Clinical Quality & Safety Improvement Strategy
‘Quality Matters’ is the clinical quality and safety improvement strategy for County Durham and Darlington NHS Foundation Trust. The purpose of this strategy is to support the delivery of the organisation’s vision, which is as follows:
‘Right First Time, Every Time’
The Trust’s ambition
Since 2011, the Trust has been an integrated healthcare provider, providing services in both acute and community settings, supplemented by health improvement services. Through consultation with our staff, we developed our mission statement ‘with you all the way’. This reflects our commitment to provide the best possible care to our patients at all stages along their care pathway and the best possible experience to our patients and staff, using resources wisely. Reflecting these different elements, we also articulated four ‘best’ touchstones to supplement our mission statement.
Recently the Trust has reviewed its future direction, with its staff and external stakeholders and has affirmed both: a
· A vision for the future of ‘Right First Time, Every Time’: we want to ensure that our patients are treated in the right place, by the right clinician, first time and every time, 24/7; and
· A set of strategic principles setting out standards that our services should meet in order to realise our vision.
‘Quality Matters’ is one of the Trust’s two core strategies for realising our vision, together with our Organisation Development Strategy, ‘Staff Matter’. They will be supported with strategic developments in enabling areas such IT, Estates and Workforce.
This strategy therefore complements the Trust’s Organisation Development Strategy, ‘Staff Matter’. Together these two strategies set out the organisation’s principles and objectives in order to:
· Improve the quality of patient care (Safety, Effectiveness and Experience)
· Improve the experiences of staff in terms of career development and behaviours.
The whole framework is encapsulated in the diagram overleaf:
Values and behaviours
Alongside the development of the above framework, we have decided to adopt the NHS Constitution values as our Trust values. We used the values to engage with staff to develop our behavior framework. These will underpin the delivery and success of this strategy. We will recruit and nurture our staff so that we see these values and behaviours at all times from all staff. The values are as follows:
The behaviour framework can be found at Appendix 1.
How we developed the Strategy
We have used a discussion document for over 12 months to enable stakeholder engagement to influence our evolving clinical and quality strategy. These were originally two separate documents ‘Right, first time, 24/7’ and the Quality Strategy 2013-2015. However, these have now been merged into one overarching strategy; this document. The decision to have one document for both the provision of clinical services and the ongoing improvement of quality and safety was suggested by our lead clinicians and one that stakeholders agreed with. As such, this document encompasses and replaces the Quality Strategy approved by the Board in October 2013. The Clinical Strategy Steering Group will continue to drive the ‘Effectiveness’ priorities of this strategy, building on all the work which has taken place to date in evaluating options for service configuration and service improvement areas under the three ‘Breakthrough’ headings of:
· Transforming Unscheduled Care
· Centres of Excellence; and
· Integration and Care Closer to Home
In addition, this strategy incorporates the Trust’s obligations and priorities in its Quality Accounts and other safety initiatives including the ‘Sign up to Safety’ pledges (Appendix 2). The priorities were agreed via stakeholder events, Quality Account engagement and more recently focus groups with a variety of staffing groups. The aim of this is to bring all of our priorities into one overarching strategy and plan.
Areas that are still important but that the Trust has already made significant improvements on, such as health care acquired infections, will still be monitored internally and outcomes shared with our stakeholders. However, this strategy focuses on the organisation’s most significant quality improvement priorities.
Priorities for 2015-2017
The NHS, since the publication of High Quality Care for All[1] in 2008, has used a three-part definition of quality. NHS England describes this on its website as:
‘The single common definition of quality which encompasses three equally important parts:
• Care that is clinically effective- not just in the eyes of clinicians
but in the eyes of patients themselves;
• Care that is safe; and,
• Care that provides as positive an experience for patients as
possible
High quality care is only being achieved when all three dimensions are present- not just one or two of them. And when we strive for high quality care, we must do so for everyone, including those who are vulnerable, who live in poverty and who are isolated. By seeking to deliver high quality care for all, we are striving to reduce inequalities in access to health services and in the outcomes from care.’
As such, the priority areas for clinical quality improvement and safety for CDDFT are aligned to these three essential dimensions.
Safety
Patient Falls
Sepsis
Learning from incidents
Effectiveness
Right patient, right place, right time
Care bundles
Health Improvement
Unscheduled Care
Experience
Dementia Care
End of Life
Nutrition & Hydration
Monitoring & Reporting
The Quality & Healthcare Governance Committee is responsible for providing assurance to the Board of Directors that the Trust is managing the quality of patient care, the effectiveness of clinical interventions, patient experience and patient safety. The Committee will review the quality goals at its meetings to ensure that progress is being made in relation to the key areas for improvement.
Operational Committees within the Trust will also provide specialist advice and monitoring for their dimension (see table below).
In order to track progress there will be one singe quality improvement plan that is cross referenced to other relevant quality initiatives, e.g. CQUIN, Quality Accounts, Sign up to Safety etc. Progress will also be reported in the Trust’s annual Quality Accounts, which will be made available on the Trust’s website, NHS Choices and included in the Trust’s annual report.
Measurement tools and outcome measures will be identified, developed and agreed by Quarter 1 2015 to enable quantitative monitoring in addition to work-stream updates.
Priority / Operational Lead (s) / Accountable Director / Operational CommitteePatient Falls / Joanne Todd / Director of Nursing / Safety Committee
Sepsis / Lisa Ward / Medical Director / Safety Committee
Learning from Incidents / Joanne Todd / Director of Nursing / Safety Committee
Right Patient, Right Place, Right Time / Diane Murphy / Medical Director / Clinical Strategy Steering Group
Care Bundles / Jeremy Cundall / Medical Director / Clinical Strategy Steering Group
Health Improvement / Lee Mack / Medical Director / Clinical Strategy Steering Group
Unscheduled Care / Stuart Dabner / Medical Director / Clinical Strategy Steering Group
Dementia Care / Jayne McClelland/David Bruce / Director of Nursing / Patient Experience Forum
End of Life / Julie Clennell / Director of Nursing / Patient Experience Forum
Nutrition & Hydration / Jennie Winnard / Director of Nursing / Patient Experience Forum
Patient Falls
What do we want to achieve?
We will ensure that all appropriate measures are taken to reduce the chance of patients falling & suffering harm.
Why is this important?
Patient falls continue to be one of the highest adverse events reported. This often results in harm to patients and occasionally death. Successful prevention strategies include identifying patients who have the highest risk for sustaining a serious injury from a fall and taking preventive action to modify and compensate for these risk factors. Reporting all falls or near misses as incidents helps us identify additional risk factors, take action where appropriate and share learning.
How will we achieve this?
· Falls Group to investigate the causes of preventable falls, using incident and near miss information
· Work-stream plan to be developed and monitored by the Falls Group
· Falls Care Bundle to be monitored as a process measure
· Root cause analysis (RCA) investigations to be undertaken rapidly following any serious harm caused following a fall
· Aggregated RCA to be undertaken of falls resulting in serious harm over the last 12 months.
How will we know we have been successful?
RNo preventable deaths from falls
ê Year on year reduction in incidents reported for preventable falls
causing harm to patients
é Increase in compliance with the Falls Care Bundle
Sepsis
What do we want to achieve?
We will identify & treat sepsis at the earliest opportunity.
Why is this important?
Sepsis is a life threatening condition that arises when the body’s response to an infection injures its own tissues and organs. Sepsis leads to shock, multiple organ failure and death, especially if not recognised early and treated promptly.
Sepsis claims 37,000 lives annually in the UK. Early intervention can save lives, reduce length of hospital stay and the need for critical care admission.
How will we achieve this?
· Implement the sepsis care bundle in all areas of the Trust
· Develop a post-1hour pathway to start when the bundle elements have been completed
· Develop an audit tool and identify outcome measures
· Raise professional awareness internal and external to the Trust through partnership working, study days and ward based education
· Raise public awareness of sepsis through the World Sepsis Day & Medicine for Members events
How will we know we have been successful?
RZero ‘failures to rescue’ (people whose clinical condition deteriorates
but where this could have been better managed or prevented) as a
result of sepsis
RNo deaths from sepsis where the sepsis has not been identified &
treated appropriately.
RCompliance with the care bundle
Learning from Incidents
What do we want to achieve?
We will inform patients, families and staff when we make mistakes, investigate and share any lessons we learn, and implement change to prevent recurrence, where possible.
Why is this important?
It is important that patient safety incidents that could have or did harm a patient receiving care are reported so they can be learnt from and any necessary action can be taken to prevent similar incidents from occurring in the future, where possible.
How will we achieve this?
· Understand which areas/staffing groups are good or poor reporters of incidents
· Develop an education/awareness programme to increase the reporting of incidents that could have or did cause harm
· Train staff to undertake robust Root Cause Analysis investigations to identify causes & contributory factors of incidents
· Monitor actions taken to reduce harm – both in response to RCA investigations and following thematic analysis of incidents
· Aim for a reduction in the proportion of incidents causing harm to patients, including patient falls, medication issues and avoidable pressure ulcers.
How will we know we have been successful?
RNo Never Events
RNo preventable pressure ulcers
ê Year on year reduction in medications incidents resulting in harm
ê Year on year reduction in avoidable falls resulting in harm
é Year on year increase in patient safety incident reporting (particularly
near misses & no harm incidents). Reported as being in the upper
quartile in the National Reporting & Learning System for patient safety
incident reporting.
Right care, right place, right time
What do we want to achieve?
We will ensure that patients and service-users are cared for in the most appropriate clinical environment by staff with the right skills, and ensure that all transfers of care to other clinicians and care settings are clinically necessary.
Why is this important?
The earlier a patient is seen, diagnosed and treatment plans agreed the better their outcomes of care and experience are. This also improves use of resources by removing, repeated, unnecessary or duplicated assessments and tests. It is also known that many patients have been moved from one ward to another for reasons not related to their specific care or condition. These issues can resulting in a poor patient experience and increase risks to patient safety as a result of fragmented care. If a patient does not receive the right care in the right place at the right time, this can result in delayed discharge or unplanned readmission to hospital.
How will we achieve this?
By developing and implementing plans and service improvements, including the work on service configuration and strategies in our three ‘Breakthrough areas: Transforming Unscheduled Care; Centres of Excellence and Integration and Care Closer to Home – led by the Clinical Strategy Steering Group:
· Understanding patient flow to implement change
· Planning patient discharges as early as possible in the patient and enacting plans in a timely manner
· Monitoring and understanding why patients are transferred between wards for non-clinical reasons
· Reviewing and implementing new ways of working that focus on removing duplication and waste in a patient’s pathway of care
· Developing workforce plans that focus on “front of house” services being consultant delivered
How will we know we have been successful?
ê Year on year reduction of patient transfers for non-clinical reasons
é Year on year decrease in patients with delayed transfer or discharge
ê Year on year reduction of readmissions to hospital
é Improved clinical outcomes i.e. mortality
ê Reduction in length of stay
é Improved staff experience as measured in the staff survey
J Positive patient feedback in the FFT, outpatients’ survey, discharge
surveys & national inpatient surveys.
Care Bundles
What do we want to achieve?
We want to achieve the best clinical outcomes in nationally benchmarked pathways, such as fractured neck of femur. We will identify other clinical pathways/best practice bundles that could increase the quality & effectiveness of our care.
Why is this important?
A number of ‘best practice care bundles’ have been developed to support clinicians in providing care that is evidence based and known to provide the best results. Research continues to provide innovative solutions and develop new pathways to treat patients. It is important that the best possible care and treatment is provided to achieve the best clinical outcomes.