Leading Better Care
Sharing Good Practice
NHS Board:LANARKSHIRE
Ward / department / team:8
Details of Improvement:
What was the particular problem that this case study isabout?
Risk assessments not completed on admission/transfer. Also not being updated weekly.
How was this identified?
From the results of the weekly and monthly patient safety and leading better care data.
Audit carried out at beginning of releasing time to care pilot of all ward patients.
Datix’s and complaints.
What were the implemented improvements (whattools/techniques did you use)?
Staff informed of result of initial risk assessment audit and importance of ensuring same accurate and updated to reflect patient’s current condition. (1:1 and via memo).
SCN checked risk assessment on a weekly basis to ensure compliance.
SSKIN care bundle training was provided by tissue viability and implementation of Safety Cross to track number of pressure ulcers acquired in the ward.
What is the situation now?
Compliance with documentation significantly improved.
Marked reduction in pressure ulcers acquired within the ward.
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How is the change sustainable?
SCN will continue to monitor.
Risk assessment checklist now devised. Designated members of staff highlighted on rota at least twice weekly to ensure all risk assessments in situ and filled in appropriately (see attachment 1)
Measurable outcomes
What are the patient benefits?
Improved standards of care; person centred, safer and more effective.
Reduction in pressure ulcers. Most recent information on 11/10/12-36 days since last pressure ulcer.
Reduction in HAI’s. Most recent information on 11/10/12-360 days since last C.difficile and 334 days since last Staph Aureus Bactaraemia.
What are the staff benefits?
Being able to assess patient to provide a more patient centred approach, enabling them to provide improved standards of care.
What are the organisational benefits?
Improved standards of care. Reduction in pressure ulcers reducing Length of Stay and costs associated with treating pressure ulcers. Being able to meet HEAT targets.
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How did staff feel before the improvement/during theimprovement and after the improvement?
Staff frustrated at lack of risk assessments being completed. Some staff more likely to comply than others and felt it was ‘always the same staff’ filling out the assessments. Staff more clear on what and when assessments are to be done.
What are the lessons learnt and what would you dodifferently next time?
Staff have recognised the importance of completing risk assessments and can see the evidence for themselves that standards of care can be improved by recognising patient’s at risk acting upon this.
What plans are there to spread the improvement?
Risk assessment checklist can be used by other SCN’s.
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Contact information for case study
Liz Johnston, SCN, Ward 8, HairmyresHospital, 01355 585081