what is risk management?
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‘Active Risk Management at Rotherham’ Rotherham NHS FT QUEST presentation 24th June 2011 Dr Trisha Bain. What is risk management?. - PowerPoint PPT PresentationTRANSCRIPT
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‘Active Risk Management at Rotherham’
Rotherham NHS FTQUEST presentation
24th June 2011
Dr Trisha Bain
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What is risk management?
‘Risk management is the identification, assessment, and prioritisation of risks followed by coordinated and economical application of resources to minimise, monitor, and control the probability and/or impact of negative events or to maximize the realisation of opportunities’
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QUEST topicsVTE
Falls, Pressure Ulcers, UTIs• Falls care pathway
assessments• Pressure ulcer
assessment , including MUST
• UTIs – blood sampling method to accurately identify catheter related UTIs
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Identification of risks • Web Datix Incident • Web Risk registers • Serious Incident process• Mortality reviews (Trust and CSU MDT)• Global Trigger• NICE/NCEPOD, National Audits • CHKS :national and peer benchmarking
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Monitoring and prioritisation of risks
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Assessment and management of risk across pathways: Falls • A&E: Falls and Fracture pathway (50-75yrs)• Referral Osteoporosis and Bone Health Clinic• Referral to community: home safety
assessment, falls management• FNOF pathway were appropriate• Ward Falls assessment and MDT Action Plan• Discharge forms to the community team
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Community to BoardMonitoring and ImprovementProgrammes
• SNAP electronic data collection tool• All wards, community sampling• Automated ‘real-time’ feedback reports• Linked to quality accounts programmes
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% Patient assessment completion
Hospital Acquired Pressure Ulcers by Month and Grade
PATIENT SAFETY & EXPERIENCE% Patient assessment completion
PATIENT SAFETY & EXPERIENCENumber of incidents per month by type
0
10
20
30
40
50
60
70
80
90
100
110Bed railsassessmentcompleted
Bed railassessmentactioned
Falls assessmentcompleted
Falls assessmentactioned
0
10
20
30
40
50
60
70
80
90
100
Falls
Medicationerrors
All Incidents
0
1
2
3
4
5
6
7
8
9
10
Grade 1 Grade 2 Grade 3 Grade 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
0
10
20
30
40
50
60
70
80
90
100
110
Nutritionalassessmentcompleted onadmission
Smoking statusdocumented
Smoking cessationrecorded in nursingnotes
% Patient assessment completion
Hospital Acquired Pressure Ulcers by Month and Grade
PATIENT SAFETY & EXPERIENCE% Patient assessment completion
PATIENT SAFETY & EXPERIENCENumber of incidents per month by type
0
10
20
30
40
50
60
70
80
90
100
110Bed railsassessmentcompleted
Bed railassessmentactioned
Falls assessmentcompleted
Falls assessmentactioned
0
10
20
30
40
50
60
70
80
90
100
Falls
Medicationerrors
All Incidents
0
1
2
3
4
5
6
7
8
9
10
Grade 1 Grade 2 Grade 3 Grade 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
0
10
20
30
40
50
60
70
80
90
100
110Nutritionalassessmentcompleted onadmission
Smoking statusdocumented
Smoking cessationrecorded in nursingnotes
B3 Ward Quality Indicators
B2 Ward Quality Indicators
Local level monitoring
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Falls from height: April 2009 – March 2011
Falls same level April 2009 – March 2011
Trust wide monitoring
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National benchmarks of reported slips, trips and falls in acute (NPSA 2010)
hospitals
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VTE90% target metevidence ofactions
Proxy measures
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Linked to improvement programmes: Quality Accounts
•Linked to Improvement programmes
•On-going : Mortality. Fluid balance and MUST tool
• CQUINs, National Priorities
• Reducing 30day re-admission rates for Falls, Diabetes,
COPD•Continue to achieve month on month 90% VTE risk assessment
•Ensure 90% of VTE prophylaxis prescribed as per national guidance
• Increasing responsiveness to our patients needs on composite indicator (PET)
• Increasing compliance to 95% of key measures of End of Life care pathway
• 95% high risk prescriptions, opiates, anticoagulants, antibiotics prescribed as per protocol
• Reduce number of communication incidents : handover/hand-off
• Continue to have zero Never Events
Patient Safety
Patient Experience
KPIsClinically Effective
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Continuous improvementand management of risks
1 Quality Account indicators at a glance
Baseline type
Baseline period
Baseline Value Target QTR 1 QTR 2 QTR 3 QTR 4 Year to
DateQTR
ChangeYTD
RatingData
Rating
Employee sickness rates (unplanned) Quarter Qtr 4 2009/10 4.8% 3% 4.0% 3.9% 4.3% 4.4% 4.2%
National Inpatient Survey - % of questions where the trust's performance is in the top 20% of trusts nationally Year 2009/10 16.9% Increase 23.4% 23.4% -Staff satisfaction survey - number of key findings in the top 20 percent of 40 domains Year 2009/10 11 Increase 13 13 -Increased IR1 reporting (Datix) Year 2009/10 6555 Increase 1799 2065 1968 1920 7752
All applicable staff to have in year PDR Snapshot Qtr 4 2009/10 69% 100% 61.9% 57.8% 44.1% 56.2% n/a -All staff receive mandatory and statutory training (data quality issues are significant)
Reduction in hospital acquired UTIs (related to catheterisation) per 1,000 occupied bed days 2 Qtrs Qtrs 3/4 2009/10 0.12 50% baseline 0.14 -
Reduction in intrapartum stillbirth rates Year 2009/10 0.0% Reduce 0.0% 0.1% 0.0% 0.0% 0.0%
Reduction in unexpected neonatal admissions (babies over 2.5Kg) Year 2009/10 8.7% Reduce 9.9% 10.1% 4.9% 6.6% 7.9%
Reduction in Caesarian Section rates Year 2009/10 22.0% Reduce 18.4% 21.3% 16.3% 20.7% 19.2%
Number of patients with hospital acquired MRSA Year 2009/10 5 3 0 0 0 0 0
Patients with hospital acquired Claustridium Difficile Year 2009/10 43 Reduce 22 5 7 16 50
Inpatient falls (from height) per 1,000 inpatient admissions Year 2009/10 4.4 Reduce 4.6 4.0 4.7 5.9 4.8
Inpatient falls (same level - SLIP) per 1,000 inpatient admissions Year 2009/10 5.7 Reduce 5.6 6.3 6.6 5.8 6.1
Patient medication errors per 1,000 dispensed item episodes Year 2009/10 1.1 Reduce 1.6 1.7 1.6 1.6 1.6
'Never' events that occur within the hospital Year 2009/10 0 0 0 0 0 0 0
Reduction in the number of complaints from baseline Quarter 4 Qtr 4 2009/10 171 Reduce 168 140 162 181 651
Increase in the number of patients on the end of life care pathway Year 2009/10 28.7% Increase 33.6% 43.9% 42.9% 45.7% 41.6%
Increase in the number of patients assessed using the MUST nutritional tool on admission (SNAP) Quarter 1 2010/11 89.2% 100% 89.2% 93.0% 89.0% 92.6% 91.1%
Reduction in hospital acquired pressure ulcers grade 2 and above (Datix) Year 2009/10 267 Reduce 66 43 58 51 218
Increase in the number of patients undergoing VTE assessments from baseline Month Jun-10 53.2% 90% 53.2% 57.7% 66.8% 88.5% 64.9%
Increase in patients on Hip & Knee replacement bundle (calculated on combined raw data from 3 indicators) Quarter 1 2010/11 96.3% Increase 96.3% 96.4% 96.9% 94.3% 95.9%
Appropriate reduction in LoS for patients following (EL & NEL) surgical intervention (CHKS) Quarter 4 2009/10 1.4 Reduce 1.5 1.3 1.2 1.2 1.3
Reduction in 'Risk Adjusted Mortality Indicator' (RAMI 2010 by CHKS) Year 2009/10 93.6 80.0 76.7 73.9 88.8 79.3 79.7
Reduction in unplanned readmission rates within 28 days (CHKS) Year 2009/10 7.5% Reduce 8.4% 8.3% 7.9% 6.4% 7.7%
Reduction in unplanned readmission rates within 14 days (CHKS) Year 2009/10 5.4% Reduce 6.1% 6.0% 5.8% 5.0% 5.7%
Increase in depth of coding - Average diagnosis per coded episode (CHKS) Year 2009/10 2.6 Increase 2.9 3.0 3.1 3.1 3.0
Clinical Quality
Data Quality
Culture
Annual survey
Annual snapshot audit
Annual survey
Insufficient data quality to report
Patient safety
Patient Experience
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Any Questions