Leadership in Clinical PracticeQuality of Care Rounds

Improving Quality Programme and Ward Accreditations

Deborah CarterDeputy Director of Nursing (Quality)

What did we want to achieve?

• Improve our patients experience

• Empower ward leaders to gather their own data about the environment of care

• Ward teams able to directly influence the quality of care and the environment

• Patients and staff giving direct feedback

• Board level assurance on the quality of patient care

Where Did We Start?

• In 2008 ~ no Trust wide approach to data collection on the environment of care or patients view of this

• Review of results from 5 years inpatient survey

• Analysis of complaints feedback

• Understanding the national picture

• Choosing which aspects to measure

Understanding What Matters

• Environment of Care• Privacy and Dignity• Clean• Infection control• Communication• Food• Pain

Quality Care Dashboard

Presenting the

Quality of Care For

Ward Part of the

PatientExperienceMetricsQualityCampaign.co.uk Reported Distributed on 16/01/2011 December 2011

Providing Good Nutrition

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

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03

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04

/11

05

/11

06

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07

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08

/11

09

/11

10

/11

11

/11

12

/11

Ensuring Patient Safety

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

/11

03

/11

04

/11

05

/11

06

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07

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08

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09

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10

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11

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12

/11

Ensuring Patient Satisfaction

40%

50%

60%

70%

80%

90%

100%

12

/10

01

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02

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03

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04

/11

05

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06

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07

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08

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09

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10

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11

/11

12

/11

Achieving Good Communication

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

/11

03

/11

04

/11

05

/11

06

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07

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08

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09

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10

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11

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12

/11

Ensuring Pain is Managed

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

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03

/11

04

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05

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06

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07

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08

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09

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10

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11

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12

/11

Respecting Privacy & Dignity

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

/11

03

/11

04

/11

05

/11

06

/11

07

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08

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09

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10

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11

/11

12

/11

Achieving a Clean Environment

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

/11

03

/11

04

/11

05

/11

06

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07

/11

08

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09

/11

10

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11

/11

12

/11

Ensuring Infections are Controlled

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

/11

03

/11

04

/11

05

/11

06

/11

07

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08

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09

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10

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11

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12

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Involving Patients & Carers

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

/11

03

/11

04

/11

05

/11

06

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07

/11

08

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09

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10

/11

11

/11

12

/11

KEY: Scored by… Blue - Patients via Tracker Turquoise - Ward Managers via MWR/QCR (New QCR started April 2011)

Overall Quality

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

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03

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04

/11

05

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06

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07

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08

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09

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10

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11

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12

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Meeting Equality & Diversity Needs

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

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03

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04

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05

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06

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07

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08

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09

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10

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11

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12

/11

Meeting Personal Hygiene & Care Needs

40%

50%

60%

70%

80%

90%

100%

12

/10

01

/11

02

/11

03

/11

04

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05

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06

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07

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08

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09

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10

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11

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12

/11

85% Lower Threshold - 95% Upper Threshold

Quality Care Dashboard

Delivering the Best Patient Experience in the NHSCentral Manchester University Hospitals NHS Foundation Trust.

Brown - Safeguarding IncidentsGreen - PALS Compliments, Blue - PALS Complaints and Red - ComplaintsBlack - MRSAGreen - Median Length of Stay Purple - CDIFF

Monitoring Medication Errors

0

5

10

15

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25

30

35

40

12/1

0

01/1

1

02/1

1

03/1

1

04/1

1

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1

06/1

1

07/1

1

08/1

1

09/1

1

10/1

1

11/1

1

12/1

1

Total Reported Incidents

0

10

20

30

40

50

60

70

80

90

100

12/1

0

01/1

1

02/1

1

03/1

1

04/1

1

05/1

1

06/1

1

07/1

1

08/1

1

09/1

1

10/1

1

11/1

1

12/1

1

Monitoring Patient Falls

0

5

10

15

20

25

30

35

4012

/10

01/1

1

02/1

1

03/1

1

04/1

1

05/1

1

06/1

1

07/1

1

08/1

1

09/1

1

10/1

1

11/1

1

12/1

1

Monitoring Pressure Sores

0

2

4

6

8

10

12

14

16

18

20

12/1

0

01/1

1

02/1

1

03/1

1

04/1

1

05/1

1

06/1

1

07/1

1

08/1

1

09/1

1

10/1

1

11/1

1

12/1

1

Average Length of Stay

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

12/1

0

01/1

1

02/1

1

03/1

1

04/1

1

05/1

1

06/1

1

07/1

1

08/1

1

09/1

1

10/1

1

11/1

1

12/1

1

Reducing Complaints

0

2

4

6

8

10

12

14

16

18

20

12/1

0

01/1

1

02/1

1

03/1

1

04/1

1

05/1

1

06/1

1

07/1

1

08/1

1

09/1

1

10/1

1

11/1

1

12/1

1

Monitoring Infection Rates

0

2

4

12/1

0

01/1

1

02/1

1

03/1

1

04/1

1

05/1

1

06/1

1

07/1

1

08/1

1

09/1

1

10/1

1

11/1

1

12/1

1

Safeguarding Patients

0

2

4

12/1

0

01/1

1

02/1

1

03/1

1

04/1

1

05/1

1

06/1

1

07/1

1

08/1

1

09/1

1

10/1

1

11/1

1

12/1

1

KEY: By Severity…Teal - Low/Grade 1 Green - Minor/Grade 2 Yellow - Moderate/Grade 3 Orange - Major/Grade 4 Red - Catastrophic (L5) *Grades refer to Pressure Sores only

For

Trust

Part of the

PatientExperienceMetrics Showing data for Number of Audit taken place:

Report Produced byColin HunterInformation AnalystQuality Campaign Team (Analysis)

Patient Experience Tracker DashboardAll Categories

940December 2011

Central Manchester University Hospitals NHS Foundation Trust.Delivering the Best Patient Experience in the NHS

75.0%

89.4%

82.8%

82.2%

73.7%

75.5%

81.5%

80.9%

78.4%

74.0%

79.7%

80.3%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95%

How Clean is your Environment

Are we doing our best to Control Infections

How Safe do you feel in this Environment

How Effective is our Communication

Are we Offering Good Nutrition

Are we Managing your Pain Levels

Do we give you Privacy & Dignity

How Aware of Equality & Diversity

Did we Involve You and/or your Carer

How Satisfied are you

National NHS CQUIN Measures

Overall Patient Experience Score

Lower Threshold UpperThreshold

Monthly Snap Shot

For

Trust

Part of the

PatientExperienceMetrics Showing data for

IP Quality Care Round DashboardAll Categories

December 2011

Central Manchester University Hospitals NHS Foundation Trust.Delivering the Best Patient Experience in the NHS

96.0%

97.8%

96.6%

98.0%

93.8%

93.3%

95.5%

91.0%

96.1%

85.5%

94.8%

95.4%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95%

How Clean is your Environment

Are we doing our best to Control Infections

How Safe do you feel in this Environment

How Effective is our Communication

Are we Offering Good Nutrition & Hydration

Are we Managing your Pain Levels

Do we give you Privacy & Dignity

Are you Satisfied with our Service

Did we Involve You and/or your Carer

Have we met your Equality & Diversity requirements

Are we meeting your Personal Hygiene needs

Overall Quality Score

Lower Threshold UpperThreshold

Continuous improvement

• Review of process with matrons and ward managers

• Understand what adds value to the patient experience

• Improve report functions

• Spread to non-ward areas

• Developed the tool further

• Board Assurance

Improving Quality Programme

• NHSi Productive Ward – whole hospital roll out pilot site 2007-2010

• Recognised some good ideas started but not spread– Lacked standardisation

• Not embedded as a culture– Seen as a project

• Had become another performance measure– Rated red, amber or green

• Reviewed sustainability– What did we want to sustain?

Key Elements

• Well organised environment (WOW)

• Improving Quality data board

• Patient Status at a Glance (PSAG)

• Shift Handover

Key Elements

Shift Handover

To include patient details e.g. location, name, age, gender andto provide summary of current admission e.g. current diagnosis and management plan / interventions.

To include requests for next shift related to patient care needs, management plan or any outstanding tasks.

To include an overview of patient care during your shift, e.g. relevent observations /monitoring, EWS etc., any 'risks', MDT involvement

To include relevent past medical history and social circumstances.

ecommendation

ssessment

ackground

ituationS

B

A

R

Verbal Prompt for Shift HandoverWard Area Date Time of Handover

No. Alert Specific requirements Report Details

1Patients with similar

namesList all patients names and

Hospital Numbers

2Deteriorating patients with

EWS above 3List all patients names and

Hospital Numbers

3Safeguarding / Vulnerable

patient issuesList all patients names and

Hospital Numbers

4 Falls risks Confirm completed assessments, actions, traffic lights

5 Infection Control Issues check screening, pathways, VIP charts, any barrier nursing

6 Absent Patientsinclude names of patients not on ward, current location if known

and last time seen

7Patients on Liverpool Care

PathwayList all patients names and

Hospital Numbers

8 Patients with DNR order List all patients names and Hospital Numbers

9Confused / Wandering

PatientsList all patients names and

Hospital Numbers

12Relatives / Carers resident

on wardGive details

10 Incidents or Complaints Details of significant clinical incidents or complaints

11 Staffing Issues Off duty checked and NHSP booking made / outstanding

12 Cleaning Matters discuss with H.S.A any issues affecting cleaning schedule

Handover to………………………………

Shift Handover - Core Huddle

Handover from……………………………………

ONCE DATA COLLECTION COMPLETED OPEN A3 REPORT IN SHIFT HANDOVER AND CLICK ON THE PALE BLUE TAB TO FIND CORRECT PAGE TO INPUT DATA

No

Yes

1 23 45 6

7 8 9 10 11 1213 14 15 16 17 1819 20 21 22 23 24

25 2627 28

29 30 31

1 23 45 6

7 8 9 10 11 1213 14 15 16 17 1819 20 21 22 23 24

25 2627 28

29 30 31

Was S.B.A.R. used for all patient handovers?

Was a core huddle completed?

1 23 45 6

7 8 9 10 11 1213 14 15 16 17 1819 20 21 22 23 24

25 2627 28

29 30 31

1 23 45 6

7 8 9 10 11 1213 14 15 16 17 1819 20 21 22 23 24

25 2627 28

29 30 31

Day to Night - Shift Handover Monthly Audit - August

No Date this month

Improving Quality ProgrammeSet minimum standards with flexibility to apply in all areasDeveloped agreed Trust wide ‘gold standards’

Provide teaching in methods:Provided a 14 week programme of master classes andfacilitation to all wards

Provide resources:Provided handbooks, data collection tools and electronicresource files

Establish 30 day project mentality:Feedback sessions after 30 days with expectation of further learning and improvements

Create motivation:Assessments to achieve Bronze, Silver or Gold

Layered Approach

Standardisation

Align to normal business

Embed knowledge

Layered Assessments

Wards are assessed and rated as:• White• Bronze• Silver or • Gold

Standardisation: At end of 14 weeks assessing successful implementation of standards (withfacilitation)

Embedding knowledge: 12 weeks laterassess ability to apply methods to issues identified in data(without facilitation)

Align to normal business: 12 weeks later comprehensive ward accreditation process

Clinical Leadership

In wards that were successful in achieving and

maintaining silver or gold:

• Leaders with clear vision and good communication

• High level of staff involvement and engagement in IQP work

• Good understanding of data and methodology

Ward Accreditation Process• Data review• Observation

• Culture of continuous improvement• Environment of care• Communication about and with patients• Nursing processes

• Discuss findings of observation and review in context of data

• Score standards as White, Bronze, Silver or Gold

• Overall score validated at panel review

Aims to…

Support ward leaders and their staff in….

• achieving the best patient experienceon their ward through continuousimprovement work

• thus provide a level of assurance to theboard about the quality of care on wardsand departments

As measured by…

• Number of wards assessed and rated

• Improvements in Quality Care Dashboard data

• Findings of external assessors including CQC

• Staff and Patient survey results

How are we doing?

Number of wards achieving overall results as Gold, Silver, Bronze or White

0

5

10

15

20

25

30

GOLD SILVER BRONZE WHITE number tocomplete

Achieving Good Standards

% of wards acheiving silver or gold for each category

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Culture ofcontinuous

improvement

Environment of care Communication aboutand w ith patients

Medicines - process Meals - process

Communication About Patients

Using Standardised Communication Tools

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

CoreHuddle

Status ata GlanceBoards

90%target line

Improving Risk Assessments

Documentation - Risk Assesments Completed Within Timescale

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

Falls

Bed rails

PressureulcersNutrition(adult)Continence

90% targetline

Medications - Ensure Drugs Fridge Locked

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

Focus on Process

Meals - Offering Hand Wipes With Meals

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

Supporting White Wards

• Understanding that areas are safe

• Diagnostic assessment

• Individual support for ward manager

• Blended approach to providing support to ward team to achieve improvement

Celebrating Gold

“Never tell people how to do things. Tell them what to do and they will surprise you with their ingenuity”

George S Patton