quality improvement strategy 2018 - 2023

James Paget University Hospitals NHS Foundation Trust QUALITY IMPROVEMENT STRATEGY 2018 - 2023

Quality ImprovementStrategy 2018 - 2023

Where YOU come first

At the James Paget University Hospitals NHS Foundation Trust, each and every member of our staff has both an individual and a united responsibility to ensure that the quality of care and the safety of our patients is central to everything we do. Sharing good practice and learning from past errors is essential to ensure that we continually enhance the services we provide.Our Quality Improvement Strategy demonstrates a continued commitment and focus on quality improvement; to transform organisational culture; to support change in order to enhance the delivery of sustainable quality health care and to embed excellence.

Patients are our priority and they should feel confident that our Trust delivers safe, effective, caring, well led, and responsive care. In addition, care provision should be patient centred, accessible and equitable.


Executive Summary


We want all our staff and those working in partnership with us to know that they are valued and we want to support them in providing the best care possible for our patients, to ensure that the right care is delivered, in the right place, at the right time, every time.

Integral to the strategy and fundamental, in terms of itsprogression, will be the development of a fully integrated, dynamic Quality Improvement Team who will assist with the provision of targeted, clinical support across the Trust, whilst simultaneously encouraging and supporting staff to embrace a culture of quality improvement.

Measurement will underpin this approach, to ensure that the quality of healthcare being delivered progresses, by measuring the before and after situation; thus requiring staff to look at what they do, how they do it and why they do it.

Professional requirements, national and local drivers and policy will help steer the strategy direction, to ensure that quality remains at the forefront. This strategy will naturally dovetail with our other Trust strategies, maintaining a unified organisational vision; one where we can continue to deliver sustainable quality healthcare whilst concurrently managing the future political challenges the NHS faces.

Creating a culture of continuous improvement todeliver sustainable quality healthcare


Patient and Staff

Experience

PatientSafety

ClinicalEffectiveness

Quality Improvement Strategy 2018 - 2023

Our Planon a Page

Quality Improvement Pyramid

OurPriority

Our Patients

Our VisionTo be a well-led

organisation delivering compassionate and safe patient care through an engaged and

motivated workforce

Our ValuesCourtesy and respect

Attentively kind and helpfulResponsive communicationEffective and professional

Our Strategic Ambitions1: Deliver the best possible level of safe and effective care

2: Provide education, support and development for our staff to deliver excellence in practice and be the employer of choice

3: Effectively manage our financial resources, our estate and our infrastructure to ensure we are sustainable

4: Actively participate in innovation, research and partnerships to transform our services

Our Work StreamsExcellent communication and information - Outstanding Leadership - Outstanding Services - Excellent

experience (Linked to Trust Strategy; 5 Year People Strategy; Organisation Development Strategy; Clinical Strategy; Commercial Strategy; Patient Engagement Strategy, IT Strategy; Education Strategy; Health & Safety

Policy; End of Life Care Strategy; Sustainability & Transformation Plans)

Our ApproachEmbedding a culture of quality improvement to continually enhance our services



Quality Improvement Ambition 1Develop and embed an organisational quality improvement culture.Executive Lead: Director of Governance

Aim Activity Measures

To develop a fully integrated, dynamic Quality Improvement (QI)Team (Hub)

Source and connect current staff who have a quality improvement title/have completed a validated quality improvement qualification

Identify additional multidisciplinary team staff able to be co-opted to the QI team

Identify a Lead for co-ordination of the QI team

Develop Quality Improvement training/goals/objectives/work plans for the team to discuss/agree approach/way forward

Identify training needs for QI team

Source and provide appropriate QI training to upskill staff

Definitive list of QI staff and contact numbers will be available

There will be a named QI Team Lead

The QI Team roles, responsibilities and governance reporting processes will be clearly defined

QI team terms of reference in place

Training needs analysis will be evident

Staff training records


Quality Improvement Ambition 1 continued:

Develop and embed an organisational quality improvement culture. Executive Lead: Director of Governance/Director of Nursing


QI Team to offer clinical support across the Trust to fully embed a culture of quality improvement to enhance patient safety, patient experience and clinical outcomes via programmes of targeted support

KPI data related to performance, incident reporting, patient experience feedback and workforce issues will be analysed to identify clinical hotspots (areas where improvement is required)

KPI data (as above) will be analysed to identify ‘below radar’ areas to target support in order to enhance staff education and engagement with governance processes.

QI team will utilise service improvement tools as a framework for improvement projects/initiatives

Clinical audit and effectiveness will be integrated and embedded into the quality improvement methodology and culture

A toolkit of improvement skills for all staff will be developed

Involve patients in quality improvement initiatives

The ongoing review of NICE Quality Standards and National Guidance will ensure best practice is adopted and compliance is monitored.

Clinical audit findings related to QI initiatives

Data related to performance, incident reporting, patient feedback and workforce to monitor ongoing performance

Staff training records/competencies

Patient feedback


Quality Improvement Ambition 2To be in the top 10% of all NHS Trusts in the UK for safety.Executive Lead: Director of Nursing


Patients will receive safe harm free care as measured by the following six harms:• hospital acquired

pressure ulcers• catheter associated

urinary tract infections

• avoidable VTE (venousthromboembolism)

• harm from falls• hospital acquired

infections• medication errors

Continuously seek out and reduce patient harm

Staff development in harm prevention/human factors training

Development of safety competencies for staff

Staff development to enhance reporting/governance compliance

‘Making a Difference’ Assurance Framework to be utilised to determine focus (i.e. for medicines management the focus may be critical meds)

Number of Patient Safety Incidents related to six identified harms

VTE audits

Patient safety incident Root Cause Analysis (RCA) findings

Safety thermometer

‘Making a Difference’ Assurance Framework findings

National Patient Safety Agency (NPSA) reports


Quality Improvement Ambition 2 continued:To be in the top 10% of all NHS Trusts in the UK for safety.Executive Lead: Medical Director


There will be no Never Event incidents

Review of previous Never Events (timescale tbc) for learning/ identification of themes

Enhanced staff training/skills bespoke to learning from Never Event RCA findings

Enhance staff education/training governance/monitoring processes

Number of reportable Never Events

NHS Improvement Never Event data publication

Findings from internal audits

Staff training records

Executive Lead: Medical Director


To meet all the requirements of the National Safety Standards for Invasive Procedures (NatSSIPs)

World Health Organisation (WHO) surgical checklist audits

Safety Checklists for Invasive Procedures Audits

Findings from internal audits

Compliance with NatSSIPS




Not to be above the expected mortality rate as measured against the national baseline

To have no preventable deaths

Develop a programme to review every death occurring in the Trust and conduct structured reviews based on professional judgement

Review current processes, test concept and roll out of systematic mortality reviewprocess

Review and share findings with staff to develop quality improvement actions to address any themes/gaps identified

Enhance implementation of care bundles to improve the recognition and care of physiologically deteriorating patients

Trust mortality rates

Percentage of deaths in hospital having a structured review

Number of serious untoward incidents that result in patient death

Inquest outcomes & Prevention of Further Deaths reports

CHKS (Caspe Healthcare Knowledge System) intelligence

Dr Foster Publication intelligence




Achieve the NICE Quality Standards for Sepsis management

Develop and enhance staff education/training for sepsis management

Monthly audit of 100 patient records to determine whether quality standards have been met

NHSI CQUIN Publication data

Training compliance

Sepsis related incident reporting

Audit findings

Executive Lead: Director of Governance


Trust to agree Patient Safety Quality Priorities each year

To be determined by agreed quality priorities Achievement of Patient Safety Quality Priorities


Quality Improvement Ambition 3To be within the top 20% of all NHS Trusts for Patient Experience.Executive Lead: Director of Governance


To be in the top 20% of all Trusts for National Survey findings

Develop annual national survey action plans focussing on requires improvement areas focussing on:• Reducing waiting for appointments,

medication, information, discharge• Enhancing patients/carers/ relatives

involvement in care decisions• Improving communication and information

to patients and relatives/carers• Developing bespoke local patient surveys

aligned to the national surveys to monitor performance

Local survey findings

Annual NHS survey findings

Patient Experience feedback: Complaints

Patient Advice & Liaison Services (PALS)

Social media/online feedback

Friends and Family Test (FFT) data

Governor/Stakeholder feedback

Quality Improvement Ambition 3 continued:To be within the top 20% of all NHS Trusts for Patient Experience. Executive Lead: Director of Governance


To achieve a greater than or equal to 97% FFT recommend score across the Trust

Analysis of monthly FFT data

Monthly review of narrative themes

Initiate improvement actions to address requires improvement themes

Roll out FFT champion initiative to support engagement of staff

NHS England FFT data publication

Trust Internal FFT summary data

Named FFT champion for each ward/department



Quality Improvement Ambition 3 continued:To be within the top 20% of all NHS Trusts for Patient Experience.Executive Lead: Director of Governance


Annual number of written complaints to remain within the lowest 20% of all acute Trusts

Enhance local resolution opportunities/support and training for staff

Enhance learning from complaints processes via openness and transparency

Conduct an annual complaints process survey

Offer patients/relatives the opportunity to be engaged in investigatory processes following serious incidents

Offering patients the opportunity to share their story in person at board

Work in partnership with patients and their Carers and families to meet their needs and better their lives

Published complaints data (NHS Digital)

Monthly complaints data; including upheld/not upheld complaint information

Monthly complaints KPI data

Annual national and local patient experience survey findings

Annual in-house complaints process patient experience survey findings


Quality Improvement Ambition 3 continued:To be within the top 20% of all NHS Trusts for Patient Experience.Executive Lead: Director of Governance


Develop opportunities for patient / stakeholder involvement in service improvement/redesign

Develop a JPUH Patient User Group

Develop clear governance processes and terms of reference for the JPUH User Group

JPUH User group will be operational

Terms of reference and governance processes will be endorsed and available

Minutes of JPUH User Group will reflect involvement in service improvement/redesign initiatives

Executive Lead: Director of Governance


Trust to agree Patient Experience Quality Priorities each year

To be determined by agreed annual Quality Priorities

Achievement of Patient Experience Quality Priorities


Quality Improvement Ambition 4To be in the top 25% of all NHS Trusts for Staff Experience. Executive Lead: Director of Nursing/Medical Director/ Associate Director of Workforce/ Director of Governance


To achieve a CQC rating of outstanding forWell-Led

Build capability and capacity in our workforce to continually improve quality leadership

Explore the feasibility of establishing a Quality Improvement Academy

Deliver band 5/6/7 development programmes

Implementation and roll out of Always Events

CQC Inspection Report findings

Always Events Audits



To be in the top 25% of all NHS Trusts for Staff Experience. Executive Lead: Associate Director of Workforce


To be in the top 25% of all hospitals based on the National Staff Survey findings

Review any trends of work related ill health and identify preventative programmes as required.

Develop line manager skills in managing staff health and well being

Develop ongoing programme of well–being activities for staff

Develop a programme for regular engagement (Listening) activities with staff

Introduce Schwartz Round or similar methodology

Develop enhanced clinical supervision/support opportunities

Enhance development/appraisal processes

Develop and roll out resilience training programmes

Annual NHS Staff Survey Publication



To be in the top 25% of all NHS Trusts for Staff Experience.Executive Lead: Associate Director of Workforce/ Chief Executive


To continually develop individuals, teams and the organisation to enable them to engage in and embed a culture of continuous improvement

Develop quality improvement education/training programmes for staff

Develop a toolkit of improvement skills for all staff

Develop fellowships through the Health Foundation

Develop enhanced involvement of junior doctors /multi-disciplinary staff in quality improvement initiatives

Create a healthcare campus and collaborate with local universities to support research developments

Promote development opportunities to enhance clinical leadership (NHS Leadership programmes; talent management)

Develop an annual leadership summit for discussion of priorities, aims and goals for the forthcoming year to be led by Chief Executive/Executive team

Availability of training

Training records

Staff competency records

Evidence of fellowships

Involvement of junior doctors /multidisciplinary staff

Health Care Campus Status

Availability and uptake of leadership programmes

Training records

Staff certification/qualifications

Five Year Trust Strategy

Ambition 1:Deliver the best

possible level of safeand effective care

Ambition 2:Provide education, support and development for our staff to deliver excellence

in practice and be the employer of choice

Ambition 3:Effectively manage our

financial resources, our estate and our

infrastructure to ensure we are sustainable

Ambition 4:Actively participate in

innovation, research and partnerships to transform

our services

Quality Improvement Strategy Clinical Strategy 5 Year People Strategy Organisational

Partnerships

StaffEngagement

Clinical Audit

Pharmacy & Medicines

Management

SafeguardingSite Development

& Estates

Mobile & FlexibleInformation

Access

Patient Experienceand Engagement

Risk Management& Assurance

EmergencyPlanning

Resilience & Response

End of LifeHealthcareFile Records

Management

Clinical Enabling

BusinessContinuity

Communication

Membership Procurement

EducationIT Digital/IT Security

Carbon Management & Environmental

Commercial

Staff Engagement

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For further information contact:

Ann Filby, Head of Communications & Corporate AffairsJames Paget University Hospitals NHS Foundation TrustLowestoft Road, Gorleston, Great Yarmouth, Norfolk NR31 6LA

Telephone: 01493 452162Email: [email protected]

www.jpaget.nhs.uk Facebook.com/jamespagetuniversityhospitals @JamesPagetNHS

quality improvement strategy 2018 - 2023

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