Reducing Harm and Mortality in
Hywel Dda Health Board
May 11th 2010
Reducing Harm and Mortality in Hywel Dda Health Board
Reducing Harm & Mortality in
Hywel Dda - Our Main Aims
• Reduce RAMI to below 100 in 2 years
• Reduce episodes of harm by 25% in 2
years
Reducing Harm and Mortality in Hywel Dda Health Board
Executive Leads
Janet Wilkinson:Leadership
Dr Simon Mahon Medical Director:Critical Care& Rapid Response to Acute Illness
Bernadine Rees:Medicines Management
Tony Chambers:Healthcare Associated Infections
Reducing Harm and Mortality in Hywel Dda Health Board
Executive Leads
Caroline Oakley Director of Nursing:Hospital Acquired Pressure Ulcers
Chris Wright:Surgical Complications
Kathryn Davies:Hospital Acquired Thrombosis
Dr Sue Fish Medical Director:Acute Stroke
Reducing Harm and Mortality in Hywel Dda Health Board
RAMI 2010
Our aim is to reduce
the RAMI to below 100
and also to reduce the
variation in our
monthly RAMI scores
Reducing Harm and Mortality in Hywel Dda Health Board
How We are going To Achieve
Our Aims
• By Using Continuous
Quality Improvement
Methodology
Reducing Harm and Mortality in Hywel Dda Health Board
How We are going To Achieve
Our Aims
Reducing Harm and Mortality in Hywel Dda Health Board
How We are going To
Achieve Our Aims
• Each ward/department required to sign
up to at least one quality Improvement
project inline with the requirements of the
Health Board Quality Improvement
strategy and 1000 Lives+ content areas
Reducing Harm and Mortality in Hywel Dda Health Board
How We are going To
Achieve Our Aims
Quality Improvement Project Notification Form
(For guidance on completion please see the how to guide)
1.
• Each
ward/department
has to complete
quality improvement
project notification
and approval form
What is the area/service for improvement
Page 1
of form
2.
Who are the team members?
Name
Role
Name
Role
Name
Role
Name
Role
Name
Role
3.
Improvement Aims (aim should be clear, specific, measurable, time-specific and patient centred)
4.
Project deliverables
a. What numerical target are you striving for
b. What changes in the system are you expecting
Reducing Harm and Mortality in Hywel Dda Health Board
How We are going To
Achieve Our Aims
• These forms will be used to track the
quality improvement projects and ensures
that each project has a sponsor and has
been agreed
• They will also set out the reporting
arrangements for the project
Reducing Harm and Mortality in Hywel Dda Health Board
Quality Improvement Project
Feedback/Communication form
Quality Improvement Project
Progress form
Ward/Department
County
Each ward/department will be
required to provide updates
on progress on to the 1000
Lives+ teams monthly
Month
Project Leader
Project Progress
Planning
Testing
Implementing
Spreading
Number of PDSA’s completed so far
(please attach copies)
Successes this month
Problems this month
Signature
Reducing Harm and Mortality in Hywel Dda Health Board
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Driver Diagram
Weekly review of all deaths in secondary care
Analysis of CHKS data to identify areas of concern to identify
specialities that have high RAMI and/or excess deaths
Reduce Mortality
Levels within Health
Board
Validation of CHKS and coding data in Mortality and Morbidity
meetings
Address data quality Issues with CHKS data
 Address Backlog of un-coded notes
 Difficulty in coding some patients notes
Reduction of
RAMI to below
100 and the
numbers of
harm to
patients by
25%
Implementation of
Quality Improvement
and Patient Safety
Strategy
Being Safe
Being effective
Improving the Patient Experience
Undertake GTT audits in all localities (20 sets per hospital minimum
Train enough staff to undertake GTT audits
Episodes of harm
occurring to some
patients
Execs to drive forward content areas of 1000 lives+ campaign to
reduce episodes of harm to patients
 Leadership
 Critical Care
 Medicines management
 Healthcare Associated Infections Hospital Acquired Pressure
Ulcers
 Acute Stroke
 Hospital Acquired thrombosis
 Surgical Complications
Quality & Safety teams to be setup in each County which
incorporates 1000 lives+ and Quality & Patient safety
strategy
Reducing Harm and Mortality in Hywel Dda Health Board
Reduction of RAMI and Harm
Primary Drivers
• Reduce Mortality Levels
– Weekly Review of all Deaths in Secondary Care
– First review meeting held (Execs & AMD’s in attendance).
– 39 Deaths reviewed
• Implementation of Quality Improvement
and Patient Safety Strategy
– How to Guide for Health Board staff being written
• Reduce episodes of harm to our patients
– This will be achieved by ensuring all elements of the 1000 Lives+ are
implemented along with achieving the aims of the Quality Improvement
Strategy
Reducing Harm and Mortality in Hywel Dda Health Board
Reduction of RAMI and Harm
Secondary Drivers
• Analysis of CHKS data to identify areas of
potential concern
– This work has already started
• Address data quality issues
– Reduce backlog of un-coded notes
• 6000 sets of un-coded notes coded in 6 weeks
– Improve systems for coding of patients notes
• Discharge summaries/letters being revised
Reducing Harm and Mortality in Hywel Dda Health Board
Reduction of RAMI and Harm
Secondary Drivers
• Improve systems for undertaking GTT
audits in 4 main hospitals
– 10 sets every two weeks
– Train more staff to undertake GTT audits
– Improve system for obtaining patients details
and retrieval of notes
Reducing Harm and Mortality in Hywel Dda Health Board
Reduction of RAMI and Harm
Secondary Drivers
• Executive lead for each content area
tasked with driving forward the initiatives
helping to ensure that harm and mortality
reduction targets are met
• Quality and Safety teams to be set up in
each county
Reducing Harm and Mortality in Hywel Dda Health Board
Clinician Engagement
• Mortality and Morbidity meetings to be rolled out
across the Health Board
• Standard Agenda to include
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–
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Mortality Review
CHKS validation
Unexpected admissions to ITU
Cardiac Arrest Qualitative audits
Adverse Incident
Infection control issues
GTT
Reducing Harm and Mortality in Hywel Dda Health Board
Key Quality Issues Currently
Being Addressed
•
•
•
•
•
•
Standardised Handover (SBAR)
Clerking Performa
Track and Trigger
Improved discharge/death documentation
Clinicians engagement with clinical coding
DNAR
Reducing Harm and Mortality in Hywel Dda Health Board
Driver Diagram
Develop an
infrastructure that
promotes
quality care
(Transformational
Leadership)
Improved
general
ward
outcomes
(Reduced
infections,
crash calls,
pressure
ulcers, falls,
medication
errors,
increase
sense of
patient
empowerment
and improve
care,
communicatio
n and
discharge
processes)
Implement Empowering Ward Sisters leadership development standards
Ensure the patient care objectives for each ward are aligned to Health Board priorities
Develop strong leadership for ward based integrated multidisciplinary teams
Measure, track and communicate progress towards achieving the vision and objectives
Provide an
environment that
has efficient and
organised systems
in place
(Releasing Time to
Care)
Create efficient and sustainable working environments and systems of work
Develop visual information and communication systems to convey patient information
Reduce pressure ulcers by 50% (See separate Driver diagram)
Provide appropriate,
reliable and safe
care to patients
using evidencebased therapies
(Safety & Reliability)
Early warning system (EWS) to identify patient deterioration & early response systems in
place to respond to deterioration
Reduce patient falls by 50% (see separate driver diagram)
Reduce healthcare associated infections by targets contained within the quality strategy
and AOF
Create a highly
effective and
collaborative
multidisciplinary
team and safety
culture
(Teamwork &
Vitality)
Ensure patient and
family centred care
(Patient and family
centred care)
Reliable multi-disciplinary care planning, communication and collaboration
Use of SBAR principles by 100% of staff
Ensure patient’s physical comfort
Optimise patient transfer / discharge to their own home or other facility
Involve patient and family in goal setting processes
Promote open communication among team, patient and family
Ensure patient centred end of life care planning
Reducing Harm and Mortality in Hywel Dda Health Board
General Ward Primary Drivers
• Develop an infrastructure that promotes quality care
(Transformational Leadership)
• Provide an environment that has efficient and
organised systems in place (Releasing Time to Care)
• Provide appropriate, reliable and safe care to patients
using evidence-based therapies (Safety & Reliability)
• Create a highly effective and collaborative
multidisciplinary team and safety culture (Teamwork
& Vitality)
• Ensure patient and family centred care
Reducing Harm and Mortality in Hywel Dda Health Board
General Ward Secondary
Drivers (Transformational
Leadership)
• Continue to implement the ‘Empowering Ward
Sisters’ principles for leadership & development in all
areas
• Establish integrated multi-disciplinary teams
supported by the ward/ department Leader
• Ensure patient care & ward objectives are
measurable & aligned to the Health Board priorities
Reducing Harm and Mortality in Hywel Dda Health Board
General Ward Secondary Drivers
(Releasing Time to Care)
Establish open and accessible processes to report outcome
measures
‘Knowing How We Are Doing Boards’ are creating opportunities for staff, patients &
public to understand the information and it’s implications for practice.
Create efficient sustainable working environments and
systems of work
5’s principles are one example being used to achieve sustainable changes with staff
commitment
Develop visual information/ communication systems to convey
patient information
‘Patent Status At A Glance’ Boards are being developed to support this, with some areas
investing in white board technology
Reducing Harm and Mortality in Hywel Dda Health Board
General Ward Secondary
Drivers (Safety & Reliability)
• Reduce Pressure Ulcers by 50% (See
separate driver diagram)
• Reduce Patient Falls by 50% (See separate
driver diagram)
• Reduce HAI infections by targets within
the Quality strategy and AOF
Reducing Harm and Mortality in Hywel Dda Health Board
General Ward
Secondary Drivers
(Safety & Reliability)
• Modified early warning system (MEWS)
to identify patient deterioration
– Currently 3 different systems in use
– Scoring systems being aligned to ensure
consistency
– Health Board wide system being developed
Reducing Harm and Mortality in Hywel Dda Health Board
General Ward
Secondary Drivers (Teamwork &
Vitality)
• Establish accurate & accountable
MDT care planning
• Ensure all MDT communication /
handover processes apply the
principles of SBAR
some areas have linked the handover to the Patient Status
At A Glance board, improving accuracy of information,
patient safety and effective use of staff time
Reducing Harm and Mortality in Hywel Dda Health Board
General Ward Secondary
Drivers (Patient & Family Care)
• Ensure patients physical comfort
• Involve patients & family with care planning goal
setting and discharge planning
National Fundamentals of Care Audit provides information regarding the patients’ perception
annually to all wards, additional short stay areas to be included .
• Communicate openly and effectively amongst the
MDT, Patient & Family
• Ensure Patients wishes are respected within end
of life care planning
–
End of life care pathway provides auditable information
Reducing Harm and Mortality in Hywel Dda Health Board
Driver Diagram
Risk Identification
Reduce the
Percentage
of Hospital
acquired
Pressure
Ulcers(per
1000 patient
days
By 50% by
2012
Understand the risk factors for
acquiring pressure ulcers
Understand the local context &
analyse local data to assess patients
on ward/unit most at risk
Utilise patient ‘At risk’ cards to quickly
identify those at increased risk
Assess pressure ulcer risk on
admission for ALL patients
Risk Assessment
Re-assess skin every 8 hours
Initiate and maintain correct and
suitable preventative measures
Address these areas:
Reliable
Implementation of the
SKIN ‘bundle’
Identification, grading
of pressure ulcers
existing on
admission/transfer &
appropriate
intervention
Education
Surface
Keep Turning
Incontinence
Nutrition
Initiate and maintain correct and
suitable treatment measures
Utilise the local Tissue Viability
nursing expertise
Educate staff regarding the
assessment process, identification
and classification of, and treatment of
pressure ulcers
Educate Patients & family
Develop patient information pack
Reducing Harm and Mortality in Hywel Dda Health Board
Falls Primary Drivers
•
•
•
•
•
Identification of Risks
Multifactorial risk assessment
Multifactorial interventions
Communication of falls risk status
Education of staff, patient and family
carer
Reducing Harm and Mortality in Hywel Dda Health Board
Falls Secondary Drivers
• Each area to assess their local falls risk– analysis of falls on units by: time of day,
patient’s age range, type of patients,
condition.
• Utilisation of warning cards (above
patients head) for patient with a history of
falls
Reducing Harm and Mortality in Hywel Dda Health Board
Falls Secondary Drivers
• Each ward/Department to work with allied health
colleagues to assess
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Falls History/ Medication review
Gait Balance, mobility, muscle weakness
Osteoporosis risk
Functional ability
Visual & Cognitive impairment
Urinary incontinence
Cardiovascular assessment - Hazards
Reducing Harm and Mortality in Hywel Dda Health Board
Falls Secondary Drivers
• Involvement of patient & family
– Include falls status in ward handovers and
safety briefings
– Develop a Falls prevention information pack
for patients, families and caregivers
– Develop a Falls education pack and Falls
preventions program for staff
Reducing Harm and Mortality in Hywel Dda Health Board
Driver Diagram
Understand local falls risk- analyse
falls on units by: time of day, patient’s
age range, type of patients, condition.
Utilise warning cards for patient with
history of falls
Risk Identification
Multi-Factorial
Risk Assessment
Reduce the
Percentage
of Falls (per
1000 patient
days
By 50% by
2012
Multi-factorial
Interventions
Communication
of
Falls risk status
Education of Staff,
Patient and family/
carer
Falls History/ Medication review
Gait Balance, mobility, muscle weakness
Osteoporosis risk
Functional ability
Visual & Cognitive impairment
Urinary incontinence
Cardiovascular assessment - Hazards
Medication review/withdrawal
Vision assessment
Strength & Balance Training
Preparing the environment
Diversional therapy
Falls prevention toolkits
Hourly toileting rounds
Use of Visual Cues
Involvement of patient & family
Falls intervention team
Include falls status in ward handovers
and safety briefings
Develop a Falls prevention
information pack for patients, families
and caregivers
Develop a Falls education pack and
Falls preventions program for staff
Reducing Harm and Mortality in Hywel Dda Health Board
Pressure Sores
• Baseline
data for
pressure
sores within
the Health
Board
Data is from CHKS
Reducing Harm and Mortality in Hywel Dda Health Board
Pressure Sores Primary
Drivers
•
•
•
•
Risk Identification
Risk Assessment
Implementation of the SKIN bundle
Identification, grading of pressure ulcers
existing on admission/transfer & appropriate
intervention
• Education
Reducing Harm and Mortality in Hywel Dda Health Board
Pressure Sores Secondary
Drivers
• All staff to be able to understand the risk
factors for acquiring pressure ulcers
• Understand the local context & analyse local
data to assess patients on ward/unit most at
risk
• Utilisation of patient ‘At risk’ cards to quickly
identify those at increased risk
Reducing Harm and Mortality in Hywel Dda Health Board
Pressure Sores Secondary
Drivers
• All patients to have their pressure ulcer
risk assessed on admission
• Re-assess skin every 8 hours
• Initiate and maintain correct and suitable
preventative measures when needed
Reducing Harm and Mortality in Hywel Dda Health Board
Pressure Sores Secondary
Drivers
• All wards/Departments to implement the SKIN
bundle which aaddresses these areas:
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–
–
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Surface
Keep Turning
Incontinence
Nutrition
Reducing Harm and Mortality in Hywel Dda Health Board
Time Scales
• May 11th 2010 Health Board Executives and others
attend 1000 Lives+ launch
• May 12th 2010 Aims of 1000 lives+ conveyed to all
Health Board Staff
• End of May/Beginning of June ward/department sign
up to at least one intervention
• The Transforming Care initiative to be implemented
into all ward/in-patient areas by the end of 2012
Reducing Harm and Mortality in Hywel Dda Health Board
Thank You
Reducing Harm and Mortality in Hywel Dda Health Board
Reducing Harm and Mortality in
Hywel Dda Health Board
May 11th 2010
Presenter: Dr Simon Mahon
Medical Director
Reducing Harm and Mortality in Hywel Dda Health Board
Reducing Harm & Mortality in
Hywel Dda - Our Main Aims
• Reduce RAMI to below 100 in 2 years
• Reduce episodes of harm by 25% in 2
years
Reducing Harm and Mortality in Hywel Dda Health Board
Executive Leads
Janet Wilkinson:Dr Simon Mahon:Bernadine Rees:Tony Chambers:Caroline Oakley:Chris Wright:Kathryn Davies:Dr Sue Fish
Leadership
Critical care& Rapid Response to
acute illness
Medicines management
Healthcare Associated Infections
Hospital Acquired Pressure Ulcers
Surgical Complications
Hospital Acquired Thrombosis
Acute Stroke
Reducing Harm and Mortality in Hywel Dda Health Board
RAMI 2010
Our aim is to reduce
the amount of variation
in our monthly RAMI
(2010) scores and
make it more
consistent
Reducing Harm and Mortality in Hywel Dda Health Board
• By reducing the amount of variation in the
RAMI will improve the predictability of
patient outcomes and will help to reduce
the frequency of poor results.
Reducing Harm and Mortality in Hywel Dda Health Board