‘Active Risk Management at Rotherham’ Rotherham NHS FT QUEST presentation 24th June 2011 Dr Trisha Bain

What is risk management? ‘ Risk management is the identification, assessment, and prioritisation of risks followed by coordinated and economical application of resources to minimise, monitor, and control the probability and/or impact of negative events or to maximize the realisation of opportunities’

QUEST topics VTE Falls, Pressure Ulcers, UTIs Falls care pathway assessments Pressure ulcer assessment, including MUST UTIs – blood sampling method to accurately identify catheter related UTIs

Identification of risks Web Datix Incident Web Risk registers Serious Incident process Mortality reviews (Trust and CSU MDT) Global Trigger NICE/NCEPOD, National Audits CHKS :national and peer benchmarking

Monitoring and prioritisation of risks

Assessment and management of risk across pathways: Falls A&E: Falls and Fracture pathway (50-75yrs) Referral Osteoporosis and Bone Health Clinic Referral to community: home safety assessment, falls management FNOF pathway were appropriate Ward Falls assessment and MDT Action Plan Discharge forms to the community team

Community to Board Monitoring and Improvement Programmes SNAP electronic data collection tool All wards, community sampling Automated ‘real-time’ feedback reports Linked to quality accounts programmes

B3 Ward Quality Indicators B2 Ward Quality Indicators Local level monitoring

Falls from height: April 2009 – March 2011 Falls same level April 2009 – March 2011 Trust wide monitoring

National benchmarks of reported slips, trips and falls in acute (NPSA 2010) hospitals

VTE 90% target met evidence of actions Proxy measures

Linked to improvement programmes: Quality Accounts Linked to Improvement programmes On-going : Mortality. Fluid balance and MUST tool CQUINs, National Priorities Reducing 30day re-admission rates for Falls, Diabetes, COPD Continue to achieve month on month 90% VTE risk assessment Ensure 90% of VTE prophylaxis prescribed as per national guidance Increasing responsiveness to our patients needs on composite indicator (PET) Increasing compliance to 95% of key measures of End of Life care pathway 95% high risk prescriptions, opiates, anticoagulants, antibiotics prescribed as per protocol Reduce number of communication incidents : handover/hand-off Continue to have zero Never Events Patient S a fety Patient Experience KPIs Clinically Effective

Continuous improvement and management of risks

Any Questions