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UCLPARTNERS QUALITY FORUMHosted by Basildon & Thurrock University NHS Foundation Trust
“Embedding quality through an organisation, and building capability/capacity for improvement”
Friday 21st November 2014
2-5pm
@UCLPartners
#UCLPQF
From ‘special measures’ to ‘good’ Clare Panniker CEO
It started here….
• 10 year old girl died due to failings
• 50% of staff wouldn’t recommend the hospital for family or friends
• It required visible leadership where we listened
• Care and compassion in the heart of everything we do
Patient stories were the catalyst for ‘act one’
Culture change • Honesty and transparency
• Approachable and available to staff, politicians and patients
Outcomes – improved quality and moraleTimely up to date data is key
Cardiac arrest reduction
Decreased mortality Staff mini survey shows month on month Improvement and staff now recommend BTUH for friends and family
It was exhausting but we have improved, but the journey has only just begun…. ‘act two’
Our next challenge
Giles Thorpe, RN MScDeputy Director of Clinical Governance
Clinical Governance at BTUH
It is good to have an end to journey toward, but it is the journey that matters in the end.” ―Ursula K. Le Guin
Serious Incident Management at BTUH
• Historical incident management at BTUH evidenced low reporting numbers and high gradings of harm (2011/2012)
• Outcome 16: Concerns and Notices– (2010) - There are concerns that the trust is identifying what constitutes a serious
untoward incident as there were three recent incidents fitting the criteria which were reportedto the National Patient Safety Agency but not raised or investigated as a serious incident
– (2013) - The trust did not have a system in place to identify trends in incidents. Wefound 1300 incidents not closed. We looked at two recent serious incidents, it was not clearif specialist advisers had been consulted as part of the investigation. By failing to properlyinvestigate incidents there is a significant risk that the trust was missing opportunities toidentify common themes and put actions in place to reduce the risk of them recurring.
• Organisation wide cultural shift to true understanding the importance of incident reporting for all staff– Non clinical– Non nursing– Senior staff
• Blame culture to be minimised
• Accountability and responsibility to be understood and shared across all Clinical and Corporate Divisions
• Dedicated resource to focus on systems and processes
What needed to happen
First wave quality improvement
• Mandatory training in Incident Managementand Risk Assessment – ALL STAFF
• Bespoke Investigation Officer and Risk Management Training developed
• Divisional ownership of all areas of incident management– Performance Management framework– Bespoke liaison with Corporate Team members– High visibility/Maximum Impact interactions
Second wave quality improvement
• Development of Quality Assurance to provide accurate grading of reports (subjectivity)– Corporately– Divisionally
• Managing increased reporting with increased number of SIs– Externally mandated SI reporting (Falls resulting in fracture/HI)
– Enhanced understanding organisationally
• Developing trend analysis– SI groupings– Incident trends
Third Wave Quality Improvement
• Further refinement of SI process (Lvl 0/1/2 SIs) -
• Enhance the process of Duty of Candour compliance in line with NHS Standard Contract (2014/15) and proposed legislation
• Development of training for wider staffing groups for IO roles within the Trust
• Devolvement of Quality Assurance function to Clinical Divisions (as per Divisional maturity)
First & Second stage completion (13 months)
“Raise your quality standards as high as you can live with, avoid wasting your time on routine problems and always try to work as closely as possible at the boundary of your abilities.
Do this, because it is the only way of discovering how that boundary should be moved forward.”
―Edsger W. Dijkstra
Dr. Rim El-RifaiConsultant Paediatrician
Divisional Clinical Director for Women's and Children’s Services
Making Improvement Happen to Turn Around Our Service at BTUH
Alarm raised: Serious Clinical Incidents
• Series of failures leading to death of a child– medication errors, medication out of date– Delay in escalation– Lack of senior medical presence– Lack of nursing leadership– Poor systems and processes– Poor working relationships
• Lack of senior attention and visibility within the division• Culture
• November 2012-January 2013• Diagnostics of the problem• Whole system approach• Real time changes
– Nursing– Medical– Management
• Governance systems• Corporate support,
responsibility and accountability
First External Review of Paediatric Services
Problems flagged
Diagnosis
Action plansimplementation
Outcomes
• Clinical Leadership– Medical– Nursing
• Management structure: Triumvirate– Divisional– Clinical Service Unit
• Governance structure• Staffing
Medical
NursingManagement
Culture: Artefacts
System changes: Listening, Responsive, Caring
• Listen to our patients, carers and staff• New Divisional structure: Clinically led
– Governance– Operational
• HR processes– Recruitment of staff– The right people in the right jobs– Spot and nurture talent– Managing poor performance
• Development and leadership programmes
• We can do it• Patient safety first and
foremost• Parents and carers matter• Staff empowerment• Accountability and
responsibility• Influencing others
Culture: beliefs
Corporate
Division
Medical &
nursing
Patients& carers
Safety
Quality
Value
• Check and Challenge systems• Incident reporting• Guidelines• Learning
– Medical– Nursing– Management
• Trust systems– New governance processes– Senior Management Teams– Trust Board
Change the Language- Change the Behaviours
External engagement
Improved services
Education and Training
Safeguarding
CCG’s engagement
Areas affected by change
Improved safety and quality
PAU
WardPED
Excellent Hospital
paediatric services
Community services
Social Care and Mental
HealthPrimary
care
• Stronger Clinical Service Unit– Learning– Cross fertilisation– New ideas
• Service Developments• Quality Improvements• Market share
• Excellence
The Future: Values-Based
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John WelchConsultant Nurse – UCLH
Margaret-Mary DevaneyImprovement Advisor – UCLPartners
Tracy TurnerClinical Effectiveness Unit Manager
Delivering Quality – Basildon
Wilson AlvaresSenior Nurse - Basildon
Sepsis: What’s The Big Deal?
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Sepsis: what’s the big deal?
Tissue injury
Microvascular coagulation/thrombosis
Organ dysfunction
Death
Mitochondrial dysfunction
Activation of coagulation
Inhibition of fibrinolysis
Endothelial dysfunctionTissue factor expression
Microvascular flow redistribution
Inflammation
Leucocyte activation
Anti-inflammatory mediatorse.g. IL-10, IL-1ra receptor antagonists
Pro-inflammatory mediatorse.g. Tumour necrosis factor, IL-1, IL-6, IL-8, nitric oxide
Pathogen Infection Host responses
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Sepsis: what’s the big deal?
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Sepsis: what’s the big deal?
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NCEPOD Sepsis Study: 2 weeks in May
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Outreach patientsCritical Care Unit
patients
Princess Alexandra 9 9
Royal Free 46 1
UCH 27 7
Whittington 14 8
Total 96 25
Adult patients seen by critical care outreach team
or admitted directly to critical care with sepsis
340
5
10
15
20
25
30
35
1 day 1 week 1 month 3 months
% mortality
≈ 120 000 ward patients referredto Critical Care / Outreach each year≈ three quarters stay on the ward- 60% likely / very likely septic
-fr
om
SP
OTl
igh
t d
ata
(th
an
ks t
o D
r S
Ha
rris
)
1 in 30
1 in 7
1 in 4
1 in 3
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Sepsis: what’s the big deal?
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Sepsis: what’s the big deal?• Organisations need to develop care pathways
• Places outside hospital should ensure staff are trained
• Resources should be allocated
• Sepsis should be included on risk registers
• Improvement work should be supported
• CCGs should commission streamlined care
• Data should be collected on incidence / tx on regional basis
• Guidelines should be developed for coding
• Boards should monitor trends in incidence and care quality
• Professional and academic bodies should assess their
provision of education
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Sepsis: what’s the big deal?
• NHS England: 8 lives to be saved per 100.00 with Sepsis 6
• CQUIN
• JDI: coding
• New definitions, markers from ESICM / SCCM
• more judicious antibiotic therapy
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We can beat this!
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Measuring for Quality Improvement:BTUH approach to sepsis
November 2014
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BTUH Improvement Board
Sepsis Improvement
Board
QI Facilitators
Local champions • Exec lead
• Clinical leads for AE
• Consultants-Critical care, Acute Medicine, AE.
• Consultant microbiologist
• Pharmacist
• Nurse consultant ITU
• Matrons- ED
• Nursing staff ED
• Patient safety team
• CCOT
• User representative
• Clinical Effectiveness team
• Clinical coding
• Information's team
• East of England Ambulance
Aim
Reduce mortality
50 % within 1 year
Severe sepsis
triggers recognised every
time
When triggers
identified pathway started
every time
Whenpathway
started all 6 interventions
delivered within 1 hour
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Measurement plan
Resources:NHS Scotland: QI HUBhttp://www.qihub.scot.nhs.uk/media/340181/2012-06-15_measurement_improvement_journey_process.pdf
Emergency Dept symphony
Clinical effetciveness
team
Infrmations team
Hospital intranet
outcomes portal
Monthly sepsis board
Feedback
ED team
Clinician reviews
10%
Separates admissions
only
Mortality and LOS
Review trends in weekly
data and discuss PDSA
Narrative of data & patient
timelines/ journey
Shared PatientSafety Drive
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Sepsis triggers
observations
Medical review
Prescriptions done
All 6
interventions
done
Pre- hospital alert
Early recognition
MDT : medical emergency
MDT: re-assessment and escalation
Time zero 60 mins
Challenges at each step
Cant always see severe sepsis
Presenting Complaint…. Young people Elderly ‘unwell adult’ ‘collapsed adult’ ‘infection’ ‘pneumonia’ ‘UTI’ ‘Abdo pain’ ‘DIB’ Cancer Tx Post op Post trauma
Changes for Improvement need frontline leadership
Access reliable pathway
Rapid access to sepsis 6
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Measuring Severe Sepsis : Improvement Drivers
0
10
20
30
40
50
60
70
actu
al n
um
,be
rs
Weekly ED Sepsis bundles started
Bundles admitted as in patient Bundles started in ED
Symphony introduced
Pen and paper
Total number 801 Total number 1072
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Measuring Severe Sepsis : Improvement Drivers
QI measurement &Improvement board
Matron post vacant
Feedback board & emails
Grab bags Grab bags
New Matron New Clinical lead Grab bags out of stock
Board rounds
UCL
LCL0
10
20
30
40
50
60
70
80
9th
feb
feb
17th
…
24th
…
31st
…
7rh
april
5th
may
2nd
june
9th
june
16th
23rd
30th
7th
july
14th
21st
28th
4th
aug
11th
18th
25th
aug
1st s
ept
8th
sept
15-S
ep
22nd
sep
t
29th
sep
t
6th
oct
13th
oct
20th
oct
27th
3rd
nov
10th
nov
Improvment sample achieving all sepsis 6 within 1 hour%
Mean 5%
mean 30%
47
Weekly measurement :% achieved sepsis 6 bundle
0
20
40
60
80
10017
th…
24th
…31
st…
7rh…
5th…
2nd…
9th…
16th
23rd
30th
…7t
h…14
th21
st28
th 4th…
11th
18th
25th
…1s
t…8t
h…15
-…22
n…29
th…
6th
oct
13th
…20
th…
27th 3rd…
10th
…
Achieving 02 within 1 hour Median%
0
20
40
60
80
100
17th
…24
th…
31st
…7r
h…5t
h…2n
d…9t
h…16
th23
rd30
th…
7th…
14th
21st
28th 4th…
11th
18th
25th
…1s
t…8t
h…15
-…22
n…29
th…
6th…
13th
…20
th…
27th 3rd…
10th
…
Measured lactate within 1 hour Median%
020406080
100
17th
mar
ch24
th m
arch
31st
mar
ch7r
h ap
ril5t
h m
ay2n
d ju
ne9t
h ju
ne16
th23
rd30
th ju
ne7t
h ju
ly14
th21
st28
th4t
h au
g11
th18
th25
th a
ug1s
t sep
t8t
h se
pt15
-Sep
22nd
sep
t29
th s
ept
6th
oct
13th
oct
20th
oct
27th
3rd
nov
10th
nov
IV Antibiotics given within 1hour Median%
LCL
020406080
100
17th
…24
th…
31st
…7r
h ap
ril5t
h m
ay2n
d ju
ne9t
h ju
ne16
th23
rd30
th ju
ne7t
h ju
ly14
th21
st28
th4t
h au
g11
th18
th25
th a
ug1s
t sep
t8t
h se
pt15
-Sep
22nd
sep
t29
th s
ept
6th
oct
13th
oct
20th
oct
27th
3rd
nov
10th
nov
Blood Cultures taken within 1hour%
0102030405060708090
17th
…24
th…
31st
…7r
h…5t
h…2n
d…9t
h…16
th23
rd30
th…
7th…
14th
21st
28th 4th…
11th
18th
25th
…1s
t…8t
h…15
-…22
n…29
th…
6th
oct
13th
…20
th…
27th 3rd…
10th
…
Fluid challenge Median%
0102030405060708090
17th
…24
th…
31st
…7r
h…5t
h…2n
d…9t
h…16
th23
rd30
th…
7th…
14th
21st
28th 4th…
11th
18th
25th
…1s
t…8t
h…15
-…22
n…29
th…
6th…
13th
…20
th…
27th 3rd…
10th
…
Monitoring Fluid Balance Chart Median%
48
QI measurement &Improvement board
Matron post vacant
Feedback board & emails
Grab bagsGrab bags
New Matron New Clinical lead Grab bags out of stock
Board rounds
UCL
LCL0
10
20
30
40
50
60
10th
feb
17th
mar
ch
24th
mar
ch
1st a
pril
7th
april
5th
may
2nd
june
9thj
une
15th
june
23rd
june
30th
jum
e
7th
july
14th
july
21st
july
28th
july
4 th
aug
11th
aug
18th
aug
25th
aug
1st s
ept
8th
sept
15th
sep
t
22nd
sep
t
28th
sep
t
6th
oct
13th
oct
20th
oct
27th
oct
3rd
nov
10th
nov
% MortalityED pathways started and admitted
%
New Resus Bundlechanged Resus Bundle
Changed Resus Bundle V8
49
Celebrating improving sepsis
50
For more information please contact:
www.uclpartners.com@uclpartners
Thank You
Tom Downes MB BS, MRCP, MBA, MPH (Harvard)Clinical Lead for Quality Improvement, Sheffield Teaching HospitalsInstitute for Healthcare Improvement Fellow21st November 2014
@sheffielddoc
Sheffield Microsystem Academy:Building improvement capacity across a healthcare economy
Why Clinical Microsystems?
Why Clinical Microsystems?
Nurse commenting to Dr Paul Batalden
www.sheffieldmca.org.uk
Cohorts 1, 2 & 3
√n
CoachTraining
Microsystemconditions
Intro QI courses
Networkcommunity
MCA
RHH
S
WPK
JW
OSSCA Spec Med &
Rehabilitation
Diagnostics & Therapeutics
Head & Neck
Emergency Care
Corporate
Surgical Services
Emergency Care
Surgical Services
Spec Med &
Rehabilitation
SYRS
Diagnostics &
Therapeutics
Corporate
Community
Chest Medicine
STH
The Big Room (Oobeya)
Outcome measure: 34% increase in discharge within 1 day
Frailty Unit
opens
Length of stay for frailty unit patients reduced by more than
4 days
Frailty Unit
opens
Balance measure: No increase in readmissions
Frailty Unit
opens
In-hospital mortality dropped by over 13%
Frailty Unit
opens
Discharge to Assess (D2A)
Implem
entation of D
2A
Implem
entation of D
2A
Chest Medicine
STH
‘Leaders should create and support the capability for learning, and therefore change at scale, within the NHS.
I would put this at the top of the list of recommendations.’
A promise to learn – a commitment to actDon Berwick, August 2013
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The next Quality Forum will be on:
Friday 21st March 2015
Thank you for attending today’s Quality Forum
