Northampton General Hospital NHS Trust Quality Account 2016-2017

Recommendations

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We said we would: Reduce Avoidable Harm from Failures in Care: Falls with Harm What we achieved: What: To reduce moderate, severe and catastrophic falls/1000 bed days How Much: Reduction of 0.02 moderate, severe and catastrophic falls/1000 bed days and maintain rates below the Royal College of Physicians (RCP) national threshold of 0.19 moderate severe and catastrophic falls/1000 bed days When by: 31 st March 2017 Outcome: In the year to date: The Trust has reduced the rate of moderate, severe and catastrophic falls/1000 bed days by a mean average of 0.03. The Trust has consistently remained below the RCP national threshold up to the year to date. Over the last year the Inpatient Falls Prevention Team have focussed on best practice and developing care plans to reduce each patient’s risk of a fall. A trust-wide quality improvement project on Lying and Standing Blood Pressure was commenced which included: A trust wide audit of availability of manual sphygmomanometers and stethoscopes - all wards now have these. Lying Standing Blood Pressure guidelines have been reviewed, updated and new laminates are available on all wards as part of the SilverLinks folder and are available on the intranet. A Lying Standing Blood Pressure workshop was held as part of a Frailty seminar as well as continuing ward based training. To improve Staff knowledge and practice with Neurological observations a training programme has commenced and been delivered in conjunction with the Simulation Suit. A new head injury poster and neurological observations poster has been completed and has been circulated to all ward areas and is available on the intranet. 14
A new Falls Care Plan has been trialled and continues to be developed across the Trust. The Bed Rails care plan has also been updated and reviewed. This continues to be trialled across inpatient ward areas. A ‘Top Six’ task and finish group established in September 2016 has involved the six wards across the Trust with the highest number of falls. Each of these ward areas has developed action plans and initiated ‘Tests of Change’. Positive results have resulted from this approach with a reduction in falls on three of these wards during this period. Specific Health Care Assistant and International Nurse Training has been commenced alongside the Trust wide training programme with work underway to support areas to identify their role specific training needs. Ward level information is analysed for trends to focus further improvement work to reduce the future risk of falls. Quarterly Bed Rail Audits have commenced allowing practice to be reviewed, informal teaching and learning to commence, and areas for improvement to be identified. We said we would: Reduce harm from hospital acquired pressure ulcers What we achieved: What: To reduce the number of Hospital Acquired Grade 2 & 3 Pressure Ulcers. The Trust will have no Hospital Acquired Grade 4 Pressure Ulcers How Much: A reduction on 2015-2016 incidence When By: By March 31 st 2017 Outcome: From April 2016 to March 2017 there were a total of 164 grade 2 hospital acquired pressure ulcers. When compared to the same time period for 2015/2016 this represents a reduction of 22%. Between April 2016 and March 2017 there have been a total of 31 grade 3 hospital acquired pressure ulcers. When compared to the same period for 2015/2016 this represents a reduction of 45%. There have been no grade 4 pressure ulcers since May 2013. Overall the Trust has achieved a 28% reduction in pressure ulcers in 2016/2017 Hospital Acquired Pressure Ulcers Grade 2 Grade 3 Total 2015-2016 210 59 265 2016-2017 164 31 194 % reduction 22% 45% 28% 15
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Page 3 and 4: Introduction What is a Quality Acco
Page 5 and 6: Part One A statement on quality fro
Page 7 and 8: Statement from the Director of Nurs
Page 9 and 10: Statement of Directors’ Responsib
Page 11 and 12: Part Two Priorities for Improvement
Page 13: When: March 2017 Outcome: There wer
Page 17 and 18: We said we would: Reduce the number
Page 19 and 20: We said we would: Aim to Deliver Pa
Page 21 and 22: In December 2016 a change to the pr
Page 23 and 24: When there has been an increase in
Page 25 and 26: We said we would: Provide care that
Page 27 and 28: A&E (ED) NGH received the most favo
Page 29 and 30: When: In 2016/17, we are measuring
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Page 33 and 34: We made 25 submissions of QI work c
Page 35 and 36: Our reporting structure provides cl
Page 37 and 38: Some of our other projects include:
Page 39 and 40: Dare to Share Learning Events We ha
Page 41 and 42: Red2Green The Red2Green approach is
Page 43 and 44: NHS Staff Survey We have continued
Page 45 and 46: There have been improvements across
Page 47 and 48: Detailed below are some examples of
Page 49 and 50: Real Time Survey The survey adopts
Page 51 and 52: Improving our complaints process Si
Page 53 and 54: Pressure Ulcer Collaborative A pres
Page 55 and 56: Priorities for Improvement in 2017/
Page 57 and 58: Priority 4: To Lead and Promote a R
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Page 61 and 62: IBD Registry Y Data collection ongo
Page 63 and 64: o Safe discharge for children from
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National audit mortality and consul
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Consent in total hip and total knee
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The CQUINs for 2017/18 have been ag
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Care Quality Commission (CQC) The t
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The HSMR 100 looks at all hospital
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Following on from this the Secretar
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An action plan, work schedule and a
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Themes of Good Practice Noted Stan
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Palliative Care Coding - (percentag
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NGH is reviewing the scores in orde
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The results show that the trust is
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Northamptonshire County Council FAO
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Private & Confidential Carolyn Fox
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Q R S PROMs QCI QELCA QI RCPH R&D R
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Northampton General Hospital NHS Trust Quality Account 2016-2017

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