Northampton General Hospital NHS Trust Quality Account 2016-2017

We achieved this reduction in harm by:
A change in culture. Openly acknowledging the challenges we faced in
relation to the harm caused to our patients through the development of a
pressure ulcer.
Quality Improvement session led by the Director of Nursing was designed
to challenge well-established cultural norms with the express purpose of
re-establishing patient focused care by creating new norms and a
fundamental belief that zero harm can be achieved. This included the
removal of terminology such as avoidable/unavoidable pressure ulcers
and focused on lapses in care.
Development of a grade 2 pressure ulcer post incident report (PIR) tool to
identify the reasons why the pressure ulcer developed and to identify
lessons learnt.
Sharing and learning from incidents at the Pressure Ulcer Prevention
Group.
Increased training for all nurses and allied health professionals, including
simulation suite work.
Development of a ‘SWOT’ team to provide prompt targeted support for
areas of increased incidence of pressure ulcers.
Successful tests of change developed from the pressure ulcer
collaborative are being implemented across the Trust.
90 day rapid improvement model has been commenced to support teams
to develop changes using quality improvement methodology
The Practice Development Team is undertaking a review of training in
relation to continence management and skin care.
Raised awareness through a monthly newsletter.
Compliance with positional changes for at risk patients as part of
Intentional Rounding.
Trust wide SSKIN compliance audit with learning from the results shared
across the Trust.
Whilst there has been a reduction in the overall number of patients developing
pressure ulcer harms over the last 6 months, we are clear there is still work to do.
A Pressure Ulcer Collaborative using a ‘Breakthrough Series Model’ commenced
in October 2015 with representation from relevant clinical professional groups and
most wards. A series of learning sessions have been held through the year and
the work will culminate in a pressure ulcer prevention summit in spring 2017.
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