a new mindset for nhs wales - 1000 lives plus process reviewed as lack of clinical engagement •yg...

BCUHB

A new mindset for NHS Wales

National Learning Event – 11th June 2013

Betsi Cadwaladr University Health Board

Betsi Cadwaladr University

Health Board

Ysbyty Gwynedd

Ysbyty Glan Clwyd

Ysbyty Maelor


Background• We are the largest health organisation in Wales, and are responsible for providing

community, hospital and mental health services, and overseeing primary health care

services, for a population of around 676,000 people in North Wales, together with

providing some services to residents of North Powys and parts of Cheshire and

Shropshire.

• Our services are provided from three acute hospitals (Ysbyty Gwynedd in Bangor, Glan

Clwyd Hospital near Rhyl and Wrexham Maelor Hospital), along with a network of

community hospitals, health centres, clinics, mental health units and community team

bases. We employ c. 16,000 staff. We also coordinate the work of 191 GP practices, and

the NHS services provided by dentists, opticians and pharmacists across the region.

• We are a clinically‐led organisation. Our Executive Team is a mixture of clinical and

management professionals with experience of health systems in the UK and abroad.

Clinical services are delivered by Clinical Programme Groups (CPGs) that bring together

related clinical disciplines and have academic links with a number of Universities in Wales

and England, notably Bangor, Glyndwr and Cardiff. Each CPG is led by a Chief of Staff,

who is either a Consultant or senior health professional


Mortality Review[Betsi Cadwaladr University Health Board]


BCU HB Mortality Review

How many in-hospital deaths have there

been in your organisation in the last 12

months?

0

50

100

150

200

250

300

350

400

450

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

No

Of

Dea

ths

BCU HB - Secondary Care All Hospitals Number of Deaths Period April 2012 - March 2013

No of Deaths Median

0

20

40

60

80

100

120

140

160

Apr-12

May-12

Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

No

Of

Dea

ths

BCU HB - Ysbyty Maelor & Community Hospitals Number of Deaths Period April 2012 - March 2013

No of Deaths Median


How often are mortality reviews

undertaken?

• A review of a sample (20) of all deaths occurs on the Maelor site

– Approximately 500 case notes reviewed Sept 2011 –May 2013 (does not include M&M’s undertaken by specialities and SIR’s)

– Reviewers include both medical and nursing staff

• YGC – sample of deaths taken for mortality reviews; process reviewed as lack of clinical engagement

• YG – mortality reviews undertaken as part of their M&M process


How often are mortality reviews

undertaken?

• Mortality review process reviewed – and a programme of themed reviews is planned.

• Pilot of mortality reviews of patients having died following #NOF. Reviews planned per site following pilot.

• Next area identified as pneumonia


Reporting

• Monthly reports are (and were previously at YGC) submitted monthly to both Hospital Management Teams and Safer Patient Groups

• Mortality reviews and data is discussed at both Q&S and at Board level


Feedback

• Are the findings of your mortality reviews fed back to the staff involved and how is this done?

– monthly reports of themes/areas for improvement are taken to HMT & SPG for dissemination to CPG’s

– Reviews requiring further senior review (due to reviewer concern) have resulted in both individual and organisational feedback and actions


Learning

• What has your organisation learnt so far from the mortality review process?

– Clinical engagement is key to a robust and systematic review process

– Confirmation of issues that require improvement e.g. response to the acutely ill, documentation of DNA CPR

– How communication with the coroner is documented


WalkRounds™[Betsi Cadwaladr University Health Board ]


BCU HB WalkRounds

WalkRound™ 2012-201361 visits completed between

May 2012 – March 2013

(Aim 100)• All Executive Board Members

• Associate Directors

• Chiefs of Staff

0

10

20

30

40

50

60

70

Patient safety leadership walkrounds

2012/2013

cumulative no. of walkrounds

Leadership Team

• Conducted by 2 leads where

feasible (usually Executive and

Independent Member)

• Scribe and discussion supported by

Improvement & Business Support

Team

Visit Structure

• Visits scheduled to patient contact areas

across both acute and community sites

BCU HB WalkRounds

WalkRound™ PROCESS

• Opening & Closing

statements, requiring 2-3 key

issues for action

• Prompt questions, including

understanding of FREDA

principle and use of patient

stories

Staff are asked to consider

impact of the issue to patient

safety, and what steps could

be taken to mitigate any risk

identified

• Summary report provided to

the area within 1-weekOpening / Closing Statement Prompt Questions

Leaders provided standard

documents to ensure

consistency of approach:

BCU HB WalkRounds

WalkRound™ - ANAYLSYS

Theme Analysis

• Key issues categorised and

entered onto SharePoint for

analysis (based on IHI methodology)

e.g.

– Equipment Availability

– Equipment functionality

– Patient Handover

– Communication

Follow-up & Reporting

• Areas are provided 3-months

from receipt and acceptance

of the visit summary, and key

areas for action.

• Individuals responsible asked

to supply an update on

progress.

• Onward reporting and

discussion at Quality & Safety

Committe

BCU HB WalkRounds

WalkRound™ - BENEFIT

Issue Progress Lack of space on the ward as well as the day room remains an issue

due to the increasing population and demand.

De-clutter activity carried out on both ward and day unit areas. Available space utilised to

the maximum efficiency. Plans to extend the day unit are ongoing, working with the

estates department and various charitable funds.

Specialist mattresses used in the unit need to be sent for specialist

cleaning, However the unit is not usually informed by the Laundry

when these mattresses are returned. The consequence is that the

mattresses are often sent to wards instead

Issue resolved having implemented a Specialist Mattress direct returns process

Ward requires increased support for falls work, resources are

required to embed falls pathway and staff need to be released for

training.

Ward based training in falls awareness and the use of the falls pathway has been

facilitated; to continue on a rolling programme. Alongside this, the use of falls information

such as leaflets for patients and families is now available within the ward area – these

have been purchased along with a leaflet holder.

The reporting process has been reviewed; this now enables senior nursing staff to review

the situation and ensure that the falls pathway has been commenced to reduce the risk of

any further incidences. It also supports the accurate reporting and signing off of report.

As part of the transforming care work a ‘location chart’ is being introduced to log where

falls are occurring within the ward environment to highlight ‘hot spots’ from an

environmental perspective.

Due to increased Theatre sessions staff felt under pressure to deliver

the correct care for each patient returning to the Ward after surgery.

Particularly during the evening when several patients return from

theatre at the same time.

Bank availability for trained and untrained nurses has improved.

We have two full time staff nurses completing their preceptorships, this helps covering

sickness and maternity leaves.

All vacancies have been approved by the vacancy control group.

Ward clerk hours have been changed to suit the ward environment.

Lack of linen often results in patients having to bring their linen with

them from the ED

Linen allocation for this ward has been reviewed - issue has been addressed and reported

as closed.

Some examples of improvements made as a direct result of the visit:

WalkRound™ - NEXT STEPS

• Process reviewed to:

– mitigate short notice cancellation by ensuring two ‘leaders’ are able to attend;

2-monthly rolling schedule in operation – previously arranged12-months in

advance.

– Improve communication with CPG management and identified action lead;

this will ensure that issues are addressed and the loop is closed.

• Testing of unannounced visits (one visit held to date, with positive feedback)

• Revisit spread to Primary Care areas (early discussions taken place, specific

tailored structure required)

BCU HB WalkRounds

Improving Mouth Care for

Adult Patients in Hospital

Mouth care is an integral part of nursing

practice. Maintaining good mouth care for

patients in hospital is imperative in

reducing the risk of Health Care

Associated Infection and improving

patient comfort and experience.

BCU HB Mouth Care Programme

Organisational Aim & Objectives

• We aim to improve the experience and

comfort of patients requiring mouth care

– To improve the assessment and

management of mouth care for adult

patients in hospital

– Provide staff with training and resource

information to perform mouth care


Reducing harm

from

inadequate

oral hygiene

and increasing

the proportion

of patients

reporting good

mouth care

experience

Mouth care risk

assessment

Mouth care

plan delivery

Build an

understanding of

the importance of

mouth care as part

of holistic care

All patients assessed using

mouth care risk assessment

tool

Care plans reflect mouth care risk assessment

Toothbrushes and toothpaste available to

patients within 24 hours

Dentures cleaned and stored appropriately

Identify mouth care champions to lead in all

clinical areas

Staff trained to deliver effective mouth care

Engage appropriate departments and staff (include Pharmacy /

medical / dental teams & procurement)

Develop internal support mechanisms with FoC and

Transforming Care leads

– intentional rounding, PSAG boards

Driver Diagram


Progress to date

Training: ‒ Training needs analysis

– Workshops for trained & untrained staff

– Identification of mouth care champions

– Training programme for student nurses


Snapshot of Pre and Post Training Analysis

Could you carry out the appropriate treatment of the following oral

conditions?

0

10

20

30

40

50

60

70

80

90

100

% A

nsw

erin

g "Y

es"

Students

Pre Training

Post Training

0

10

20

30

40

50

60

70

80

90

100

% A

nsw

erin

g "Y

es"

Nurses

Pre Training

Post Training


Progress cont/d…

Development of:‒ User friendly care plans

‒ Resource pack

‒ Referral pathway

‒ Patient information leaflet

‒ Centralised share point for nursing staff to access

resource pack and patient leaflets and ad hoc

information


Progress cont/d.....- Mouth care bundle piloted on 3 wards

- Initial data collected via nursing care metrics

Snapshot of initial data collected

Mouth Care Assessment: Morfa Ward

0

20

40

60

80

100

Aug-12 Sep-12 Oct-12 Nov-12

Pe

rce

nta

ge

Co

mp

lia

nc

e

Mouth Assessment Mouth Care Plan: Morfa Ward

0

20

40

60

80

100

Aug-12 Sep-12 Oct-12 Nov-12

Perc

en

tag

e C

om

pli

an

ce

Mouth Care Plan


What next?

- Further workshops arranged

- Maintain momentum through excellent

staff engagement

- Increase the speed of spread across



Debbie Murphy & Julie Parry

Improvement & Business Support Team

Discharge Drop In Sessions

Discharge Drop In Sessions[Betsi Cadwaladr University Health Board ]

Purpose of the Drop

in sessions• Raise awareness and

share knowledge

• Provide updates on key

changes

• Opportunity to share good

practice, ideas, concerns,

problems, challenges

• Make improvements

• Receive expert support


Why is there a need for the

Discharge drop in

sessions?


Staff Report;

• Confusion about aspects of discharge i.e different

processes, access criteria to community teams etc

• Limited knowledge on basic discharge planning, for

both simple and complex cases.

• There is a lack of training and education on discharge

All of these affects efficiency of discharge planning

Session format• Issue log - group discussion

where issues are raised, and

possible solutions discussed.

When appropriate, issues are

escalated to relevant

managers/forums

• Topic of the week – examples of

good practice is shared, MDT

members provide guidance

• Information provided on new

developments and changes

relating to discharge


Topics covered over 14 weeks

• Quality of referrals/assessments

• When is the patient ‘fit for discharge’?

• Paperwork, duplication, time

• The Transfer lounge

• Continuing Health Care cases

• Facilitating MDT meetings

• Social work timescales

• Predicting Date of Discharge

• Patient Involvement

• Unsafe discharge

• The role of the nurse: Decision making

• Referrals to Social services

• Community hospital transfers

• Problematic discharges


Attendance• 138 attendances over 14 weeks

• Between 7 and 17 attendees at each session

• Those who attend include nurses (district nurses, ward

staff and community nurses), student nurses,

occupational therapists, physiotherapists, social workers,

student social workers, The Red Cross, discharge liaison

team, support workers, medical students

• There is a commitment from Improvement & Business

Support team, Discharge Liaison team and Conwy Social

Services


Evaluation results


Evaluation results


When asked what they found useful about the Discharge drop in sessions,

here were some of the answers that the respondents gave:

• ‘being able to share experiences with other staff’

• ‘learning new information regarding policies and procedures’

• ‘being able to discuss best practice issues with MDT members’

• ‘being able to problem solve and begin to find solutions to improve

discharge’

• ‘the informal atmosphere assisted with engagement’

• ‘I now have a better understanding of other people’s role in the discharge

process and can see things from their perspective’

• I am now aware of the need to provide further information on the nursing

assessment’

Feedback on Drop in

sessions


Improvements

emerging from the

Drop in sessions

Improved communication

•Staff are now receiving regular

updates on key changes relating

to discharge


Improvements

emerging from the Drop

in sessionsPeople are coming up with

new ideas for improving the

discharge process

The Red Cross have suggested that a

volunteer could spend a few hours each

day in the Transfer lounge. The

volunteer will provide company to

patients, run errands, collect medication

etc, allowing the nursing staff more time

to concentrate on discharging patients

More education on discharge

available for student nurses


Student nurses receive basic education

or training on discharge planning – they

requested more knowledge.

Training sessions are now available for

third year students at Bangor and

Glyndwr universities

Improvements

emerging from the

Drop in sessionsImprovement work is being undertaken

• Standardisation of Social

Services referral process.

The current process is a

longstanding source of

confusion amongst nursing

staff


• A Traffic light discharge system

is due to be piloted. The aim is

to make it easier for staff to

identify if the patient’s

discharge is simple,

intermediate or complex

Lifestyle Programme

Lifestyle Programme[Betsi Cadwaladr University Health Board ]

What is the Life Style Programme? • The prevalence of overweight and obesity in Wales is

57% of which 21 % are obese.

• This program will support and deliver a weight management and exercise programme for adults with a BMI of 35 or over that may require a hip or knee replacement.

• Also designed to reduce the need for knee/hip replacement when weight is reduced (estimated at 20% of total).

• The programme is jointly run by BCULHB and The National Exercise Referral Scheme (NERS)

• Supported by Dieticians, Exercise professionals and Physiotherapist.

NERS team. Cathy Wynne. Steven Grayson

Why ?• Ensure that individuals are in optimal condition

to undergo surgery if needed

• Improve strength, mobility, coordination and balance

• Improve health and well being

• Reduction in the risk of post operative complications

• Links into a healthier lifestyle

• Ensures efficient and effective use of public resources


NERS Team. Cathy Wynne. Steven Grayson

Patient Leaflet

BMI

<35*

CMATS

High Pain &

joint

destruction

High Pain

and

moderate

destruction

Low pain

moderate

joint

destruction

Orthopaedics

Injection

8 weeks

Weight and Dietetics

Eva

luat

ion

Public

AwarenessLink to Literature

search

Severe

Pain score

& severe

Functional

limitations

Lifestyle

Programm

e

16 weeks (L4) Condition specific. Physio 1;1.

Aqua-cise. Group exercises

16 weeks (L3) NERS

16 weeks (L4) Condition

specific

Pain Score - Classification

of pain level and functional

limitations tables.

BMI

>35

* Or artificial BMI affected by

large muscle bulk i.e.

sportsmen / women

Discharge /

Active

Monitoring

GPPatient

Low

Pain score

low

function

limitation

Lifestyle programme

Physiotherapy Triage

Lifestyle Hip and Knee pathway

Results Nov 2012- April 2013


0

100

200

300

400

500

600

700

Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Lifestyle Programme Monthly AttendancesNovember 2012 to March 2013

10

20

30

40

Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Patients Entering Lifestyle ProgrammeNovember 2012 to March 2013

Hip Knee

Enhaned Recovery After Surgery

Enhanced Recovery After Surgery[Betsi Cadwaladr University Health Board ]

Progress Score

Programme West Centre East

Orthopaedics 3 4 8

Colorectal 4 5 5

Spread areas:

Gynaecology 2 NA NA

Upper GI NA NA 2

Enhanced Recovery After Surgery


- Colorectal

Progress

• Voluntary Organisation involvement

at Patient Education Groups (Centre

and East)

• Patient Education Film in production

• Reduced total length of stay since

introduction of ‘school’ at East site

• Information dashboard in place

• ‘ERAS Champion Nurse’ identified

• ERAS Integrated Care Pathway in

development (all sites)

• Programme re-launch at West site

• Web-based information site in

development

Challenges

• Engagement with Primary Care

• Variability in clinical approach

• Staffing issues – Ward and

Physiotherapy in particular

• Data collation and entry



- Orthopaedics

Progress

• Continued reduction in average length of

stay observed across sites

• Informational dashboard in place

• Patient Education ‘Joint School’

involvement of patient representative,

excellent feedback

• Patient Education Film (knees) in post

production

• Cost benefit analysis – Joint School

attendance: Total saving £41,105.56 over

4 years (Wrexham Maelor Hospital)

• Web-based information site in

development

• Increased Joint School sessions (East)

Challenges

• Clinical variability and programme

uptake

• Physiotherapy – low staffing

• Slow progress at our West site;

plans in place to review and

recommence

• Data collation and entry


Median Length of Stay – Colorectal

(all sites)Key:

West

Centre

East


CHKS dataset

Length of Stay – Colorectal

(Wrexham Maelor site)

Reduction in length of stay – 1 day since introduction of ‘School’ Feb 2012

Average Length of Stay Knees

– All Sites

CHKS dataset (ALOS)

Key:

West

Centre

East


Spread Areas

Enhanced Recovery After Surgery - Spread

Gynaecology

• Ysbyty Gwynedd is the primary

location for major Gynaecological

Oncological surgery in North Wales

• Many elements of the ERAS Gynae

pathway are beginning to be

implemented with a full roll out

anticipated by November 2013

• A single Integrated Care Pathway for

all major Gynaecological surgery is

in development and is anticipated to

be in use for all patients by

November 2013

Upper GI

• Wrexham Maelor Site is the primary

location for major GI surgery in the

North Wales area, extending to the

North West

• All elements of an ERAS GI pathway

are in place with the exception of

pre-operative nutritional

supplements (discussion ongoing re

benefit of immunonutrition vs.

Carbohydrate loading)

• A single Integrated Care Pathway for

all major GI surgery has been

drafted and is under consultation

Reducing Harm from Falls in the

Community

North Wales Falls Prevention

Service Model[Betsi Cadwaladr University Health Board ]


Why Falls?

Why Falls?

• Over a third of people aged 65 or over fall each year increasing to 45% for the over 80s, and 60% of people living in residential homes will fall repeatedly

• Link with an increased fear of falling, which has an impact on mental and social well-being

• 10-20% of falls cause serious injuries such as fractures or head injury; the most common serious injury being a fractured neck of femur (hip fracture)

• Half of hip fracture survivors fail to regain their pre-fracture level of independence. 7% die within a month of injury, 25% die within the following year

• Estimated cost of a single hip fracture £25,424*; annual cost (including medical and social care) for all UK hip fracture cases is approximately £2 billion (NICE, 2011)

*The Economic Cost of Hip

Fracture in the UK – University of York (2000)

The Good News

• Falling is not an inevitable part of ageing

• Evidence for interventions to reduce the risk of falling and subsequent injury – ‘consider the faller, not the fall’

• Increasing importance of a healthy lifestyle as we move into older age

• A contribution to be made from all services, older people and their carers

• Development of a North Wales Falls Prevention Service Model, with an emphasis on prevention, early intervention, and maintenance of gains in all settings

• Taking a positive approach to ageing well – focus on the things that help maintain and improve physical, mental and social wellbeing, which also have an impact on reducing the risk of falling

North Wales Project

• Multiagency – led by Betsi Cadwaladr University Health Board

• Evidence base & current good practice – focus on prevention and early intervention in all settings

• Objective – develop an evidence based falls prevention pathway (service model) for older people living in their own home, those living in care homes, and those who are in community or acute hospital care

• Implementing the pathway regionally will be a phased approach going forward

Project Structure – 3 settings

Older people

(65+) living in

their own

home

Older people

in a

Community

or Acute

Hospital

Older people

living in a

care home

Prevention & Early Intervention –

Ageing Well

Population aged 50+

Evidence Based Action

Older people

in Acute &

Community

Hospital Care

Older

people

living in a

Care

Home

Next Steps

• Following the launch of the approved Service Model, implementation will be a phased approach over time.

• There will be different challenges across the region, and it will take time to influence the shape of local services to more closely match the Service Model.

• This will require strong leadership and effective collaboration across partnerships, along with ongoing engagement with older people, their families, and their communities.

Contact

• If you would like further information in relation

to the Falls Prevention Service Model please

contact:

Leah Williams – Service Improvement Facilitator

01978 726148

[email protected]

mailto:[email protected]

a new mindset for nhs wales - 1000 lives plus process reviewed as lack of clinical engagement •yg...

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