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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
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!