Transcript Governance & Risk - Royal Devon and Exeter Hospital

Respond, Deliver & Enable
Jul-07
Actuals
Month
Target
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30
-08
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25
Mar-09
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Jan-09
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Mon
Feb-09
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Dec-08
7
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-07
7
t-0
7
Oc
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5
Nov-08
Oct-08
Sep-08
Aug-08
7
p-0
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Inf
15
Jul-08
Se
g-0
10
Jun-08
Au
7
l-0
7
Ju
3
May-08
Apr-08
Ju
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7
5
Mar-08
Feb-08
r-0
y
Ma
Ap
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Jan-08
2
Dec-07
Nov-07
Oct-07
Sep-07
4
Aug-07
Bloodstream Infections
6
Jun-07
May-07
Apr-07
9
Improving Patient
Safety
at the
RD&E
Council of Governors
January 2010, Item 9
Florence . . .
“ It may seem a strange
principle to enunciate
that a sick patient in
hospital will come
to harm ”
Harm can be defined as
anything unwanted or
unexpected
Why should we worry?
 Estimated 900,000 incidents a year result in harm
or near harm to NHS patients (2006)
 25% of incidents and 39% of near misses go
unreported
 840 incidents where a patient will die
 400 will die due to medical device incidents
 27,000 extra bed days
 Average cost of £7.4m per hospital
 Adverse events cost £2b in hospital stays alone
 £400m clinical negligence settlements
(Source: NPSA)
Where are we at?
All new cases of MRSA
identified m ore than 3 days after adm ission
40
35
30
25
20
15
10
5
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M 3
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No of MRSA
Mean
Upper Control Limit
Low er Control Limit
Reduction in Clostridium difficile Infection . . .
Clostridium Difficile Infections
72 hours post admission
Clostridium Difficile Infections 72 Hours Post Admission
30
Total bed days saved per annum = 1815
@ £200 per bed day = £363,000
25
15.11
15
10
7.91
End of First Deep
Cleaning Programme
5
Month
Infections
Mean
Ju
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Clostridium Difficile Infections
20
Patient safety
The vision
for the
Campaign
Previous
Improvement and
safety initiatives:
Pursuing Perfection
2003
Leading Improvement
In Patient Safety
(LIPS)
Programme
2007
Signed up to:
•Patient Safety First Campaign in September
2008
•South West Quality & patient Safety
programme Oct 2009
The campaign cause is:
 To make the safety of patients
everyone’s highest priority
The campaign aim is to achieve:

No avoidable death,
and no avoidable harm
Respond, Deliver & Enable
Is patient safety our top priority?
We’ve made a public statement to our staff and
promoted the use of a number of evidencebased interventions so we can track
improvement over time
RD&E’s own Intervention
(not yet part of Campaign)

Leadership for Safety

Reducing harm from Deterioration

Reducing harm in Perioperative Care
Surgical Site Infection
WHO Surgical Safety Checklist

Reducing harm in Critical Care
Ventilator care bundle
Central line bundle

Reducing harm to patients from Falls
What
have we
signed
up to
SW Quality & Patient Safety Improvement Programme
LEADERSHIP
•
•
•
•
General Ward
Deterioration
HAIs
VTE
Safety briefings
Critical Care
• Central line infections
• VAP
•
•
•
•
Perioperative Care
Surgical site infections
Team briefing
WHO surgical check list
Pe-op VTE
Medicines Management
• Warfarin
• Insulin
• Medicine reconciliation
Leadership for Safety
National & SW Campaign Expectations
Six Actions to Improve Quality and Safety

Develop explicit strategic priorities

Provide demonstrable leadership

Ensure executive accountability

Establish and monitor
explicit system level
measures

Monitor progress and
drive execution of
projects
Build improvement
knowledge and
capability
6
5
Number of Walkrounds

Number of Executive Walkrounds
7
4
3
2
1
0
Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09
Month
The deteriorating patient
SBAR Generic Communication tool
Situation
Background
Action required
Response needed
Piloted and now in use
Proposed new
Observation Chart
piloted and now
in production
one-day snapshot audit results
“… significant improvement in the 08/09 recording
of EWS across all areas compared to 2007 ”
(over 80% of patients had EWS scores)
Aide memoire
Funded by the League of Friends
• Issued to all staff on induction
• EWS plus phlebitis score
• Plans to link to self assessment and ESR
Annual Mortality Review Standards of Care
Review of 50 sets of casenotes of patients who have died
Comparison of October 2007 and November 2008
90
Reviewing:
• 2x2 mortality
table
• Process of care
• Adverse events
80
70
Oct-07
%
Nov-08
60
50
40
Reduction in
Adverse Event Rate:
Mortality Notes
30
20
10
0
Planning failures
Examples
of some
planning
failures
Failure to
recognise,
rescue
Failure to
communicate
ICU admission
Missed ICU
admission
• Management of
– VTE treatment
– GI bleeding
– AF
• Delay in antibiotic treatment
• Missed deterioration
DNR order
120
per 1000 bed days
100
80
60
40
20
0
2007
2008
Interventions
Medicines Reconciliation
 New clerking pro-forma
Small Tests of Change underway
Spreading tests in early 2010
Roll-out of pro-forma during Q2
2010
Audit standards of practice Q3
2010
Falls and Intentional Rounding
• After fatalities, Lead Nurse led a ‘rebellion’ to achieve a
change in staff attitudes and behaviours
• Used tools from ‘improvement science’ and patient safety
– Plan; Do; Study; Act (PDSA) small test of change
– Checklist
for staff
– Intentional
Rounding
check patients
hourly
– Pace
The value of annoted run charts
Weekly Number of Patient Falls
SPC - Wards A & B weekly number of patient falls
Wards A and B - SPC
12
10
IR of all high
risk patients
commenced
Weekly meetings
commenced with
Lead Nurse
8
Number of falls
One very
confused patient
6
4
Initial success
2
Cohorting
patients
commenced
31
/0
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20
14
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/0
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28
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/0
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12
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26
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/0
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/0
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23
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/0
6/
20
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08
/0
7/
20
21
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/0
7/
20
04
08
/0
8/
20
18
08
/0
8/
20
01
08
/0
9/
20
15
08
/0
9/
20
29
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/0
9/
20
13
08
/1
0/
20
27
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/1
0/
20
10
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/1
1/
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24
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/1
1/
20
08
08
/1
2/
20
22
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/1
2/
20
05
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/0
1/
20
19
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/0
1/
20
02
09
/0
2/
20
16
09
/0
2/
20
02
09
/0
3/
20
16
09
/0
3/
20
09
0
Patient Falls
Median
UCL
Date
06/07/09
15/06/09
25/05/09
04/05/09
13/04/09
23/03/09
02/03/09
09/02/09
19/01/09
29/12/08
08/12/08
17/11/08
27/10/08
06/10/08
15/09/08
25/08/08
04/08/08
14/07/08
23/06/08
02/06/08
12/05/08
21/04/08
31/03/08
Individual Value
C
Reducing number of inpatient Falls
Total number of inpatient falls in 10 medical wards
April 2008 to July 2009
Number of falls
Special Cause Flag
60
50
40
30
20
10
0
Patient Safety Structure
Board of Directors
Governance Committee
Medicines
Management
Committee
Patient Safety Steering
Group
Resuscitation
Committee
VTE
Committee
Falls
Project
Adverse
Events
Forum
Learning
Lessons
Group
New group
established
March 2009
New group
established
October 2008
New group
established
July 2008
New group
established
March 2009
Information to be cascaded to Directorate Governance Groups (DGGs)
via members who sit on each committee listed above
Infection
Control
Committee
These groups are existing subcommittees of the Governance
Committee, but have reporting
responsibilities on the national
PSF & SWQPSFP interventions
to the PSSG
Quality Dashboard for the Board
Quality Dashboard
Adverse Events
Adverse Events per 1000 Bed Days
Hospital Standardised Mortality Rate
120
250.0
100
600
150.0
500
100.0
50.0
Lower Control Limit
Upper Control Limit
200
National Average
Adverse Events/1000 Bed Days
CL
-1σ
+1σ
+2σ
+3σ
The HSMR for the 'Diagnoses - HSMR' Groups as published on NHS Choices website
was re-based on the 5th October. This had the efffect of moving the May-08 and Jun09 figure from 89.3 to 94.2, the HSMR for the current 12 month period Jun-08 to Jul09 is 93.2 and as such the RD&E is deemed to be 'as expected'. It should be noted that
this figure is liable to change as the data is refreshed.
A stable baseline has now been ascertained and improvements or deterioration
should be measured against the value of 70.6 Adverse Events per 1000 Bed Days. The
current adverse event rate is being maintained at a level consistant with the 70.6
events per 1000 bed day baseline.
C.difficile Infections ( CDI)
MRSA Bloodstream Infections
Ap
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HSMR
300
0
7
80
400
100
0.0
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7
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Oc
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9
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90
r-0
700
First month of GTT monitoring
200.0
All Incidents
110
Ap
All Incidents Reported
Employee
Patient Anywhere
There were 6867 patient incidents between Oct 08 and Oct 09. This was an increase
of 15% from the same period last year. 10 were catastrophic, 34 major, 128
moderate, 2787 minor and 3908 no harm. For employee incidents there were 2455
between Oct 08 and Oct 09. This was an increase of 6% from the same period last
year. 1 major, 81 moderate, 1540 minor and 833 no harm.
Patient Experience
5
20
4
3
r-0
Ap
Au
Ju
n
r-0
Ap
Higher numbers of CDI have been recorded, in the main due to a period of increased incidence
on one ward. Ribotyping is being undertaken to determine if this reflects an outbreak. In the
interim however, all control measures required for an outbreak have been implemented. For
December ( up to 18th), only 2 cases have been identified trustwide and it is anticipated that by
the end of this month we will be back on trajectory for this quarter.
96%
95%
94%
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Have you felt safe throughout your stay?
g07
Oc
t-0
7
De
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7
Fe
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Ap
r-0
8
Ju
n08
Au
g08
Oc
t-0
8
De
c-0
8
Fe
b09
Ap
r-0
9
Ju
n09
Au
g09
Oc
t-0
9
0
97%
92%
Au
0
98%
93%
7
1
-0
7
5
g07
Oc
t-0
7
De
c-0
7
Fe
b08
Ap
r-0
8
Ju
n08
Au
g08
Oc
t-0
8
De
c-0
8
Fe
b09
Ap
r-0
9
Ju
n09
Au
g09
Oc
t-0
9
2
7
10
Ju
n
15
99%
Answered 'Yes definitely'
6
25
Infections
30
-0
7
Clostridium Difficile Infections
100%
Previous good performance has been maintained.
Have you felt cared for throughout your stay?
Would you recommend this hospital to your friends and family
6 Patients = 1 Nursing Quality Assessment on 1 ward.
Jun-09 Jul-09
Aug-09 Sep-09 Oct-09 Nov-09 TOTAL
Patients 6
24
42
52
49
38
211
Wards 1
4
7
9
10
8
39
29 of 30 Inpatient wards have conducted an NQAT. The Paediatrics tool is finished &
due to be piloted on Bramble and NNU in Dec 09 - Jan 10. The Theatres tool has also
been completed & is to be piloted in Dec 09.
Any questions?