HQIP Partnership Working Award
Clinical Audit Manager (Community Services, Surrey)
Tissue Viability Nurse Specialist (Community Services, Surrey)
Community Hospital Matron (Community Services, Surrey)
Tutor in Community Nursing at Surrey University
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Aims – how the session is planned
Explanation of award category
Describe clinical audit project
Key reflection on success in partnership working
Achieving an ‘outcomes’ focus
Critical success factors
Discussion
The broader national context
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‘part·ner·ship’ (n)
A collaborative relationship... based on trust, equality and mutual
understanding for the achievement of a specified goal (World Health
Organisation, 2009)
Arrangements typically involve joint working to achieve common goals,
with partners sharing risks and rewards. (Audit Commission, 2012)
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HQIP Partnership working award category
Projects submitted for this category must be:
– Jointly carried out with other organisations
– Could include working across NHS sectors
– Trusts from the same sector
– Social care, industry and/or independent healthcare
organisations such as charities or private healthcare
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Our entry
‘...Relentless pursuit of continuous quality improvement in the
prevention and management of pressure damage, to eliminate
avoidable harm, distress and discomfort, experienced
disproportionately by older people in community settings’
Fulfils essential criteria for clinical audit
Florence Nightingale wrote in 1859
“If he has a bedsore, it’s generally not the fault of the
disease, but of the nursing”
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What is a pressure ulcer?
“Localised injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in
combination with shear. A number of contributing or confounding
factors are also associated with pressure ulcers; the significance
of these factors is yet to be elucidated.” (EPUAP 2009)
Pressure damage is associated with:
longer hospitalisation
Increased complications and dependency
Increased vulnerability to infection
Pain, discomfort/infringement of dignity
Increased cost
A significant proportion are avoidable
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Pressure ulcer productivity calculator
Department of Health (June 2010)
Based on 2008/9 prices
– Category 1 = £1,000
– Category 2 = £6,000
– Category 3 = £10,000
– Category 4 = £14,000
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_116669
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Clinical audit aims
Improve prevention
Minimise skin damage
Benchmark to drive improvement over time
Reduce inconsistency
Eradicate avoidable pressure damage
NHS Outcomes Framework:
Domain 4 – Ensuring a positive experience
Domain 5 – Safe environment
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Audit methodology
On ‘audit’ day, all patients with pressure ulcers included
Process measures: Documented
1. Timely Waterlow risk assessment/review
2. Timely nutrition assessment/review
3. Individual care plan
4. Pressure relieving equipment
5. Incident form submitted (category 2, 3 and 4)
Prevalence
Outcome measure
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Examples of key players in this partnership
Patients and carers
General Practitioners
Tissue viability nurse specialists
Community Hospital wards – multidisciplinary
Community nursing teams
Care homes (residential and nursing)
Acute hospital wards – multidisciplinary
Social care
Wound care companies
Safeguarding
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Patient pathway
Own home
Acute hospital
Community hospital
Intermediate care
Step up/step down
Nursing home
Residential home
Community nursing team
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Home
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Resulting culture
Unavoidable complication of immobility?
Inevitable consequence?
Difficult to influence?
Reactive management versus proactive prevention
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Successful partnerships depend on
1)
2)
3)
4)
5)
6)
7)
8)
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Effective communication and leadership
Measurable outcomes
Sustained clinician engagement
Positive culture
Focussed education
Shared responsibility
Jointly devised solutions
Sustainability and ongoing improvements
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Focus on each element of partnership working
In each aspect we:
– reviewed our processes and systems
– strived to work in collaboration with others
– talked and shared ideas
– were brave and changed the way we did things
Examples from each of the elements of partnership working that we hope
will resonate with you
Allow time for questions and sharing of other examples/ideas
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Communication
Raising awareness
Discussing progress
Cooperation
Sharing/transparency
Comparative benchmarking
– Over time
– Between participants
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Measurable outcomes
Improved quality – experience and safe care
Incidence reduced
Prevalence reduced
Experience of pain and discomfort reduced
Time saved to be used more appropriately
Costs reduced
Length of stay reduced
Sustainability – continue to monitor over time
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Sustained clinician engagement
Engagement of all – assessment tools
Consistency
Embedding changes into routine practice
Changed incident reporting form
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Culture
Raised awareness of pressure damage
From ‘treatment’ focus to one of ‘prevention’
‘Unavoidable’ to ‘unacceptable’
Positive incident reporting – how?
Transparency – an open culture
Reflection on shared problem
Joint ownership of need for eradication
Shared drivers for change
Acceptance of ability to influence
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Focused education
Internal and external
Collaboration – bring clarity to quality
One size does not fit all
Targeted education based on identified need
Skills sharing
Ongoing targeted support
Implementation of best evidence
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Shared responsibility
Pressure ulcer pathway
– Prevention, treatment and reporting
– Responsibility, ownership and equality at each level
– Visible focus for action
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Jointly devised solution
Safe Care Steering Group
Community SSKIN bundle
– five best practice elements
Use of SKIN bundle to support local incident reporting
Serious incidents
– Root Cause Analysis (RCA)
– RCA panels and action plans
– Shared learning
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Sustainability
Incident reporting triggers routine clinical audit
Ongoing measurement
Triangulation of data
Education
Review of tissue viability specialist resource
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Template discussion
Sharing of:
– thoughts
– solutions
– innovation
– one action you will take
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National Safe Care CQUIN (May 2012)
Rationale
‘Whilst some 10-12% of all patients suffer from
pressure ulcers, a substantial proportion of these can
be avoided
More older people and more vulnerable patients suffer
from pressure ulcers in community settings. The gap
between the best and worst performers is substantial
Simple inexpensive nursing interventions can
dramatically reduce prevalence’
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‘Safety Thermometer’ CQUIN
improvement goal 2013/14
Pressure ulcers originate across and outside of the
health and social care system
No distinction should be made between ‘old’ (present on
admission) and ‘new’ (developed post-admission)
pressure ulcers for the improvement CQUIN
Organisations should work with partners across the
health and social care system to address the causes
and reduce their prevalence, regardless of source’
Commissioning for quality and innovation (CQUIN):
2013.14 guidance
Draft – December 2012. NHS Commissioning Board
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Best practice evidence and drivers
The management of pressure ulcers in primary and
secondary care – NICE CG 29 (2005)
Pressure ulcer treatment – EPUAP (2009)
Essence of Care – DH (2010)
SSkin Care Bundle – Health Improvement Scotland
(April 2011)
Achieving consensus in pressure ulcer reporting –
Tissue Viability Society (2012)
National monthly Safety thermometer census and Safe
Smarter Care ‘harms’ measurement – CQUIN (2012)
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Best ‘clinical audit’ practice and pressure damage
High quality care in pressure ulcer prevention depends
on simple but consistent nursing (and other clinician)
interventions to prevent ‘harm’
Clinical audit measures consistency across teams,
settings and over time (re-audit)
Critical success factors: CIREM research
– strong likelihood of effective clinical audit
– high impact on patient outcomes
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Alignment between frameworks supports ‘partners’
to identify common ground for integrated working
NHS Outcomes Framework
– 2. Enhancing quality of life for
people with long term conditions
– 5. Treating and caring for people in
a safe environment and protecting
them from avoidable harm
Adult Social Care Framework
– 1. Enhancing the quality of life for
people with care and support needs
– 4. Safeguarding adults who are
vulnerable and protecting them from
avoidable harm
HQIP Clinical audit: ten simple rules for NHS Boards:
‘Ensure with others that clinical audit crosses care boundaries and
encompasses the whole patient pathway’
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Questions
Food for thought on closing:
– ‘Some is not a number’
– ‘Soon is not a time’
– Our partnership audit has given us clarity
– Joint and clear expectation for continual improvement
– ‘Our contribution will be what did not happen to them’
‘The 5 million lives campaign: Institute for healthcare improvement 2006-8’
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