A Regional Approach to Improvement Julie Branter Associate Director for Clinical Governance and Patient Safety 21 September 2010 South West Strategic Health Authority Venous Thromboembolism Exemplar Site

Introduction The context Did we have a problem? How does the regional approach to improvement work? What have we learnt?

Did we have a problem? Organisations thought they were doing it well but …. All Party Parliamentary Thrombosis Group Self Reported Survey (2008) 99% of acute trusts are aware of guidance 86% have Venous Thromboembolism committees ENDORSE study (2008) 50% receiving appropriate prophylaxis (62.3% by 2010)

How we did it – the Regional Approach

South West VTE Prevention Initiative Aims: Review trust compliance with National Venous Thromboembolism Prevention Strategy –all adult inpatients have a documented risk assessment –all inpatients receive appropriate prophylaxis Explore better methods of measurement Evaluate health economy approach Consider options for further research

Developing a systems-based approach to the prevention of Venous Thromboembolism in hospitalised patients Patient admitted to hospital Individual patient assessed for risk VTE Professional workforce aware of VTE risk Appropriate preventative strategy implemented Evaluation of outcome What will success look like?

The NHS South West approach Infrastructure: Steering Group Venous Thromboembolism Clinical Peer Review Team Expert Reference Group Assessment process: Self assessments: –Acute trusts, November 2008 –Independent Sector Treatment Centres, February 2009 –Primary Care Trusts, March 2009 Clinical Peer Review visits April – June 2009 Improvement; South West Quality and Patient Safety Improvement Programme

Clinical Peer Review Visits Findings from 18 acute trusts Policy and Leadership Risk Assessment Measurement and Audit Staff Education and Training Patient Education/Awareness

Policy and Leadership 18 Venous Thromboembolism committee (10 yrs – 5 months) 15 Report to Clinical Governance committee 11 Executive involvement 6 Primary Care Trust included 2 Patient representative 15 Trust Risk Register 10 Policy in place 11 Staff unaware of Venous Thromboembolism guidelines 4 Dedicated specific financial resource

Risk Assessment Overall, very little evidence of documented risk assessment Systematic process Safety check systems 1 (exemplar site) 12 Surgery 13 Medicine 15 Inconsistencies 12 Nurse involvement 4 Post-take ward round 3 Review of Risk Assessment during stay 7 Safe Surgery Checklist (World Health Organisation) 5 Prescribing prompt Pharmacists

Measurement and audit Greatest driver for improvement 12 Monitor compliance 2 Small frequent cycles 3 Electronic tools 4 Feedback to clinical staff 6 Monitoring outcome data 13Future Venous Thromboembolism metric in quality accounts

Staff Education/Training 50% of Trusts lacked clarity of guidelines 1 Trust (exemplar) education programme in place; 11 New doctors induction 2 Regular training for nurses 3 E-learning tool 3 Venous Thromboembolism events/critical incidents to trigger learning Reliance on ad hoc teaching

Patient Awareness/Education 13 Written information 0 Availability throughout Trust Varying standards of patient information –verbal –written/leaflet –electronic

Improvement South West Quality and Patient Safety Improvement Programme Collaboration with Institute of Health Care Improvement (IHI) Breakthrough Collaborative learning model Model for improvement – PDSA cycles Monthly reporting outcome/process measures  Critical Care, General Ward, Peri-op, Medicines Management, Leadership  Total 5 data entries for Venous Thromboembolism (risk assessment/appropriate prophylaxis)  Measurement for improvement - run charts  Aim to achieve 95% reliability

Next Steps

Commissioning – drivers for improvement South West Operating Framework 2010/2011 Trust contracts 2010/2011 CQUIN National Goal Mandatory VTE risk assessment reporting via Unify June 51% July 59% Local CQUIN schemes National Institute for Health and Clinical Excellence VTE Quality Standard

Commissioning - drivers for improvement Health Economy Venous Thromboembolism Committee Leadership Opportunity for pathway approach Multi - professional working opportunities Measurement GP consortia South West Quality and Patient Safety Health Community Programme QIPP Safe care

What have we learnt?

Key success factors Senior leadership commitment: Clearly articulating the vision from board to ward; Shared language and purpose; It’s about the patient and quality of care. Sharing outcomes/data: Real time feedback to frontline staff. Everyone’s business and everyone’s success: Ownership by frontline staff; Multidisciplinary team approach.

Key success factors Using a meaningful improvement methodology at the frontline : Using PDSA cycle as a learning opportunity Creating an improvement community: Staff want to be part of it

Any questions?