Paper 06 - NHS Ayrshire and Arran.

NHS Board Meeting
10 August 2011 Paper 6
NHS Board Meeting
Wednesday 10 August 2011
Subject
Continuous Clinical Improvement
Purpose
Recommendation
To update the NHS Board on the work of the
Continuous Clinical Improvement Board (CCIB)
To consider the work that is being undertaken
by the CCIB across priority areas and identify
issues that should be considered to further
support and/or strengthen the plans that are in
place to deliver the improvement aims
1. Background
1.1 NHS Ayrshire and Arran is committed to aligning all current quality and clinical
improvement activity in support of the delivery of the NHSScotland healthcare
quality ambitions:
• Mutually beneficial partnerships
• No avoidable injury or harm in a clean safe environment
• Appropriate care, treatment and interventions without wasteful or harmful
variation.
The Healthcare Quality Governance and Standards Unit and Clinical Improvement
Unit are encouraged by early signs of increased capacity and capability to provide
regular reports on progress to measure and monitor the delivery of these within
NHS Ayrshire and Arran. As described in the NHS Board paper of the 11 May, all
Continuous Clinical Improvement Priorities fit within the 3 Quality Ambitions.
2. Current Situation
2.1 At the meeting of 14th June the CCIB reviewed the progress made by the 5 Clinical
Improvement workstreams over the last year and took time to discuss and debate
future work and meeting format. It was agreed, following review, that new
approaches would be taken both to the direction of some workstreams and to
improve the structure of the meetings to ensure more constructive debate and
involvement of the wider group to agree actions and direction. This will be
described in the appropriate workstream sections of the paper.
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2.2 The latest adjusted Hospital Standardised Mortality Ratios (HSMR) public release
was on 31st May 2011. (p denotes provisional release).
Jul-Sep 2010
Oct-Dec 2010 (p)
Ayr Hospital 0.91 1.02
Crosshouse Hospital 0.91 1.02
1.40
NHS Ayrshire & Arran: Ayr Hospital.
Hospital Standardised Mortality Ratio (HSMR) - Adjusted
to Oct-Dec 2010p (p denotes provisional)
1.20
1.00
Local Mean = 1.08
0.80
SMR
0.60
0.40
0.20
- - - National Target 15% reduction from Baseline Period = 0.92
0.00
___ Local Target 30% reduction from Baseline Period = 0.76
Baseline Period
Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun
2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009
Jul-Sep
2009
Oct-Dec
2009
Jan-Mar
2010
Apr-Jun
2010
Jul-Sep
2010
Oct-Dec
2010p
Month (quarters)
NHS Ayrshire & Arran: Crosshouse Hospital.
Hospital Standardised Mortality Ratios (HSMR) - Adjusted.
to Oct-Dec 2010p (p denotes provisional)
1.40
1.20
Local Mean = 1.15
1.00
0.80
SMR
0.60
0.40
0.20
Baseline Period
- - - National Target 15% reduction from Baseline Period = 0.98
___ Local Target 30% reduction from Baseline Period = 0.80
0.00
Oct-Dec
2006
Jan-Mar
2007
Apr-Jun
2007
Jul-Sep
2007
Oct-Dec
2007
Jan-Mar
2008
Apr-Jun
2008
Jul-Sep
2008
Oct-Dec
2008
Jan-Mar
2009
Apr-Jun
2009
Jul-Sep
2009
Oct-Dec
2009
Jan-Mar
2010
Apr-Jun
2010
Jul-Sep
2010
Oct - Dec
2010p
Month (Quarterly)
Data Release Dates: The latest monthly unadjusted mortality data are for April
2011, a value of 4.03% for Ayr Hospital and 2.43% for Crosshouse Hospital. The
data for May is currently unavailable due to Patient Management System (PMS)
developments.
Targets: National and local targets were calculated from October 2006 to
December 2007.
National Target (15%) Local Target (30%)
Ayr Hospital 2.9% 2.4%
Crosshouse Hospital 2.5% 2.1%
The national target is a 15% reduction and the local target is a 30% reduction for
2012.
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5.0
4.5
Baseline Mean = 3.4%
Oct 06 - Dec 07
NHS Ayrshire & Arran: Ayr Hospital.
Unadjusted Inpatient Mortality.
to April 2011
Mean lines change in relation to shifts in run chart
Apparent Seasonal Variation is
currently being reviewed
4.0
3.5
3.0
%
2.5
2.0
1.5
1.0
0.5
Baseline Period
National Target 15% ____
Local Target 30% _ _ _
0.0
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
Month
NHS Ayrshire & Arran: Crosshouse Hospital.
Unadjusted Inpatient Mortality
to April 2011.
5
4.5
Baseline Mean = 3%
Oct 06 - Dec 07
Median lines change in relation to shifts in run chart
4
3.5
3
Increased service
pressures
% 2.5
2
1.5
1
0.5
Baseline Period
National Target 15% ____
Local Target 30% _ _ _
Awareness
Training
Back to Basics. ERT
& Coding
Improvements
Implemented
0
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
Month
Comment on Results:
Adjusted mortality data continues in a downward change from the baseline period.
This is seen as a -9.2% change at Ayr Hospital and a -16.5% change at
Crosshouse Hospital.
Change in HSMR over time in Scotland and Ayr and Crosshouse Hospitals during the
quarter Oct-Dec 2010 (p).
Area
SMR
Overall trend
at Oct–Dec
Overall
change since
Average change per
Quarter
2010 Oct-Dec 2007
Scotland 0.97 0.94 -6.0% -0.5%
Ayr Hospital 1.02 0.93 -9.2% -0.8%
Crosshouse Hospital 1.02 1.00 -16.5% -1.6%
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Unadjusted mortality data for Crosshouse Hospital are showing significant
decreases from July 2009 to November 2009. During this time there was
considerable communication and awareness raising in relation to HSMR and the
potential causative factors identified during the HSMR review. From February 2010
to November 2010 there is a further reduction relative to the mean rate. This
coincides with the spread of implementation of the ‘Back to Basics’ programme
from December 2009. Seasonal variation is apparent over the winter months due to
severe weather resulting in increased service pressures and is being reviewed.
Discharge Letters: A group led by a consultant is looking at improving the time
discharge letters are produced. This would enable coding staff to code more
effectively and improve the quality of HSMR data reported externally to Information
Services Division (ISD). Two new software systems have the capability of
supporting this improvement – Patient Management System (PMS) and Digital
Dictation System.
Coding: Each month a random sample of the closed notes of 5 patients who have
died will be reviewed by the Associate Medical Director (AMD) to code the
discharge diagnosis. The results will then be compared to the codes sent to ISD to
assess the level of coding accuracy. As the time to production of discharge letters
improves, it is expected that improved accuracy in coding will be demonstrated.
Back to Basics: This is a programme to support the implementation of a range of
care processes to enhance the delivery of reliable and safe care (e.g. structured
formats for communicating clinical information to support care decision making and
delivery). Improvement interventions are being spread to continue this reduction
and progress towards the local target.
Crosshouse Hospital (excluding maternity and paediatrics)
ERT Activity per 1000 OBD
ITU Outreach per 1000 OBD ERT Calls per 1000 OBD P.A.R. Assessments per 1000 OBD
26.00
24.00
22.00
20.00
ERTActivity per 1000 OBD
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11
Month
Emergency Response Team (ERT): The ERT has now been in place for 10
months. The graph above demonstrates steady numbers in relation to ERT calls to
provide assistance with patients who have deteriorated suddenly. The numbers of
patient at risk assessments carried out as a result of ward trawls by the team have
reduced. The team however identify an increase in informal calls and speedy
escalation to the ward medical team when a patient shows signs of deterioration.
The Advanced Nurse Practitioners (ANPs) have commenced collecting data in
relation to the informal calls and interactions and this will be included in the overall
measurement as soon as a reliable process is agreed for collating the data.
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Patient Case Note Review
Patients with a predicted probability of death

• The quality of nursing record keeping
• Assessment of falls risks and implementation of appropriate actions to
reduce risk
• Implementation of the Guideline for the Clinical Management of patients with
actual and suspected head injury No. 90.
Improvement actions to date have included:
• Sharing learning from Significant Adverse Event Reviews (SAERs) within
the area, and at Charge Nurse and Clinical Governance meetings
• Education of Charge Nurses re consequence scoring escalation and
procedures
• Reviewing nursing management of patients at risk of falls – deployment of
staff, safety briefs, risk assessment and record keeping
• Falls Clinical Quality Indicator implemented and consistently > 95%
• Audit of nursing records demonstrates improvement
It has been agreed to provide dedicated clinical improvement practitioner resource
to support the required improvement interventions.
Work has also been undertaken in relation to pressure ulcers with the aim of
reducing pressure ulcers within the test areas (Ward 2a and Station 16) by 50% by
December 2011. Similar challenges to those mentioned above for falls have been
identified including; identification, classification and recording of pressure ulcers,
the use of Datix to report pressure ulcers, the development of a care bundle and
documentation, record keeping and guidelines.
2A Days between PU incidence
Time betw een events
120
100
80
60
40
20
0
3/1/11
3/23/11
3/28/11
4/5/11
5/11/11
Date
5/31/11
100%
80%
60%
40%
20%
0%
4/15/11
2A Compliance with SSKIN bundle
4/20/11
4/27/11
5/17/11
5/27/11
Date
5/31/11
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
3/2/11
Stn 16 Compliance with SSKIN bundle
3/10/11
3/31/11
4/8/11
4/12/11
4/27/11
5/6/11
Date
5/12/11
5/17/11
number of days
200
150
100
50
0
Stn 16 Days between PU incidence
45
25
0
11/1/10
11/26/10
1/9/11
date
5/31/11
142
Experience to date in the test wards has shown that the most valuable measure is
the number of days between development of a new pressure ulcer on the ward.
Compliance of the application of monitoring the pressure ulcer care bundle is also
being measured.
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(SSKIN; this care bundle ensures screening is undertaken, the surface the patient
is laying on is appropriate and not creating problems, the patient is kept moving to
reduce areas of maximum pressure, incontinence is managed and skin is kept dry,
and that the patient is nutritionally stable.)
Whilst the data above in relation to days between pressure ulcer incidences looks
encouraging, it does not pick up patients who are admitted to the ward who already
have a pressure ulcer or where they got it. Further work needs to be undertaken in
relation to the measurement system in order to identify this and track patients to
ensure appropriate care management is commenced and continued.
Through the endeavour of both workstreams it has been identified that falls and
pressure ulcers require similar essential elements of care to formulate care
bundles. It has also been identified that nutritional care elements are also essential
for both care bundles. The co-dependency of essential elements of care makes it
difficult to deliver elements of care in the isolated way that is currently happening
and makes care delivery cumbersome for staff involved.
2.4 Medicines Management
The graphs above demonstrate medicines reconciliation (MR) for the test sites in
Ayr and Crosshouse. (MR is the process of obtaining an up to date and accurate
medication list that has been compared to the most recently available information
and has documented any discrepancies, changes, deletions and additions) The
benefits of MR include;
• reducing prescribing errors
• reducing hospital admissions and re-admissions due to harm from medicines
• reducing the number of missed doses and improving the quality and timeliness
of information available to clinicians, thereby leading to improved therapeutic
outcomes
• Increasing patient involvement in their own care promoting better concordance
and reducing waste
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The results in the test site at Crosshouse have improved dramatically as the test
site is enriched due to the fact that there is a pharmacist in this area who
undertakes the reconciliation of medicines. The reconciliation process at Ayr
continues to be unreliable with signs of deterioration. Clinical leads are working
hard to identify issues, develop solutions and have identified that the Emergency
Care Summary (ECS) may present part of the solution.
The ECS is a summary of basic information about the patients health which might
be important when the patient needs urgent medical care when the General
Practitioner’s (GPs) surgery is closed, or when the patient goes to an Accident and
Emergency (A&E) department. The summary provides information regarding
current medication that has been prescribed by a patient’s GP and can act as one
of the two sources required for MR.
Currently the trainee doctors do not all access the ECS, making MR much more
difficult. The reasons for the lack of access by trainees are; ECS access is given no
priority in relation to medical induction and there is a subsequent poor uptake of
ECS training which must be undertaken to use the system; junior medical staff are
a rotational work force. They require to be trained and given passwords for ECS
when they enter employment with NHS Ayrshire and Arran. This is irrespective of
previous training and access in other Scottish Health Boards.
2.5 Safety Culture Work
Staff working with Maternity Services were asked to complete the Pascal Metrics
Safety Attitudes Questionnaire (SAQ). The SAQ is a psychometrically validated
tool for measuring patient safety culture using seven dimensions; teamwork
climate; safety climate; job satisfaction; stress recognition; working conditions;
perceptions of senior management and perception of local management.
In line with Pascal Metrics methodology, maternity staff were grouped into nine
distinct cohorts of staff who worked together in a work setting The safety culture
survey has now been completed for the maternity unit with a response rate of 62%.
Initial feedback has been delivered to over 200 staff by Michael Leonard of Pascal
Metrics.
Senior clinical leaders from the organisation have participated in a 2 day
conference with Pascal Metrics and senior leaders throughout the United Kingdom
to better understand the survey, how to brief staff of the results for their area and
how to identify safety issues and develop improvement plans.
3. Proposal
3.1 To continue with the ‘suite’ of actions outlined in this report and maintain
momentum and clinical engagement in relation to reduction of HSMR. Progress will
continue to be monitored and the data will be used to identify when the
interventions made have resulted in improvement and to allow improvement work
to be refocused as required to meet the target of a decrease of 30% by 2012. The
HSMR Steering Groups and CCIB will to continue to determine actions to support
the meeting of these targets.
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3.2 Following lengthy discussion and debate it has been agreed that the workstreams
should be merged to develop an essential elements of care bundle that would
address the falls, pressure ulcers and nutritional care. The approach favoured to
take this forward would be an intentional rounding approach using a checklist to
deliver all elements of essential care, reduce risk and improve outcomes. Further
work will be undertaken and a proposal brought to the August meeting of CCIB for
approval.
3.3 To address the issue of MR through the use of ECS, CCIB reached the following
agreement: when a patient presents to the Emergency Department (ED) as
unscheduled patient an additional question would be added to the list of questions
currently asked by the ED clerk “Do you consent for access to your ECS?” (N.B.
This is a routine question for all patients phoning NHS 24).
The triage nurse would then print the ECS along with the ED yellow card (if access
had been permitted).
The medicine information included in the ECS would be relevant for ED staff
assessing and treating all patients irrespective of whether a patient is discharged
from the ED or admitted to a ward. If a patient is to be admitted to a ward the ECS
would be transferred with the patient by ED staff along with the patient’s clinical
notes.
This would ensure a standardised process is in place for all unscheduled patients
admitted to wards irrespective of speciality.
3.4 Clinical and managerial staff from maternity services have agreed that a Maternity
Quality Improvement Team (MQIT) will be convened to oversee the culture work.
Detailed results of the survey will be delivered to the individual clinical cohorts
within the maternity service by the Assistant Directors Clinical Improvement and
Healthcare Quality and the Organisation Development Lead. At the end of the
process each of the clinical cohorts will identify their own clinical improvement
interventions and a Clinical Improvement Practitioner will be assigned to support
the teams to take the work forward. The timescale as recommended by Pascal
Metric for the debriefing and improvement intervention planning will be completed
by 27 December and whilst this may appear prolonged, it is imperative that the
work is progressed by gaining the maximum involvement of the cohorts. It has also
been agreed that a capacity building event will be held in the autumn to provide the
MQIT and key clinical cohort leaders with key skills in the science of patient safety
and quality improvement.
The MQIT will report progress to the group chaired by the Executive Nurse Director
to progress actions arising from the Royal College of Obstetricians &
Gynaecologists (RCOG) report.
Following intensive review of the safety culture requirements for maternity services,
careful consideration will be given to the roll out of the programme across other
clinical areas. This will be debated at the CCIB meeting on 16 August 2011.
4. Engagement and consultation on development of the proposal
4.1 The content of this report is a reflection of discussions between staff in the
Healthcare Quality, Governance and Standards Unit and Clinical Improvement
Unit. It also reflects discussion within the CCIB.
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5. Resource implications and identified source of funding
5.1 All of the proposals within this paper will be delivered within existing resources,
taking account of the need to deliver cash releasing efficiency savings.
6. Risk assessment and mitigation
6.1 Systems, processes and structures are being implemented to ensure that all known
risks to the delivery of the quality ambitions are being mitigated.
7. Impact assessment and consequential changes proposed to mitigate adverse
impacts identified
7.1 This is an internal document that does not require impact assessment.
8. Conclusion
8.1 Development of a revised CCIB meeting structure and format will facilitate wider
discussion, debate and action planning.
8.2 The Adjusted HSMR data continues to demonstrate a downward change from the
baseline period - a -9.2% change at Ayr Hospital and a -16.5% change at
Crosshouse Hospital. Given the ongoing reduction, the changes to practice will
continue to be monitored and the development of the HSMR group at Ayr Hospital
Site will facilitate the implementation of the suite of actions within this care setting.
8.3 A proposal will be tabled at the August CCIB meeting to describe the merger of the
falls, pressure care and nutritional care workstreams into essential elements to
provide a checklist to support a care bundle approach.
8.4 The MR results in Crosshouse have improved due to the input of a Pharmacist,
however Ayr results continue to be unreliable. It is anticipated that the roll out of the
ECS will address some of the reliability issues. Improved access to ECS by junior
doctors will also form part of the solution.
8.5 A MQIT will be convened to oversee the Patient Safety Culture work. Detailed
results will be provided to individual cohorts in order to identify their clinical
improvement activity. Following review of this work roll out of the programme will
be considered for other clinical areas.
8.6 This report identifies that progress continues to be made across the CCIB
workstreams. Clinical leads continue to be supported. Capacity and capability
building for Clinical Improvement and Healthcare Quality is planned for the autumn
and will aid future progress and reduce person dependence in some areas.
Robert Masterton, Executive Medical Director
Fiona McQueen, Executive Nurse Director
[Craig White, Diane Murray]
19 July 2011
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