Mortality and harm Learning Set. National context update Introductions – Housekeeping 4th event. Started Sept 2010. Last event 15th June At the last event we asked for feedback on what you wanted: Useful learning and networking. Wanted to do it again. Set agenda with AMD’s for Q&S. Provide opportunity to share – start the morning with a review. Bring other learning into the room. Do some action planning together and compare notes. Get a WG perspective Capture learning 2nd December 2011 Mortality and harm Learning Set. National context update Tim Heywood

Tim Heywood Together for Health “The 1000 Lives Plus initiative has pioneered a method that is proving its value in promoting safer, more effective clinical practice. Building on the success of the 1000 Lives Campaign… this will be applied in other areas” Jonkoping paper “The continuous quality improvement methodology used by 1000 Lives Plus should form the model used in improvement work across Wales”. Context has moved on, but1000 L+ is still central to policy Tim Heywood

1000 Lives Plus - a strategic approach to quality improvement Setting aims for reduction in harm, waste and variation and monitoring progress against them. Managing a portfolio of improvement activities which are aligned with strategic priorities and improvement aims. What is 1000 Lives plus. Leadership context Tim Heywood

Tim Heywood Drivers and interventions set – but may change 4 Deliver and sustain excellent services that meet the needs of patients and maximise clinical outcomes. Treat patients well and help them with their problems Deliver safe, high quality services Provide timely access to services. Primary Driver Secondary Drivers Improve stroke care Transforming Theatres (reducing surgical complications) Deliver Effective care pathways & pro- active community orientated care Depression Rapid Response to acute illness Reduce harm and variation & deliver timely access to services Enhanced recovery after surgery Zero tolerance of HCAI Hospital acquired pressure ulcers Reducing HCAI Improving critical care Hospital acquired thrombosis Improving medicines management Falls prevention in the community Dementia Stroke rehab Improve cardiac services Acute cardiac/CHF TIA’s Acute stroke Transforming maternity Services Improve mental health care Improve cancer care ‘Focus on’ pathways Transforming Care Improve major trauma & Acute illness services Improve elective care Engage workforce Leading the way to quality and safety improvement Zero tolerance of pressure ulcers Improve end of life care Improve clinical leadership BBV hepatitis action plan Drivers and interventions set – but may change Tim Heywood 4

Mortality and harm Review criteria Mortality and harm reviews. Successes/ challenges and barriers Tim Heywood

Board level reporting Tim Heywood

WG Medical Director letter (July 2011) National policy alignment - The short term WG Medical Director letter (July 2011) “A consistent approach to reporting is required that highlights the alignment between the AQF and 1000 Lives Plus programmes, and provides the Welsh Government with evidence of the progress and delivery required.” AQF delivery framework 2011/12 (August 2011) “The 1000 Lives programme will continue to support our quality improvements utilising appropriate methodologies. Progress will be monitored locally with periodic national reporting arrangements.” Tim Heywood

2011/12 delivery framework Tim Heywood

1000 Lives linked reporting at tiers 1 &2 C diff & MRSA monitoring Pressure sores Stroke, cardiac, major trauma & #NOF mortality rates Stroke bundle compliance Tier 2 Depression and dementia bundle compliance Tim Heywood

Division locality level monitoring 1. Be clear about delegated authority and accountability 2. Avoid report duplication 3. Use narrative to describe progress on an improvement journey. Full Board Q&S committee Organisation-level improvement team Division locality level monitoring & assurance Tim Heywood

Some learning points CTHB – reporting on mortality review findings. HDHB – linking of organisational level with county level reporting ABHB & ABMUHB – use of narrative in performance report to full Board. BCUHB – review of committee structures and reporting. BCUHB & C&VUHB – committee reports on internet site Tim Heywood