Quality Strategy Update

Aim

To update the NHS Board on the implementation of the NHS Scotland Quality Strategy within NHS Grampian.An update on the actions taken following the Healthcare Commission’s report on Mid Staffordshire NHS Foundation Trust is included.

Strategic Context

The NHS Scotland Quality Strategywas launched in May 2010 and sets out NHS Scotland’s vision to be a world leader in healthcare quality described through the three quality ambitions of safe, effective and person centred:

  • Safe:There will be no avoidable injury or harm to people from healthcare they receive, andan appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.
  • Effective:The most appropriate treatments, interventions, support and services will be providedat the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
  • Person Centred: Mutually beneficial partnerships between patients, their families and those deliveringhealthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

Discussion

The NHS Scotland Quality Strategy is entirely consistent with NHS Grampian’s Health Plan and Health and Care Framework. Since its publication we have continued to progress and embed the quality ambitions and outcomes in all we do.

This report is made up of a number of sections:

6.2.1 Quality in General

6.2.2 The Safe Quality Ambition

6.2.3 The Effective Quality Ambition

6.2.4 The Person-Centred Quality Ambition

6.2.5 An update on action following the Healthcare Commission’s report on Mid

Staffordshire NHS Foundation Trust

6.2.6 Patient Stories

Within Grampian there has been considerable activity in a general sense around implementation of the Quality Strategy and this is detailed in Section 6.2.1.

Patient Safety has always been a priority in Grampian with improvements being delivered. We have been working on implementing the Scottish Patient Safety Programme (SPSP) and have spread this activity to Aberdeenshire Community Health Partnership (CHP), which has an extensive action plan, and to mental health and paediatrics. We have also been implementing the Safety Improvement in Primary Care (SIPC) programme, having been successful in our application to be a pilot site. The detail of this work is given in Section 6.2.2.

A Clinical Effectiveness Strategy has been in place for several years and progress against this has been reported regularly to the Clinical Governance Committee. Section 6.2.3 covers the information about effectiveness work.

Person centred work is another quality ambition. This may be a more recent national area for focus but the range of improvement work is growing and expanding into all areas rapidly. Section 6.2.4 provides more information on our progress with local and national priorities.

The Board received a report in 2010 summarising the progress made in our internal review against the recommendations within the Mid Staffordshire report. The Board asked for an update in 2011. The detail of our own internal annual review is included in section 6.2.5. At the same time an Internal Audit has been conducted and will be reported elsewhere.

Section 6.2.6 covers introducing patient stories to the Board meetings. This will assist in pulling together all aspects of quality from a patient’s perspective.

Key Risks

  • There is a risk that the organisation is unclear on specific quality aims and objectives. The agreement of quality aims for the next year that support the achievement of the Health and Care Framework will assist in mitigating this risk.
  • Obtaining full engagement of all professional groupings to the same level of involvement and priority is challenging. Working with a range of clinical leads and champions will help to mitigate this risk.
  • The ability to produce real time data at different levels in the organisation is a risk but the use of systems such as LanQip will reduce this risk.
  • There is the potential of not being able to demonstrate progress if there are delays to the implementation of the data capture system (LanQip) and any further delays with data submission following the introduction of the Patient Management System (PMS). This risk can be mitigated via an implementation plan for LanQip and via continued work with PMS.
  • Delivering the first phase of the SPSP programme by December 2012 in all relevant wards within ARI and Dr Gray’s and the paediatric programme as well as the additional work that focuses on mortality and adverse events is challenging. This risk is mitigated by a spread plan, executive and management leadership and programme management. Additional Quality and Efficiency funding has also been added to assist with this risk.
  • A risk relates to the need for an integrated approach to quality implementation and infrastructure. The implementation of a Quality Implementation Framework will reduce this risk

Conclusion

The Quality Strategy has facilitated the integration of different aspects of quality work and this now seems to be providing a more cohesive picture and focus for staff at all levels. There is a huge and varied amount of work involving all aspects of the service relating to the three quality ambitions of safe, effective and person centred. This work needs to continue to grow and spread. Future work and programmes need to be brought into this quality integrated approach. A number of general quality improvements are taking place e.g. dashboard and data systems and these now need to be co-ordinated and considered as a whole. This has revealed that there is a need to develop and articulate the quality aims at a Board and senior level in NHSGrampian.

Recommendations

  1. The Board will consider implementing its own aims regarding quality. This could be achieved by:
  2. Developing a Quality Implementation Framework with aims and measures
  3. Reshaping the Board agenda to emphasise quality more explicitly.
  4. Undertaking a Board development session around quality
  1. The Board will prepare for the Board on Board event in 2012 by participating in a preparatory session.
  2. The NHS Grampian Board will receive an annual quality report to include the organisation-wide work relating to safe, effective and person centred care.

Background papers/supporting information

NHS Scotland Quality Strategy.

Executive Lead

Director of Nursing and Quality - Elinor Smith.

Paper prepared by

Helen Robbins- Head of Quality

Brenda J. Lurie- Clinical Effectiveness Team Leader

Jenny Ingram- Safe Team Leader and SPSP Programme Manager

Linda Oldroyd - Person Centred Team Leader and Nurse Consultant for Patient

Safety and Experience

November 2011

Section 6.2.1 Quality in General

A number of actions have been implemented relating to the Quality Strategy:

  • The Health and Care Framework has incorporated aspects of quality and the Prioritisation and Decision-making tool includes specific quality, safety and experience elements.
  • The Quality Dashboard is now a feature at the Clinical Operational Management Team (COMT). The dashboard is a regular feature in the organisation and has been amended as priorities have changed. The aim is to present the dashboard at future Board meetings.
  • The Clinical Operational Management Team has emerged as a clinical version of the standard Operational Management Team meeting but now focuses on clinical issues. The first meeting was held recently.
  • A Quality Framework and “Is your care safe?” tool have been developed and are being used by a variety of staff and in different settings. Both have been incorporated into the Quality Education sessions that have been implemented.
  • Quality Education sessions covering safe, effective and person centred care were piloted in 2010 and have been offered in 2011 and have had over 200 attendees. An evaluation report has been distributed. 94.7% of attendees stated they had decided to make improvements to team practice as a result of attending the education.
  • The second Quality newsletter has been distributed and topics for future editions are building.
  • The Clinical Governance and Risk Management (CGRM) unit has changed its name to Quality, Governance and Risk unit (QGR). The unit redesigned at the end of 2010 to align teams with the Quality Strategy and so now have staff within a safe team, effective, person centred and governance team, with Quality Informatics as the remaining team. The change in unit structure has also led to a redesign of the unit website along the lines of the Quality Strategy. Accordingly the head of the unit has changed her title to Head of Quality.
  • A Quality Implementation Framework is currently being shaped and will incorporate quality objectives to support the Health and Care framework. The framework will consider the improvement structure and capacity/capability map, networking and sharing arrangements, education for improvement, measurement framework and access to real time data, and building a quality culture. This quality model will be used to identify gaps and areas to improve. Staff from the national Quality Hub are assisting us with this work. Some of the points below relate to this framework.
  • A virtual Grampian Quality Improvement group has reconvened and is looking at replicating the national Quality Hub model. The group involves the Quality, Governance and Risk unit, Health Intelligence, Performance Management, Organisational Development, eHealth and staff that have been Scottish Patient Safety Programme Fellows.
  • Discussions are taking place with Performance and Health Intelligence colleagues as there is a growing need to enhance our reporting and sharing of progress and outcomes. For example, the excellent results that we are achieving within the Scottish Patient Safety Programme need to be more widely shared with all staff so that they can see the linkage between the care they provide for their individual patient and the overall quality outcomes that are being achieved. The development of a quality report is work in progress.
  • The aspect of sharing learning is a challenging one that is a constant area for improvement. This relates to sharing learning from a range of aspects including learning from incidents and complaints. Learning notices have been piloted and are now on a standard template for sharing learning and are distributed using the Safety Alert broadcast system. The QGS unitis also developing an electronic version of the previous Sharing and Learning Folders so that staff can provide details of improvement work and share this across the organisation. Templates are also being piloted so that staff can produce information in poster format and then these can be used to submit work for conferences and awards.
  • The availability of real time quality data will be greatly enhanced when NHS Grampian obtains the nationally supported LanQip system which is a Healthcare Quality Improvement portal bringing together data for the Scottish Patient Safety Programme, Better Together, Leading Better Care and Clinical Quality Indicators, Healthcare Associated infection and in-house reports. This is being placed on a server early in December with rollout timetabled for January.
  • A quality event is being planned for early 2012. There is a wealth of excellent quality improvement work being undertaken in NHS Grampian and this event will allow staff to share their work.
  • The national Quality and Efficiency funds have been allocated via a short life group and are to be used on improvement work for e-rostering, maternity, incident reporting in general practice, falls, patient experience, patient safety and data access. This work supports enhancing our capability and capacity around quality improvement work and will be closely monitored. We will feedback at national events as requested.
  • An annual review has taken place for agreed actions from the Mid Staffordshire review work in 2010. An audit has also been conducted by PricewaterhouseCoopers.

Section 6.2.2 Safe

The Scottish Patient Safety Programme (SPSP) is led by Healthcare Improvement Scotland (HIS) on behalf of the Government. The first phase of this work in acute adult care has key aims for reducing mortality and adverse events by December 2012. The national learning session last month asked each of the Boards to consider how work was contributing to this and this will be the major focus for the coming year.

NHS Grampian has been able to demonstrate sustained improvement in both processand outcome measures within each of the workstreams with significant spread beyondthe pilot sites. This is recognised by Healthcare Improvement Scotland with a verypositive report from the site visit to Grampian in June this year.

Peri-operative

  • All theatres in Aberdeen Royal Infirmary (ARI) are reporting sustained compliance with measures, and data is displayed outside theatres with annotations. Collective compliance across all theatres is also being sustained e.g. Surgical Briefings have been at 95% or above for seven months;Venous Thromboembolism Prophylaxis is sitting above 95% for the last four months. This is replicated in the Children’s Hospital where all theatre teams have been 100% compliant with the surgical briefing and pause for six months with general surgery compliance at 100% for 14 months.
  • All theatres in Dr Gray’s have also implemented this work and are monitoring compliance. This work is spreading now to the remaining theatre areas in Maternity and WoodendHospitals.

General Ward

  • Pilot wards are able to show links between process and outcome measures. They have reached over 300 days without a Staphlyococcus Aureus Bacteraemias(SAB) or Clostridium Difficile infection (CDI).
  • Key components of Early Warning Scoring, the Safety Brief, Hand Hygiene, SBAR and Cannula care has spread to multiple areas within ARI, Dr Gray’s, the Children’s Hospital and the Community Hospitals.

Critical Care

  • This area has demonstrated sustained changes with both process and outcome measures. It has achieved over 300 days without a Central Line, SAB and CDI infection.
  • Learning from the bundles has shown the need to link elements to make a change (e.g. Oral hygiene and 6hr cuff pressure checks to support the VAP bundle).

Medicines Management

  • Medicines reconciliation has been tested and spread to various areas in ARI and is implemented in the Children’s Hospital.
  • The Medication Safety Officer has developed acharter for a national piece of work onmedicines reconciliation across Scotland. The 180 day rapid improvement event has begun to support embedding this across admission, transfer, and discharge and Woodend and Dr Gray’s are our test sites for this work.
  • Our risk assessment for Venous Thromboembolism (VTE) prophylaxis is in the SIGN Guidelines as an example of good practice. A plan for roll-out to all appropriate areas across Grampian is now underway.
  • A Medication Safety Week ran from 31st Oct-4th November. It included; MedicationSafety update training sessions (run 38 times at ARI, Woodend, RACH, AMH,RCH and Dr Gray's hospitals with over 200 people attending). Fourteen presentations of local research and good practice developments were delivered by clinical staff and were held at lunchtime sessions and on the afternoon symposium (approx. 230 attended). A ‘Safe to Ask’ campaign aimed at patients and staff was launched. A website has been set up ( with technique cards for staff and leaflets and tools for patients. In addition the “Green bags” campaign to support patients bringing in the right medicines to hospital was also launched. Information packs were sent to all GPpractices, community hospitals and community pharmacies and a press release and 2 radio interviews with local stations were done. Initial feedback has been very positive and an evaluation of work is planned.

Mortality

  • The Hospital Standardised Mortality Rate (HSMR) at Aberdeen Royal Infirmary is stable with a lower starting rate than the Scottish average and shows a slight reduction over time. The HSMR at Dr Gray’s Hospital, shows fluctuation around the Scottish average with a more marked reduction over time in the last quarters. However, like other Boards who introduced the new Patient Management System (PMS) this year our last HSMR data is not complete but we are working with ISD to bring this back on track.
  • To help us understand our HSMR data and identify the learning points for action our Health Intelligence team worked with ISD to give a case listings breakdown so we could review individual case notes. The clinical leads for both Aberdeen Royal Infirmary and Dr Gray’s Hospital agreed to review a sample of these notes. This identified issues that need further clarification e.g. how we code admissions, early rescue, clear treatment planning on admission and other harm events (e.g. falls) will be built into our improvement programme of work.
  • The Medical Director and SPSP Programme Manager have delivered sessions on understanding our HSMR data to the Board and the Clinical Governance Committee. This was supported by information from our Health Intelligence team.

Rescue