Leading Better Care

Vicky Thompson National Programme Leader – Senior Charge Nurse Role, Clinical Quality Indicators & Releasing Time to Care NHS Scotland

Role Framework Links Releasing Time to Care SCN ROLE Exemplar Job Description & KSF Outline Activity Analysis Workforce Planning Educational Framework Development Needs Analysis CQIs

Policy Context

By the end of 2010…

• Senior Charge Nurses in hospital settings will be working in the context of the revised role • The majority of in-patient areas to have Clinical Quality Indicators in place • The SCN will be the visible embodiment of clinical leadership in NHS settings, coordinating patient care, and inspiring the nursing/midwifery team

Improving Patient Care at the Bedside

Nurs in g Mod er ni sing SCN & CQI Nurse Bank Recruitment & Retention Advanced Practice Delivering Care Enabling Health Workload & Workforce Planning HCSW s Career

• Clearly define this key role and ensure that SCNs are visible and accessible to patients and their carers. • LBC establishes a national framework for SCNs working in hospital settings across NHS Scotland. • Empowers Senior Charge Nurses to be clinical leaders and guardians of safety and quality in their area. • Developed through extensive stakeholder involvement including patient / client input.

• Four key dimensions for the Senior Charge Nurse role:

Ensuring safe and effective clinical practice Enhancing the patient experience Managing and developing their teams Contributing to the delivery of organisational objectives

• Supported by

Clinical Quality Indicators

(Falls, Pressure Ulcer Prevention & Food, Fluid & Nutrition) • The revised SCN role is applicable to nurses and midwives working in hospitals in all clinical specialities, and is supported by the NES Education and Development framework, a National Programme Leader and a Board-level facilitator network.

• Significant and essential links to the

Releasing Time to Care

initiative

The vision from

Leading Better Care

‘We will have strong clinical leadership delivered by empowered Senior Charge Nurses who are the guardians of quality and clinical standards for the patients under their care.’ Paul Martin Chief Nursing Officer

Why Change?

‘

If you always do what you’ve always done, you will always get what you always had’

Albert Einstein

Do we all see the same thing?

Supporting Framework and Tools for Implementation

Framework for Implementation

Implementation of Senior Charge Nurse Role Safe and Effective Clinical Practice Enhance Patient Experience Manage and Develop Performance of the Team Educational Framework Effective contribution To Organisational Objectives Workload and Workforce Planning Tools e QIPS CQIs Release Time to Care Productive Ward

SCN Role Framework

To Ensure Safe and Effective Practice To Enhance the Patients Experience Clinical Leadership & Teamwork Evidence Based, Clinically Effective Practice Continuous Quality Improvement Patient Safety Clinical Expertise Co-ordination of Patients Journey Promote Culture of Patient Centred Care To Manage and Develop the Performance of the Team Role Model Facilitate Learning & Development Managing the Practice Setting To Contribute to Organisations Objectives Networking Service Development Political & Strategic Awareness

Supporting Framework

• Competencies and KSF outlined • Working Document • For current SCNs and their managers • ‘Talent Spotting’ – use as framework for development

Implementation of the new role

• Crucial in leading and delivering the high quality care that our patients and the public expect. • Transition of SCNs to the revised role is a phased process that has Executive level support from NHS Board Nurse Directors across Scotland and is overseen by a national steering group. • The work of NHS Boards is supported by a funding package provided by Scottish Government Health Directorates. Board-level Clinical Facilitation, plus the delivery of education and development packages and one to one facilitation for Senior Charge Nurses will provide additional support

• Many Boards are also offering action learning for their SCNs. In addition, educational and developmental initiatives are supported by the NHS Education for Scotland (NES) Educational Framework and resources.

• Cohorts of SCNs are already developing into these roles across NHS Scotland and the initiative targets the implementation of this role for all SCNs working in hospitals by the end of 2010. • From recent information provided by NHS Boards we know that there are around 2000 SCNs in Scotland. Of them, around 1545 will be included in the revised role and around 700 are already undergoing development or working to the outline.

Clinical Quality Indicators CQIs

Why did we need Clinical Quality Indicators?

• Audit Scotland (2002) reported on limited availability of information on impact of nursing on quality • Audit Scotland (2007) – acknowledged progress but challenges for national quality indicators • Identify nurse specific measures that have impact on quality of care and patient experience

CQI Progress • Three CQIs developed:

– Falls – Food, Fluid and Nutrition – Pressure Area Care Prevention

• Data capture and reporting systems being developed locally & nationally • Further CQIs in discussion for specialist areas, eg midwifery, mental health, etc

Clinical Quality Indicators

• Change of culture • Data collection and analysis skills • Quality improvement skills

Data, data and more data… • Expect poor results initially • Use it as a tool to engage staff and improve care • If it’s not documented where is the evidence of care delivered?

Quality Indicator : Inclusion Criterion: Clinical Quality Statement:

Food Fluid and Nutrition Patients who have been admitted for longer than 24 hours Nursing staff ensure the effective delivery of food and fluid and contribute to the provision of patients' high quality nutritional care

Element Assessment Management Criterion

Patients have a nutritional risk assessment documented. Within 24 hours of admission using a validated risk assessment tool as agreed by your organisation.

Food allergies are recorded at the intial assessment of the patient.

Patients dietary needs / preferences are recorded at intitial assessment e.g Cultural, Religious and / or ethnic dietary preferences. Patients eating preferences are recorded at initial assessment.

Patients drinking preferences are recorded at initial assessment.

Definition of terms

The screening and assessment processes helps identify under nutrition and factors that may prevent patients from eating and drinking adequately. Screening should be recorded within 24 hours and repeated in accordance to clinical need. This shall include assessing and recording height and weight; eating and drinking likes / dislikes; food allergies and the need for therapeutic diet; cultural / ethnic / religious requirements; social/environmental meal time requirements; physical difficulties with eating and drinking and the need for equipment to help with eating and drinking 1,2 .

Compliance target

100% 100% 100% 100% 100% The intervention identified within the plan of care relates to the level of risk identified through assessment.

There is evidence of repeat assessments relevant to the level of idenfied risk.

There is documented evidence that nutritional information has been shared with the patient and / or relevant others. There is evidence that the discharge plan contains nutritional information.

NHS QIS Standards Food, Fluid and Nutritional Care in Hospital (2003) state that this will include the outcomes of the initial assessment; outcomes of the screening for risk of under nutrition; frequency / dates for repeat screening and actions taken as a consequence of repeat screenings. Ideally, this shall be developed in conjunction with the patient or carer. Patients food and fluid intake should be monitored and necessary action taken if this is inadequate 1 . NHS QIS Standards Food, Fluid and Nutritional Care in Hospitals (2003) recommend that the discharge plan shall include information about the patients nutritional status; special dietary requirements; and that the arrangements made for any follow-up on nutritional issues.

100% 100% 100%

Exclusion

Patient not identified as at medium / high risk 100% Patient not identified as at medium / high risk This section refers to an observation of meal times within the ward/department.

Structures and processes

Mealtimes are protected to minimise disruption to the patient over this time. Patients receive the correct choice of meals/dishes.

Meals/dishes are delivered at a temperature acceptable to the patient.

Patients who require support with eating and drinking are identified and are given help with eating & drinking as necessary.

Inflexible hospital routines, clinical procedures and ward rounds can disrupt mealtimes and thus reduce patients nutritional intake 1 . All non - essential staff activity is stopped during mealtimes; there is adequate numbers of staff available to provide food and fluid to patients and where necessary, to provide individual assistance with eating and drinking. There is a protocol for the provision of therapeutic diets, supplements, high energy and high protein food and fluid 1 . There is provision of any requirement outwith the planned menu e.g. vegan meals 1 . 100% 100% 100% meals are not provided e.g. ICU meals are not provided e.g. ICU meals are not provided e.g. ICU 100% meals are not provided e.g. ICU

References

1 NHS Quality Improvement Scotland (2003) Food Fluid and Nutritional Care in Hospitals. (www.nhshealthquality.org) 2 BAPEN (2003) The 'MUST' Explanatory Booklet. A Guide to the 'Malnutrition Universal Screening Tool' ('MUST') for Adults. (www.bapen.org.uk)

Ward / Department Date Element Assessment Management Criterion

Patients have a nutritional risk assessment documented. Within 24 hours of admission using a recognised risk assessment tool as agreed by your organisation.

Food allergies are recorded at the intial assessment of the patient.

Patients dietary needs / preferences are recorded at intitial assessment e.g Cultural, Religious and / or ethnic dietary preferences. Patients eating preferences are recorded at initial assessment.

Patients drinking preferences are recorded at initial assessment.

The intervention identified within the plan of care relates to the level of risk identified through assessment.

There is evidence of repeat assessments relevant to the level of idenfied risk.

There is documented evidence that nutritional information has been shared with the patient and / or relevant others. There is evidence that the discharge plan contains nutritional information.

patient 1 patient 2 patient 3 patient 4 patient 5 % compliance

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Section % compliance

0.00% This section refers to an observation of meal times within the ward/department. Please observe practices that relate to the whole ward/department over a breakfast, lunch and evening meal Breakfast Lunch Evening Meal % compliance Section % compliance

Structures and Processes

Mealtimes are protected to minimise disruption to the patient over this time. 0.00% Patients receive the correct choice of meals / dishes. 0.00% Meals / dishes are delivered at a temperature acceptable to the patient.

0.00% Patients who require support with eating and drinking are identified and are given help with eating & drinking as necessary.

0.00%

0.00% Overall Compliance 0.00% Exclusions

: Patients admitted less than 24 hours and meals are not provided in high dependency areas such as ITUs.

NB

Definitions of high, medium and low risk relate to the definitions identified in MUST. ( Bapen 2003) Actions relating to levels of risk have been identified through MUST.( Bapen 2003)

References

1 NHS Quality Improvement Scotland (2003) Food Fluid and Nutritional Care in Hospitals. (www.nhshealthquality.org) 2 BAPEN (2003) The 'MUST' Explanatory Booklet. A Guide to the 'Malnutrition Universal Screening Tool' ('MUST') for Adults. (www.bapen.org.uk)

0.00% 0.00%

PDSA Template

Every goal will require multiple smaller tests of change

AIM Describe your first (or next) test of change: PLAN List the tasks needed to set up this test of change Person responsible Person responsible Predict what will happen when the test is carried out DO

Describe what actually happened when you ran the test

STUDY Describe the measured results and how they compared to the predictions ACT Describe what modifications to the plan will be made for the next cycle from what you learned Measures to determine if prediction succeeds When to be done Where to be done

.

When to be done Where to be done

Impact on Quality

Compliance with CQI with Revised SCN Role (Cycle 5)

100 80 60 40 20 0 Baseline Cycle 2 Cycle 3 Cycle 4 Cycle 5 Implemented revised SCN Role Food, Fluid and Nutrition Pressure Area Care Monitoring and Observations Falls

CQI Compliance trends

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% FFN PAC MO Falls Ave compliance baseline after work

Synergies with other national programmes

Falls Programme Leading Better Care Improving Nutritional Care programme Tissue Viability Programme Scottish Patient Safety Programme Healthcare Acquired Infections Better Together/ Patient experience programme Patient Experience National Nursing / Midwifery Workforce & Workload Programme Joanna Briggs Institution initiative

Supporting Development

Supporting Development

• National Programme Leader • Network of Clinical Facilitators • Steering group chaired by Executive Nurse Director • Commitment from Scottish Government, QIS and NES

Leading Better Care

Scotland’s Executive Nurse Director’s Group (SEND) eQIPS / CQI Development Group

Leading Better Care Implementation Group

Releasing Time to Care Facilitator Network Leading Better Care Clinical Facilitator Network

1. NHS Ayrshire & Arran Susan Hannah Practice Development Lead, 01294 323457 Leading Better Care Facilitators 11 8. NHS Highland Jenny Lobban Project Manager / Facilitator, 01463 704715 2. NHS Borders Kim Smith Practice Development Leadership coordinator, 01896 827651 3. NHS Dumfries & Galloway Maureen McCrae Unit manager, specialist palliative care, 01387 241986 12 9. NHS Lanarkshire Margot Russell, Practice Development Specialist Clinical Leadership and Quality, 01698 723205 10. NHS Lothian Fiona Bonnar & Linda Conway Lead Clinical Facilitators, 01506 434274 / 07813 579660 4. NHS Fife Lynn Barker Programme Lead Leading Better Care, 01592 743505 5. NHS Forth Valley May Fallon Senior Nurse, Practice Development, 01324 678528 14 8 6 11. NHS Shetland Andrea Ridealgh, Senior Charge Nurse, 01595 743357 12. NHS Orkney Moira Sinclair, Charge Nurse, 01856 888244 6. NHS Grampian Fiona Gray, Programme Manager / Facilitator, 01224 555064 7. NHS Greater Glasgow & Clyde Kate Cocozza, Lead Nurse Practice Development, 0141 201 1695 5 7 13 4 10 13. NHS Tayside Debbie Baldie, Senior Practice Development Nurse, 01382 660111 14. NHS western isles Mary McElligot, Professional Practice Development Manager , 01851 708057 9 Special Health Boards Golden Jubilee National Hospital – Irene McGachy, Clinical Facilitator, 0141 951 5050 1 3 2

N

National Programme Leader Leading Better Care The State Hospital - Sandra Steele Please note that this diagram is for internal use only and should NOT be used in any publications – Vicky Thompson, 07920 765343

How do we know if we’ve succeeded in implementation?

By the end of 2010…

Clinical Quality Indicators will provide us with:

– Data used for quality improvement as part of day-to-day work – Quality improvement methodology known and used regularly by all nurses

By the end of 2010…

Senior Charge Nurses will be:

– Empowered clinical leaders – Guardians of quality and clinical standards – Visible, approachable and authoritative

Contact Details Vicky Thompson

National Programme Leader – Senior Charge Nurse, Clinical Quality Indicators & Releasing Time to Care 07920 765343 [email protected]