Transcript PPT - Patient Safety Federation

Buckinghamshire Healthcare NHS Trust
Nursing Quality Framework.
Introduction
Reducing harm and monitoring and improving the quality of nursing care delivered to
patients is an essential element of the role of all nurses. Whilst there are systems in place
within Buckinghamshire Healthcare Trust, they are not 100% robust and standards are not
currently at the level aspired to by the Chief Nurse and her senior team.
In order to address this, the Chief Nurse initiated a review of the quality framework, structure
and monitoring; this paper outlines the improved system.
Background
The Trust Nursing Service is currently participating in a number of quality improvement
initiatives and data collection/benchmarking/monitoring systems including Safety Express,
Safety Thermometer, Essence of Care, Releasing Time to Care (Productive ward) and there
is encouragement from the Strategic Health Authority to enlist in ‘Energising for Excellence’
the latest initiative from the NHS Institute for Innovation and Improvement (NHS Institute).
This has resulted in the requirement for comprehensive data collection by ward managers,
matrons and others across a wide range of indicators. This takes a significant amount of time
to collect and present; some is on display at ward level though it may sometimes be of little
meaning to patients and members of the public.
‘Harm Free’ Care
The Safety Express programme, a powerful measurement system and support, encourages
organisations to stop thinking about individual safety issues in isolation and to think about
complications from the patient’s perspective. It has focussed on four key harms – pressure
ulcers, VTE, urinary catheters and falls – and its aim is the absence of all four harms and
achievement of harm free care.
Harm free care is regarded as ‘a new mindset in patient safety improvement’. BHT’s Chief
Nurse contributed to the product design and the Trust Nursing Quality Framework
incorporates key elements.
Energising for Excellence
Text taken from the Department of Health website
“Energise for Excellence in Care (E4E) is a quality framework for nurses, midwives and health
visitors which aims to support the delivery of safe and effective care, creating positive patient and
staff experiences that build-in momentum and sustainability.
The framework brings together numerous tools, techniques and policies from both a national and
local level into one central portal, which is now available from a dedicated section on the DH
website.
E4E provides information at the point of care, supporting nursing staff to improve the quality of
care and productivity. Good quality, safe effective care improves the experience of both patients
and staff, resulting in shorter hospital stays, less patient complaints and fewer staff absences and
errors.
Nurses are the biggest workforce in the NHS and the E4E approach gives them the chance to
influence how they and their peers work. It empowers individuals to revolutionise the level of care
given, increase productivity, reduce spend and ensure that the skill mix for a shift is appropriate to
the type of patients on the ward. Understanding the acuity and dependency of their patients will
assist nurses in having the right staffing levels to deliver the right care at the right time and in the
right place.
E4E is now strategically positioned as the over-arching approach to the implementation of
improvement initiatives such as: High impact actions, Productive care, Safety Express, Essence
of care. Many of these initiatives are not new and the emphasis is to pick and mix initiatives and
ensure that improvement work is happening in each of the E4E domains: Get staffing right,
Deliver care, Measure impact, Patient experience, Staff experience.”
QUALITY PACK TMC dlb v3 081211
BHT NURSING QUALITY FRAMEWORK
The Trust Nursing Service has developed a local version of E4E, based on the
work of the NHS Institute and using the same five elements. It also incorporates
the primary drivers and many of the secondary drivers of ‘harm free care’; the
remaining secondary drivers form part of other structures and processes of the
Trust e.g. Active Risk Management and Medicines reconciliation.
The local nursing quality framework will be known as ‘Delivering Excellence in
Nursing Practice’.
Patient Experience
The framework builds on the existing system of Patient Trackers and the patient survey
element of the Productive Team work as well as other feedback sources
A Structure to Implement the Framework
It is acknowledged that measures and monitoring alone are not sufficient to support real
sustained improvement; knowledge, education, and expert support are also essential. To
this end a structure is proposed to support improvement in standards of patient care.
FRAMEWORK
Get staffing right
• Staffing establishments have been reviewed using AUKUH (Association of United Kingdom
University Hospitals)/ Safer Nursing Care tool.
• The Obstetric Service recognises the importance of the Birth-rate + workforce planning
tools
• ‘RosterPro’ is in place in most nursing areas and will be rolled out across the Trust
Deliver Care
• The Productive Team is well established and encouraging the use of the ‘releasing time to
care’ concepts and tools
• A planned programme of Essence of Care audits provides measurement of essential
aspects of care
Staff Experience
• The Trust already has a system of Executive Walk-abouts in place and actively encourages
staff to respond to the National Staff Survey.
• Local staff satisfaction measures are being developed and simple questions have been
incorporated into the measurement framework
Measure Impact
• The measures to be used to assess the standards of nursing practice are detailed in the
appropriate section below.
BHT NURSING QUALITY FRAMEWORK – SUPPORTING STRUCTURE
Ward Based Matrons
The role of the Matron is crucial in achieving
and maintaining high standards of nursing
practice and quality care. The structure
places them at the centre; supported by
strong nursing leadership at Trust level,
experienced external influence, internal
support teams, and developmental
resources. In addition, as individuals they
will have clear objectives and competence
development support.
Nursing Leadership
External Professional Guides/Mentors
Group
Comprising of around six key individuals
within the nursing profession nationally
including representation from the Nursing
and Midwifery Council, Royal College of
Nursing, Nurse Education, this group will
provide mentorship and facilitation to the
Chief Nurse and Associate Directors of
Nursing, external challenge and a wider
view of standards and developments in
care.
Through its links with these individuals it is
hoped that not only would standards of
patient care be improved but that the Trust
could also enhance its profile in the national
nursing arena through acting as early
implementer for new initiatives, increased
involvement in pre-registration education
and outstanding professional practice.
STRUCTURE
The Chief Nurse and Director of Patient
Care Standards, Associate Directors of
Nursing, and nurses in other senior
positions including Healthcare Governance,
Infection Control and Nutrition are
committed to and passionate about the
delivery of high quality care. They support
the Matrons and ward teams to develop and
improve through practical support,
mentorship and leading by example.
The Quality Support Crew
Members of the nursing team within the
Trust considered to be those with an
excellent understanding of what
constitutes good patient care, ward
management and organisation, and
professional behaviour. This team
would spend a period of time on each
ward initially observing care but then
working with the staff to improve care
and the patient experience.
The amount of time on each ward would
be determined by their findings during
the initial observation and the order of
their attachments would be agreed by
the Chief Nurse based on current
standards of patient care delivered.
The crew would provide this
professional assessment/ expert tutor
role whilst retaining their own roles
within the organisation.
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BHT NURSING QUALITY FRAMEWORK - TOOL KIT
In addition to the supporting structure, there is also a set of tools and other resources to
assist nursing staff in delivering high quality professional care.
Nursing documents
Documents used by nursing staff have been reviewed and revised by a group involving ward
staff, Ward Managers and Matrons.
Assessment
To ensure a good understanding of the patient’s usual level of functional ability and how that
has altered as a result of their reason for admission, and to identify risks and care needs.
Starting discharge planning on admission by gaining an understanding of home
circumstances, significant others /carers, and support from other agencies.
Simple care plan documents that enable the care needs identified during admission
assessment to be noted, goals agreed and nursing care prescribed in a manner that is not
onerous but provides a robust record of care planned and delivered, the impact and
subsequent changes to care.
Discharge Processes
A revised discharge checklist to guide staff through the key elements of good, timely
discharge planning. Also a trust-wide team of Discharge Co-ordinators who facilitate and coordinate more complex discharges whilst guiding, supporting and educating ward staff about
discharge process, legislation and interaction with other agencies.
Community In-reach
Experienced members of the Adult Community Health Teams visit wards to review patients
with a view to them being cared for in the community, supporting ward staff with risk
assessment and discharge planning support.
Royal College of Nursing Principles of Nursing Practice
The Principles of Nursing Practice tell us what all people can expect from nursing
practice, whether they are colleagues, patients, or the families or carers of patients.
© copyright BHT 2012
TOOLS & RESOURCES
Care planning and evaluation
TOOLS & RESOURCES
BHT Service Standards
Promises and Service Standards
BHT promises everyone who uses its services:
• Clean and safe practice
• A caring, helpful and respectful attitude
• Respect for your time
• Easy access to comfortable and modern facilities
• The best clinical care
These Promises are consistent ‘The Code’ issued by Nursing and Midwifery Council
(UK) that all Registered Nurses and Midwives must comply with.
The promises are underpinned by service standards pledges
All staff are given training in the Promises and Standards at induction and planned
updates. Additional sessions for teams can be arranged on request
The standard
The competency
Commentary &
Feedback
I say what is happening and why
Compassion &
Empathy
I am caring and consider others’ feelings and needs
I treat people with respect and dignity
I act in a timely manner and communicate effectively
whenever this is not possible
Communication
& Delivery
I am accountable for my actions and behaviours;
I take ownership and do not pass the buck
I keep patients and colleagues in the loop
I listen to others, encourage conversation by using open
questions and value other people’s views and opinions
Courtesy &
Professionalism
I am polite and approachable, courteous and attentive
and welcoming at all times
I keep my eyes open and offer help and support to others
I am professional and positive; I am on stage – an
ambassador for the organisation
© copyright BHT 2012
TOOLS & RESOURCES
……I set the standard
I am responsible for delivering a great service
and am committed to my service standards pledges…..
BHT NURSING QUALITY FRAMEWORK – MEASUREMENT
Delivery against the agreed indicators will be recorded in a database to generate a
‘dashboard’.
Indicators
Matron’s Ward Round
Matrons will conduct ward rounds not less than weekly in each of their areas to
observe elements of professional behaviour and nursing practice. The results will be
added to the dashboard. These rounds will provide the opportunity to be visible and
accessible to patients and their family/carers, to discuss the achievement against the
measures with the nurse in charge of the ward, and to observe other elements that
influence the standard of patient care and affect the patient experience.
The elements to be observed and measured by the Matrons is shown on the Matron’s
Round template.
Nurse sensitive Indicators
Good Practice Measures
Audit will also contribute to assessment of the standard of nursing practice particularly
hand hygiene audits, documentation audits and Essence of Care Benchmarking.
General measures
In addition to clinical practice measures, other measures will be taken including
patients average length of stay on the ward, staff mandatory training and appraisal
levels in the area and staff satisfaction.
Triangulation
The standard of nursing practice assessed through the measures outlined above will
be considered alongside patient/service user feedback and other external reviews
and data as available.
Frequency of assessment
The various indicators will be measured at different frequencies over a six-month
period; wards will be assessed at the end of each six months to determine if they have
achieved an Exemplar level of practice. Most indicators have two thresholds: the
minimum expected level of achievement, and the level of achievement expected of a
team to be considered as delivering exemplar care. However some only have one,
this is where the element is one of the ‘avoidable harms’ noted in the introduction to
this document.
The frequency of measurement and the thresholds for achievement are shown in the
‘assessment process’ section below.
© copyright BHT 2012
MEASUREMENT
There are agreed ‘nurse sensitive’ indicators agreed for use locally by the Nursing
Midwifery and Therapy Professional Board:
Cases of BHT acquired MRSA
Cases of Clostridium Difficile (C.Diff)
Number of avoidable, BHT acquired pressure ulcers
Patient falls
MEASUREMENT
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ASSESSMENT PROCESS
© copyright BHT 2012
BHT NURSING QUALITY FRAMEWORK – USING THE OUTCOMES
The database containing results and achievements will be held on the intranet to ensure that
the information is accessible to the Ward Manager, Matron, Associate Director of Nursing
and the Chief Nurse.
The Chief Nurse will report the results and the situation of wards and divisions to the Board
on a regular basis via the Healthcare Governance Committee.
Trends and significant negative measurements will form part of the regular 1:1’s between
individuals and their line manager so that
• actions can be agreed to ensure achievement of minimum standards
• good practice can be recognised
• actions to achieve further improvement and Exemplar level of practice can be identified
and implemented
The data acquired, trends and achievements can be used to provide assurance to BHT Trust
Board, local and other service users, commissioners, and other external regulators and NHS
bodies.
© copyright BHT 2012
USING THE OUTCOMES
The implementation of the Quality Framework will have a positive impact on standards of
nursing practice .
LARGER DIAGRAMS
BHT NURSING QUALITY FRAMEWORK
LARGER DIAGRAMS
© copyright BHT 2012
BHT NURSING QUALITY FRAMEWORK – SUPPORTING STRUCTURE
LARGER DIAGRAMS
© copyright BHT 2012
Patient promises
… where your needs always come first
Clean and safe practice, clinics and hospitals so you never
need to worry unduly
Respect for your time with care closer to home,
offering choice and flexibility with a minimum of delays
and cancellations
Easy access to comfortable and modern facilities,
offering privacy and dignity, personal space and good
healthy food
The best clinical care from teams of skilled healthcare
professional, who help you improve and maintain your
health
LARGER DIAGRAMS
A caring, helpful and respectful attitude from
approachable teams, who listen to you, involve you in
decisions about your care and ensure you’re clear about
what to expect
……I set the standard
I am responsible for delivering a great
service and am committed to my service
standards pledges…..
The standard
Commentary &
Feedback
The competency
Compassion &
Empathy
I am caring and consider others’ feelings and
needs
I treat people with respect and dignity
I act in a timely manner and communicate
effectively whenever this is not possible
Communication &
Delivery
I am accountable for my actions and
behaviours; I take ownership and do not pass
the buck
I keep patients and colleagues in the loop
I listen to others, encourage conversation by
using open questions and value other
people’s views and opinions
Courtesy &
Professionalism
I am polite and approachable, courteous and
attentive and welcoming at all times
I keep my eyes open and offer help and
support to others
I am professional and positive; I am on stage
– an ambassador for the organisation
I say what is happening and why
LARGER DIAGRAMS