Annual Report and Accounts 2012/13 - Royal Bournemouth Hospital

Quality Reportl New criteria for heel lift suspensionboots implemented and additionalfunding provided to support roll outl New nursing reviews anddocumentation (called care rounding)developed to record 2 hourly wardroundsAction plan priorities for 2013/14l Roll out of new standardoperating procedures and nursingdocumentationl Increase in ward based trainingl Competency standards to be agreedfor risk assessment documentationl Routine documentation audit to berolled out as part of NHS SafetyThermometer data collectionl Continue pilot of Tissue Viability wardroundsl Clinical leader wards rounds to be fullyestablished and monitored (Standardoperating procedures and auditplan to be implemented to supportcompliance)l Mattress availability to be reviewedby Equipment Library (pilot of trackingsystem to be implemented in 2013/14)Inpatient fallsLess than 1% of hospital inpatientssurveyed (6941) using the national NHSSafety Thermometer tool in 2012/13 hada fall resulting in harm whilst admitted tohospital. 99% of patients surveyed hadharm free care.Quality improvements in yearl Reduction in serious falls in yearl Falls training now part of mandatoryclinical training and inductionl E-learning and in house filmsproducedl Falls Strategy Group enhanced withmembership now including Dementialeads for the Trust, allied healthprofessionals, representatives fromall clinical directorates and RiskManagement team members.l Risk assessment complianceimproved in yearl Slippers provided to all patientsassessed at high risk of fallsl Walkrounds with Dementia lead andEstates established. Action plansin place to improve environment forpatients at riskAction plan priorities for 2013/14l Business case for protected timefor ward link staff to support FallsPrevention Strategyl Routine environment audits plannedwith Estates and Dementia leadl Competency standards to be agreedfor risk assessment documentationl Focus on actions to reduce repeatedfalls in patients and falls at nightl Routine documentation audit to berolled out as part of the NHS SafetyThermometer data collectionNew hospital acquired venousthromboembolism (VTE)Less than 0.5% (0.45%) of hospitalinpatients surveyed using the nationalNHS Safety Thermometer tool in 2012/13had a new hospital acquired venousthromboembolism (a “blood clot”) duringadmission. This compares to a nationalacute trust average score of 1.17%.Quality improvements in yearl Local clinical leadership establishedbut gaps in awareness of the need toreport hospital acquired VTE remain(focus for 2013/14)l VTE risk assessment complianceimproved to average/month of 93%(national and local target for 2012/13was 90%)l Reduction in VTE readmissionsl Decrease in number of hospitalacquired VTE root cause analysisinvestigations required in yearl Only 1 preventable hospital acquiredVTE in yearAction plan priorities for 2013/14l Improve risk assessment complianceto the national target of 95%62Annual Report and Accounts 2012/13