TIENT SAFETY PROGRAMME (SPSP) (Appendix 1) SCOTTISH PASELF ASSESSMENT PROGRESS REPORT

SEPTEMBER AND OCTOBER 2010 (COMPILED NOVEMBER 2010) Purpose of Report This report takes account of activity and outcomes over the months of September and October 2010. The purpose of this report is to provide an update of NHS Lanarkshire progress against the Scottish Safety Patient Programme (SPSP). The report takes account of the self assessment framework, demonstrating that all key changes have been implemented. Progress is demonstrated using SBAR format, outlining key areas of improvement in process and outcome measures, while identifying challenges and demonstrating organisational learning. Introduction The work streams to be reported on are as follows: • Critical Care • General Ward • Medicines Management • Peri Operative • Leadership Success of activity continues to be monitored through a measurement framework where we aim to achieve 95% process reliability. In tandem, monitoring of associated clinical outcomes is undertaken on an ongoing basis by frontline clinical staff, as well as by work stream groups to target and further drive improvement. Ownership of data is essential for driving improvement. NHS Lanarkshire continues to make very good progress with the SPSP with excellent spread of processes and sustainability being noted in same. The only area where progress is slower has been in medicines reconciliation within acute medical receiving units. This is now being tested in a more discrete area and we are achieving around 95% compliance within this area. DATA MANAGEMENT Compliance monitoring is undertaken using run charts to demonstrate same or deviance from this. The target for ALL process measures such as hand hygiene, central line insertion, PVC management is 95%. We have seen considerable progress as can be seen by the charts contained within this report. Progress is monitored (using run chart rules) and/or outcome measures for all five work streams and this data is displayed in all wards (acute hospitals) and relevant clinical departments. Our ‘Healthcare Quality Improvement Web Portal’ is now in ALL wards and relevant departments in Monklands Hospital, Wishaw Hospitals and Hairmyres Hospitals. Currently this is being utilized for General Ward monitoring and reporting (see reports generated under general ward

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section), with plans in place to add the other work streams onto this too, which will integrate the current database reporting as undertaken for the other work streams. This is a user friendly and the fact that we have included other contributory quality programmes to create a ‘Healthcare Quality Improvement’ integrated system meets their requirements of consistent, meaningful and ‘instant’ data. The creation of this functionality is now enabling us to enter data and manage this in the same way for our major quality programmes such as SPSP, Leading Better Care, Clinical Quality Indicators, Patient Experience, with the latter due to be included when data set robust. LAST REPORT: IHI COMMENTS (Incorporating NHS Lanarkshire bulleted Response) Awaiting comment Examples in support of self assessment score All key changes have been implemented. We are seeing examples of sustained improvement across a number of process and related outcomes measures as detailed below. HIGH LEVEL SPSP AIMS

Component Relevant Measures

Status Change

% Unadjusted inpatient mortality

AHO2 All other programme measures

Variable Target reduction of 15%. Mortality rates submitted to the Board separately. The next Learning Session will focus on attainment of this target across NHS Scotland. ISD were invited to the NHS Lanarkshire SPSP Leadership group to discuss our HSMR data and clarify position against target. Further statistical analysis is required by ISD and this has been formally requested

Adverse event rate

AHO3 Variable Target reduction of 30%. As with HSMR, further analysis is required, but improvements noted in areas such as early warning score compliance and related activity.

PROGRESS WITHIN WORK STREAMS

SITUATION Critical Care All relevant SPSP measures have been implemented in the three acute hospital adult critical care units. Measures such as Central Line Insertion Bundle are being spread into appropriate areas such as theatres, HDU and renal. Review of these insertion and maintenance bundles are being conducted within areas outwith critical care areas to include general wards. This intention being that the bundles will be used in these areas. A working group has been established to progress same. BACKGROUND

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Critical care has excellent ownership and this is driving their improvements and progress with the implementation of care bundles, and outcomes as noted in infection rate reductions.

Within Critical Care, shifts in positive outcomes have resulted in infections being exceptions and consequently these are treated as adverse events and are individually reviewed, should these arise. ASSESSMENT Critical Care Summary highlights (target for ALL process measures 95%, associated outcomes in bold italics)

Component Relevant Measures

Status Change

Central Line Insertion Bundle

CCP3 CCP9 CC02

Sustaining

Implemented in all three critical care units, and being spread to theatres and renal. CL insertion bundle at, or above, 95% target in all three units. All units at 95% target with maintenance bundle. NO central line infections at Hairmyres since November 2008 and over same time period, only three isolated central line infections at Monklands and two isolated infections at Wishaw.

Ventilator Associated Pneumonia (VAP)

CCP2 CCP1 CCP7 CC01

Sustaining Compliance with bundle at 95% goal in all units. Variation remains with ALOS on mechanical ventilation – all sites. Reintubation rates fairly stable. Nil VAPs Wishaw for 13 months, with nil for 2 months Monklands and 9 months Hairmyres - individual isolated prior to these timescales.

Glucose Control CC06 Sustaining All at goal. Hand Hygiene CCP4

CC02 CC04 CC08

Sustaining Excellent compliance and innovation noted with corresponding low infection rates Individual cases of CDI noted

PVC CCP8 CC04

Sustaining At or near goal in all three critical care units. Isolated SABS: No ICU acquired SABs at Monklands since May 2008 with last isolated case having been transferred into unit (and nil since July 2010 Hairmyres, with last isolated case at Wishaw in January 2010.

Daily Goals CCP6 Sustaining Daily goals sheet in place in all three areas and compliance good. However measured along with MDR (CCP5) for run charts. As it is this area that is affecting compliance, because senior staff consider it essential that the nurse in charge of the unit and not just the nurse at the bedside is present to demonstrate compliance. it would be helpful if these measure were reported separately

Multidisciplinary Rounds

CCP5 Spread Planned

Compliance with MDT rounds challenging because as above, senior staff consider it essential to have nurse in charge of the unit there as opposed to nurse at the bedside.

Central Venous Catheter Maintenance Bundle (HPS)

CCP9 CC02

Sustaining and Spreading

Excellent compliance on all three units and being spread to renal and HDU as relevant Infection rates excellent as per Central line bundle above

RECOMMENDATION Critical care continues excellent work across the range of measures in all three units. The excellent process compliance is seeing excellent outcomes in infection rates and reduction in ALOS at Wishaw. Surveillance nursing staff did not receive ongoing funding, although Senior Charge Nurses have agreed that some protected time to undertake this function for monitoring and reporting purposes.

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SITUATION General Ward SPSP is being undertaken in all three acute hospitals and maternity services, with some associated (Older Peoples Services) hospitals taking part in relevant aspects of the programme. Spread is occurring to other areas such as GP hospitals for relevant bundles. BACKGROUND The General Ward work stream continues to make excellent progress with increasing bundle compliance and improved clinical outcomes. We continue to integrate, wherever possible, all of our quality programmes and this is particularly the case with the web portal which is not program specific, but is focused on healthcare quality, with its own section for patient safety. We have ward safety briefings in all relevant areas, attached hospitals and maternity services and moving to mental health. These are being utilized to focus on all SPSP process and outcome measures and other patient safety issues such as falls, variable dose medications, equipment etc. Safety Brief theme of the week is sent out to all general wards and relevant clinical departments. This means that major safety themes and messages are circulated to all staff on a weekly basis to be added to their safety brief and discussed at every brief for one week. These alerts are retained in the SBAR structured safety brief report folder. Quality Progress Boards remain in place throughout all wards and clinical departments within the three acute hospitals. ASSESSMENT General Ward Summary Highlights (target for ALL process measures 95%, associated outcomes in bold italics)

Component Relevant Measures

Status Change

GWP1 GW01 AH02

Existed Pre-Collaborative

All wards at target.

Early Warning Scoring System

Crash call review undertaken GWP5 Hand Hygiene GWO4

Spreading At target for self monitoring. Staff hand hygiene compliance % prominently displayed beside hand gel outside all clinical departments to drive improvement. Bundle CDI results remain excellent.

GWP4 GW01

Rapid

AH02

Existed Pre-Collaborative

Hospital Emergency Care Teams (HECT) in place. Reduction in calls to HECT on all sites, especially Monklands.

Response

GWP10 GW02

Spreading At target.

Peripheral Vascular Bundle SABs demonstrate some variability.

Safety Briefings GWP6 AHO2 AH03

Spreading All sites at target These are now being used as a main vehicle for the review of run charts and actions as well as other core questions and topics. Impressive MDT working in areas.

SBAR GWP8 AHO2

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AH03

Spreading SBAR work been undertaken as observation was difficult and hence reporting was not representative. Have tested this being used during the safety brief as an alert for unwell or deteriorating patients and monitored independently regarding outcomes and improvement noted.

Hand Hygiene demonstrates improvement noted in process and outcomes at Monklands Hospital and Wishaw with ongoing testing in all areas where compliance targets or reliability not sustained. Now spreading to all wards at Hairmyres

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The following data demonstrates actual compliance at an individual ward / department level (left hand side) in relation to process measures and outcome measures at an aggregated hospital level (right hand side). All of this information is made available to clinical staff e.g. wards and departments and is used to drive improvement. This is also reviewed by work stream leads and executive sponsors. Improvements are noted in hand hygiene, PVC and infection rates. Pilot Wards are noted at the top of the first chart for each bundle as relevant. Outcome timescales to be extended to demonstrate fuller picture of improvements

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RECOMMENDATION Given the size of this work stream they are making fantastic progress and patient safety is at the forefront of their daily work. The SPSP Clinical Facilitators have begun to make a significant impact and they are working steadily and closely with senior nurses, charge nurses, infection control teams and all relevant clinical staff to progress and embed SPSP.

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SITUATION Peri operative BACKGROUND Good progress being made in this work stream and. The surgical pause which is conducted in every theatre. This is also occurring in some cases during day surgery or before patients are anaesthetised, which gives patients confidence in their immediate and ongoing healthcare. The surgical pause will begin to be structured using the SBAR format. Excellent progress now being made regarding surgical brief and work moving to debrief. ASSESSMENT Peri operative Summary highlights (target for ALL process measures 95%, associated outcomes in bold italics)

Component Relevant Measures

Status Change

Surgical Brief POP7 Implementing Making progress given slow start. Great dialogue about this and beginning to get real surgeon buy in.

Antibiotic Prophylaxis

POP2 Spreading Excellent progress. All at target.

Skin preparation/Hair Clipping

POP6 Sustaining 100% compliance. Fully spread and no razors available.

Normothermia POP5 Spreading Compliance near / at target at three sites DVT Prophylaxis

POP1 AH03

Spreading All sites at, or adjacent to target

Beta Blockers POP4 Testing Monklands demonstrating sustained improvement at >95% compliance for 14 months. Hairmyres and Wishaw demonstrating some variation.

Blood Glucose (Diabetic Patient's Only)

POP3 Spread planned 60 to 80% compliance. Difficulties remain in emergency admissions.

Surgical Pause AH03 Sustaining At target. Fully spread RECOMENDATION The peri operative work stream continues to make very good progress. It would be helpful to this work stream if more of the processes could be linked to outcome measures as this would motivate them to see that the measures they are putting in place are improving clinical outcomes. SITUATION Medicines Management

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BACKGROUND This is still our biggest challenge within NHS Lanarkshire in relation to SPSP. While all other aspects of medicine management are doing well, we still have problems with medicines reconciliation in acute medical receiving because of the nature of medical management and lack of distinct

medical leadership / ownership in these areas. As can be seen from our custom measures, we are having much greater success in a specialist area on admission and through to discharge. We do not feel that the standalone work stream approach in Lanarkshire has been conducive to promote this as everyone’s business and not just a pharmacy one. We are now linking in with our other work streams. The safety brief continues to be used as a main vehicle to get the medicines message across.. ASSESSMENT Medicines Management Summary highlights

Component Relevant Measures

Status Change

Medication

RECOMMENDATION Further work is required to ensure reliability in medicines reconciliation. This is mainly due to being seen as a pharmacy issue. Tests of change are ongoing and new initiatives being tested. Focusing on using safety brief to drive ownership and improvement. High profile campaign will be undertaken. LEADERSHIP Forty two executive leadership walk rounds have been undertaken to date. These are being seen as very successful with excellent representation from Executive and Non Executive Directors. Walk rounds are scheduled at two per month for this calendar year. Emerging themes remain HAI, storage, clinical environment and small equipment issues. Data has been extremely difficult to track interms of actions completed and a new process has been put in place. Improvements in reported data will be achieved. Quarterly Leadership work stream meetings are scheduled to enable direction to be given to the work streams and practice to be shared as relevant. COMMUNICATION

A communication plan has been formed, which focuses on creating a high and sustained profile. Other initiatives include:-

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Reconciliation MMP1 AH03

Spreading Medicines reconciliation still challenging as there is an over reliance on Pharmacy. SPSP clinical facilitators are assisting with education re same. Improvement noted at Monklands and Hairmyres A & E departments and receiving units and in Monklands in Medical receiving and ITU. Receiving unit for elderly at Monklands demonstrating at target on admission and discharge

FMEA MMP2 AH03

Implementing Repeat / recalculated FMEA at Wishaw demonstrating improvement with a decrease of 46% and 30% at Monklands

Anticoagulation MMP3a, b and c AH03

Spread planned Progress good re anticoagulant management and INR results are excellent and are being sustained. Note variation on INR>6 scale has been altered to enable small variances to be scrutinized.

SPSP on First Port Regular computer screensaver Surgical brief alerts / themes High profile and sustained medicines reconciliation plan Awareness and engagement events, which have seen excellent attendance with next NHS Lanarkshire. Pulse – regular features Newspaper articles Public website – SPSP banner Surgical pause DVD Medicines Campaign

Diane Campbell Patient Safety Manager

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November 2010