in place•Sepsis checklist and treatment plans in place•Agreed SBAR Proforma for Maternity Day Assessment areas across sites
•The electronic maternity record prompts midwives to complete the postnatal DVT riskassessment and MEWS post delivery before transfer to the postnatal ward. Thematernity records cannot be completed unless this mandatory risk assessment has beencompleted
TRANSFORMING MATERNITY
SERVICES
Cwm Taf Health Board TRANSFORMING MATERNITY SERVICES
Future Work
•Continue with mandatory training sessions to raise awareness and maintain momentum•Increase use of maternity safety briefing•Continue to forge links with Outreach Teams from Intensive Care Unit•Gain support from NLIAH with measurement supported by dedicated Clinical Audit Facilitator
Cwm Taf Health Board
Key Contact Information
Arlene Shenkorov – Clinical Audit & Effectiveness Manager
01685 728146
Sarah Davies - Senior Facilitator - Programme Support
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