Tuesday 11 May 2010
Betsi Cadwaladr University Health Board Patient Safety Goals for BCUHB
Betsi Cadwaladr University Health Board
Presenter: Dr Brian Tehan, AMD – Patient Safety
Betsi Cadwaladr University
Health Board
Ysbyty Glan Clwyd
Ysbyty Gwynedd
Ysbyty Maelor
Betsi Cadwaladr University Health Board
Aim
To reduce the Betsi Cadwaladr
University Health Board Global
Trigger Tool adverse event rate and
to also reduce the mortality rate.
Betsi Cadwaladr University Health Board
Outcome
Primary Drivers
P1. 1000 Lives
implementation
and spread
P2. Target the
top causes of
Death in BCU
Make care safer
for patients
As evidenced
by reductions in
RAMI and
Adverse Event
Rate
Secondary Drivers
Leadership and a
culture of safety
Consolidate and spread
The “New”- Stroke, Hospital
acquired thrombosis, and
Pressure Ulcers
“Amenable Mortality”?
Interventions
Planned & proposed
Normalization through
CPGs & workstreams
R&D process
Develop the measures and
use clinical data
The evidence base for what is
efficacious
The methodology for
Improvement - Spread
P3. to identify
and prioritise the
causes of harm
P4. Validate
and
standardise the
data
Collaborate- National
Campaigns, SPN ,etc.
“Amenable Harm”?
Notes Reviews, Global Trigger Tool,
IR1, Complaints & Litigation, Serious
Incident Reviews, External Notification
BCU Governance, Stakeholder Groups
etc.
Involve patients and families
in safety improvement
Clinical engagementchallenge through
use
Dash-Boards for Safety
Top Priorities
1. Rapid response to the deteriorating patient
•
•
Safe provision of acute medical care
CG50 NICE
2. Infection prevention & Control
3. Hospital Acquired thrombosis
•
•
Outcome measure
Compliance
Betsi Cadwaladr University Health Board
The Model for Improvement
When you
combine
these 3
questions
with the…
PDSA
cycle, you
get…
What are we trying to
Accomplish?
How will we know that a
change is an improvement?
What change can we make
that will result in
improvement?
Act Plan
…the Model
for
Improvement
Study Do
Betsi Cadwaladr University Health Board
1000 Lives Plus and Intelligent Targets
Existing interventions that will continue as minicollaboratives:
• Preventing stroke through timely management of
Transient Ischaemic Attack (TIA)
• Rehabilitation following Stroke
• Reducing Chronic Heart Failure
• Transforming care – including Reducing Hospital
Acquired Pressure Ulcers and falls in hospital
• Preventing Hospital Acquired Thrombosis
• Rapid Response to Acute Illness (RRAILLS)
• Improving Medicines Management
• Reducing Healthcare Associated Infections
Betsi Cadwaladr University Health Board
1000 Lives Plus and Intelligent Targets
New mini-collaboratives to be introduced from May 2010
onwards:
• Depression
• Dementia
• Preventing Acute Coronary Syndrome
• Patient Identifiers
• Enhanced Recovery after Surgery
• Reducing Falls in Intermediate Care
• Maternity Services
Betsi Cadwaladr University Health Board
1000 Lives Plus and Intelligent Targets
Improvement methodologies and maintenance of
interventions – through Web-Ex and
teleconferencing:
• Reducing avoidable
harm and mortality
• WHO / NPSA Surgical
Checklist
• SBAR
• Communications
• Trigger Tools
•
•
•
•
•
•
Leadership
Patient Stories
Model for Improvement
Normothermia
Critical Care Bundles
Acute Stroke
Betsi Cadwaladr University Health Board
Adverse event rate
Adverse Event Rate per 1000 patient days
60
Data collection
commenced
50
SPI1 2004 – Glan
Clwyd Hospital
40
SPI2 2006 – Wrexham
Maelor Hospital
GTT 2008 - NWW
30
20
Central
10
East
West
Au
g09
O
ct
-0
9
Ju
n09
Fe
b09
Ap
r09
ec
-0
8
D
ct
-0
8
O
Ju
n08
Au
g08
Fe
b08
Ap
r08
ec
-0
7
D
ct
-0
7
0
O
Per 1000 pt days
70
Month
Betsi Cadwaladr University Health Board
BCUHB CHKS
Diagnosis Codes
Top Ten Diagnoses for Deaths at Trust April 2007 to
December 2009
J18:Pneumoniaorganism unspecified
RAMI 10
98.80
C34:Malignant neoplasm of bronchus and lung
199.09
I50:Heart failure
105.93
I63:Cerebral infarction
I21:Acute myocardial infarction
95.75
110.50
A41:Other septicaemia
78.96
J44:Other chronic obstructive pulmonary disease
80.87
I64:Strokenot specified as haemorrhage or infarction
133.78
J22:Unspecified acute lower respiratory infection
101.06
S72:Fracture of femur
Betsi Cadwaladr University Health Board
70.44
Leadership
• Patient Safety Steering Group set up
• Making patient safety a priority at high level
meetings –dashboard developed
• Patient stories polices agreed for use across
BCUHB – agreed programme of use of Patient
Stories
• Previously established Executive
WalkRoundsTM – process and programme for
BCUHB under development
Betsi Cadwaladr University Health Board
Executive WalkRoundsTM
Culmulative Number of WalkRounds Completed
180
160
140
100
80
60
40
20
0
O
ct
-0
D 7
e
c0
F 7
eb
-0
A 8
pr
-0
Ju 8
n0
A 8
ug
-0
O 8
ct
-0
D 8
e
c0
F 8
eb
-0
A 9
pr
-0
Ju 9
n0
A 9
ug
-0
O 9
ct
-0
D 9
e
c0
F 9
eb
-1
0
Number
120
Date
Betsi Cadwaladr University Health Board
Global Trigger Tool
Alignment of processes across BCUHB
– Inclusion and exclusion criteria
– Number of reviewers
– To apply to notes of patients discharged
from April 2010
Betsi Cadwaladr University Health Board
Primary Care Trigger Tool
“The Annual Operating Framework includes the use of
the Primary Care Trigger Tool in one in twenty practices.
Currently, there are no practices in North Wales
consistently using this tool. Consideration needs to be
given on how BCU HB encourage and support this work
in GP Practices.”
1000 Lives BCUHB organisational briefing, April 2010
For further information please contact:Andrea.hobbs@wales.nhs.uk
Betsi Cadwaladr University Health Board
Communication
Do you have a good news/success story to share?
A template for sharing your story across BCUHB and
possibly in the local media is available from
Sylvia.hughes@wales.nhs.uk
Please help to
Spread the learning and celebrate the successes
Betsi Cadwaladr University Health Board
Leadership
“Executive leadership plays a key role in identifying and driving spread of
reliable processes – it is therefore imperative for the organisation to identify
executive leads for all content areas. Tier 1 and tier 2 posts are now well
established and all should be participating in Leadership Walk Rounds.”
1000 Lives Organisational Briefing, April 2010
Intervention
Measurement
Executive
AOF monitoring tool
accountability for
each 1000 Lives Plus
clinical content area
WalkRound
Number of Board level
programme
WalkRounds
Implementation
Date
April 2010
April 2010
Betsi Cadwaladr University Health Board
Leadership
Intervention
Measurement
Implementation
Date
Local targets for harm
reduction
Mortality Rate
Adverse Events Rate:
Trigger tool for hospitals
Primary care trigger tool (1 in 20
practices required)
Ambulance Service trigger tool
April 2010
Mini-collaborative sign-up
Number of mini-collaboratives
signed up
April 2010
Betsi Cadwaladr University Health Board
Critical Care
“Central Venous Catheter (CVC) and Ventilator Care (VC) bundles are well
established and sustained across the three sites; the sepsis bundles (sepsis
six, sepsis resuscitation and sepsis management) continue to need further
improvement focus to produce the same level of reliability.
Communication across the three sites is very good – with sharing of good
practice and improvement facilitated by the network.”
1000 Lives BCUHB organisational briefing, April 2010
Intervention
Measurement
Implementation
Date
Ventilator care
bundle
Compliance with bundle
in all adult ITU’s
April 2010
VAP rate per 1000
ventilator days
Ongoing (April
2010)
Betsi Cadwaladr University Health Board
Critical Care
Intervention
Measurement
Implementation
Date
Central line insertion
and maintenance
bundles
Compliance with both bundles in April 2010
all adult ITUs
Incidence of central line infections
per 1000 catheter days
Compliance with both bundles in
remaining areas
April 2011
Incidence of blood stream
infections including
Staphylococcus aureus
April 2010
Betsi Cadwaladr University Health Board
Rapid Response to Acute Illness
“The campaign team are aware from attendance at the learning sets that the
BCU HB teams are involved in this content area but there is paucity of reliable
process data on the extranet to comment on progress.
There was excellent work on investigating the cardiac arrest data (east) after a
signal within the data identified an increased rate. It is important that any
findings from the investigative case note reviews that result in the planning of
improvement work is implemented using the methodology advocated by the
campaign – the Model for Improvement.”
1000 Lives BCUHB organisational briefing, April 2010
Intervention
Measurement
Sepsis
resuscitation
bundle
Compliance with Sepsis Six
resuscitation bundle
in receiving units ( A&E, MAU,
SAU etc)
Implementation
Date
October 2010
Betsi Cadwaladr University Health Board
Rapid Response to Acute Illness
Implementation
Date
Intervention
Measurement
Sepsis
resuscitation
bundle
Compliance with Early Goal Directed April 2011
Therapy (EGDT) resuscitation
bundle in all Emergency and
Critical Care Areas (A&E, MAU,
SAU, HDU, ICU etc)
NICE CG 50 Admissions,
Recognition an
d Response
bundles
Compliance with 3 bundles in all
acute areas
April 2011
Betsi Cadwaladr University Health Board
Medicines Management
“Localised work ongoing but very little pace associated with the improvement
of warfarin management processes, especially across the interface between
primary and secondary care – process mapping event held before the end of
2009 does not appeared to have progressed.”
1000 Lives BCUHB organisational briefing, April 2010
Intervention
Warfarin in hospital
and community
Measurement*

Reduction in INR >5 and INR
>8

Increase the proportion of INR
within 0.5 of target
Implementation
Date
April 2010
Betsi Cadwaladr University Health Board
Healthcare Associated Infections
“Hand hygiene in secondary care, alongside antibiotic stewardship in both primary and
secondary care, remain the key process measures in relation to driving down the
incidence of Clostridium Difficile and MRSA.
Hand hygiene compliance is not sustained above 95% across the organisation (for
medical, surgical and critical care areas) although critical care has demonstrated an
improvement in the east – but this is against a background of reduced observation
sample size.
Antibiotic stewardship demonstrates reliability in both primary and secondary care
areas but again this appears to be illustrated in test/pilot areas only.”
1000 Lives BCUHB organisational briefing, April 2010
Intervention
Prevent
transmission
Measurement
Hand hygiene compliance
Patient equipment decontamination
Patient isolation
Outcome measures include incidence of
Staphylococcus aureus blood stream infections
and Clostridium difficile infections
Implementation
Date
April 2010
Betsi Cadwaladr University Health Board
Healthcare Associated Infections
Intervention
Measurement
Implementation
Date
Improve
Antimicrobial use
Compliance with local antimicrobial use
policy
Antimicrobial usage data
October 2010
Urinary catheter
related infections
Care bundle for
insertion and
maintenance of
urinary catheters
Bundle compliance
Infections surveillance
October 2010
Betsi Cadwaladr University Health Board
Hospital Acquired Pressure
Ulcers
Intervention
Skin bundle or
appropriate alternative
technique
Measurement
Compliance with skin bundle or
appropriate technique
Implementation
Date
April 2011
Betsi Cadwaladr University Health Board
Surgical Complications
“Well established, reliable process measures are sustained for this work
stream across all acute sites. Initial engagement with community care (i.e. the
use of the WHO checklist and appropriate hair removal) has commenced to
support the roll out of these interventions.”
1000 Lives BCUHB organisational briefing, April 2010
Intervention
Measurement
Implementation
Date
WHO / NPSA Surgical
Checklist
Whole team using the checklist April 2010
Prevent post operative
wound (surgical site)
infection in elective
surgery
Surgical site infection
surveillance for c section and
orthopaedics
April 2010
Betsi Cadwaladr University Health Board
Surgical Complications
Intervention
Measurement
Implementation
Date
Appropriate preoperative hair removal
How to Guide
April 2010
Maintain
peri-operative
normothermia
How to Guide
NICE guidelines
April 2010
Betsi Cadwaladr University Health Board
Hospital Acquired
Thrombosis
“There is very little engagement with this mini-collaborative at present. The
only measurement submitted to support the process of risk assessment,
appropriate prescribing and administration of thrombo-prophylaxis currently
includes only elective surgical patients, and not medical patients; therefore it is
recommended that the leadership team at BCU HB nominate a lead to support
participation in this content area.”
1000 Lives BCUHB organisational briefing, April 2010
Intervention
Risk assessment of all
patients for hospital
acquired thrombosis
Measurement
Risk assessment of all patients
Implementatio
n Date
April 2010
Betsi Cadwaladr University Health Board
Intelligent Targets – how much by when
Content
Area
Intervention
Measurement Implementation
Date
Acute Stroke
4 bundles – first
hours, first day, first 3
days, first 7 days
Compliance with
bundles
October 2010
Transforming
care
Programme
participation
Sign up
April 2010
Quality
Improvement
Capacity
Active programme to
substantially increase
skills across clinical
and managerial
workforce
From October
2010
Betsi Cadwaladr University Health Board
Organisational Briefing
Key Recommendations
The Campaign would endorse the following to ‘stack the cards’ in the favour of
Health Boards achieving their goals and aspirations.
•Take a strategic approach to quality improvement:
Building the will to make measurable systemic improvement as quickly as
possible. This will needs to be generated at all levels, and needs to include the
will of senior leaders to make new ways of working more attractive and
engage staff commitment and enthusiasm.
Encouraging and spreading ideas about alternatives to the status quo which
are robust enough to form the basis of new working systems; and also ideas
about how to introduce them.
Attending relentlessly to the execution of an aligned range of improvement
initiatives into the daily work of the organisation.
Betsi Cadwaladr University Health Board
Organisational Briefing
Key Recommendations
•
Ensure a data-driven approach to measuring progress is maintained in the
Health Board. Have the ability to understand the variation in your system
and turn data into intelligent and useful information. Boards need to
recognise that organisation level measures can mask variation between
services. The capability to drill down to examine service level mortality and
harm is therefore essential.
•
Reliable processes are the key to shifting outcomes. It is essential for
leaders to set expectations and use process improvement measures to
hold teams to account for local progress.
•
Identify executive leads for each work stream and , working with each
content team, devise spread plans to enable the good work tested within
the pilot areas to be rolled out in a structured and coordinated manner.
1000 Lives BCUHB organisational briefing, April 2010
Betsi Cadwaladr University Health Board
Organisation Briefing Overview
“BCU HB has demonstrated throughout the life of the campaign its
ability to take on new interventions and successfully test and
implement changes through the use of PDSA’s and supported by
continuous measurement. What is evident, via the extranet progress
reporting is that the ability to spread outside the pilot areas has
proved challenging and this limits the effect that process reliability
will have on organisational outcomes. Spread is not organic and can
only be affected by the continued structured application of the
methodology and strong executive and clinical leadership.”
1000 Lives BCUHB organisational briefing, April 2010
Betsi Cadwaladr University Health Board
Organisation Briefing Overview
“Participation and commitment of individuals and teams from BCU
HB have been highly visible in the majority of work streams. The
campaign team have identified that there are significant ‘enablers’
across the organisation, but as their capacity is often limited to their
own area of expertise, their ability to drive spread is restricted.
Increased capability and capacity must be a priority for BCU HB, if
the existing campaign interventions are to be reliably sustained and
spread and new interventions are to be taken on and successfully
tested and implemented by the organisation.”
1000 Lives BCUHB organisational briefing, April 2010
Betsi Cadwaladr University Health Board