Paper 02 - NHS Ayrshire and Arran.

Sustained improvement relates to run chart rules and a requirement to evidenceimprovement with nine data points travelling in the desired direction.In order to achieve an assessment of 3.5, the local programme is required toevidence sustained improvement in process and outcome measures for pilotpopulations across all five workstreams with spread of all key changes underwaybeyond the pilot populations.Achieving this level of reliability for all measures in all workstream pilot sites hasbeen challenging and has required the clinical teams to test a number of differentapproaches using improvement methodology to continuously learn and driveimprovements in clinical processes. Spreading the improvement work to otherpopulations beyond the pilot sites is evident with a number of clinical teamsadopting the changes, testing approaches to achieve reliable process andmeasuring performance as part of the improvement journey. Spread has beenparticularly successful in the general ward workstream using Back to Basics. Usingthe Back to Basics approach, Clinical Improvement Practitioners work in the wardswith clinical staff to directly support the implementation of clinical changes thatresult in improvements in process and outcome.It has been agreed that a comprehensive plan for spread across the whole systemwill be developed and reported to the Clinical Governance Committee.2.2 The SPSP has been developing and growing significantly over the past 12 monthswith the introduction of the Paediatric Programme in 2011, commencement of theannual Board on Board events and the launch of the Sepsis/Venous ThromboEmbolism (VTE) collaborative in January of this year. There are three furtherprogrammes under development nationally and these are expected to beintroduced over the next twelve months; Mental Health, Maternity and PrimaryCare.2.3 HSMRThis breadth of patient safety improvement programmes, and the increasingnumber of clinical teams involved, needs to be adequately supported by theClinical Improvement Unit (CIU) to ensure that the clinical teams involved in theimprovement work are supported to deliver the desired outcomes.NHS Ayrshire & Arran is making good progress with SPSP measures in the pilotsites, all bundles and processes are being tested, implemented and spread asappropriate. There are noted variable processes of compliance in some of the pilotsites that have required a better understanding of the data by staff in order toachieve reliability.The HSMR data released in February 2012 for the period April – June 2011,demonstrates a 24% reduction for Crosshouse Hospital and an 11% reduction forAyr Hospital. This data does come with the caveat that it may need to be revisedas the submission was incomplete, this is as a consequence of the implementationof the Patient Management System (PMS). The next data release is expected inMay 2012 and the Board has submitted all information required to generate HSMRdata, any necessary revisions in the April – June 2011 data will also be producedat this time.2 of 8