RCA analysis; a collaborative approach to preventing PU. Project

The national context: Improving health and care – the role of the outcomes frameworks Dept of Health Nov 2012 ‘Enable people to live better for longer’ ‘Focus the health and care system on improving outcomes’ ‘Can only be achieved when all parts of the system work together’ ‘Improve transparency and accountability’ The NHS Safety Thermometer – where does it fit in this? Provide a framework for partnership working Private and confidential 2

NHS Outcomes Framework –2. Enhancing quality of life for people with long term conditions –5. Treating and caring for people in a safe environment and protecting them from avoidable harm Adult Social Care Framework –1. Enhancing the quality of life for people with care and support needs –4. Safeguarding adults who are vulnerable and protecting them from avoidable harm Alignment between frameworks supports ‘partners’ to identify common ground for integrated working: Private and confidential3 HQIP Clinical audit: Ten simple rules for NHS Boards: ‘Ensure with others that clinical audit crosses care boundaries and encompasses the whole patient pathway’

How it all started! Set audit criteria in line with NICE guidelines (2005) 3 month retrospective paper audit Annual audit across all community nursing, community hospitals and nursing homes Private and confidential 4

Elements then. Private and confidential 5

Hypothesis for 2014 / 15 – New NICE/ EPUAP. RCA qualitative rich data never analysed. Anecdotally from RCA – it seemed that there were a high proportion of cat 3 / 4 Pu that crossed care boundaries. Similarly cat 2 Pu’s seemed to be going up There seemed to be a high proportion of 2’s in residential care homes? There seem to be a high proportion of M.S. patients? Needed to reflect on 2014 NICE / EPUAP guidelines and how they impact on current practice. We needed to look for commonalities from RCA to date in a structured way. Private and confidential 6

Private and confidential 7 Where are we Now?

Private and confidential 8

Sept planning meeting post EPUAP.

Moving on – who will be involved this time? Private and confidential 10 Preventing pressure ulceration !- A new collaborative partnership approach. District Nursing & Tissue viability.

Audit methodology: On baseline retrospective‘audit’month, all patients with pressure ulcers on the caseload were included. CIRIS analysis - 3 teams were identified. Highest reporters = Walton/ Medium reporters = The Mill. Godalming / Low reporters = Goldsworth park. Process measures: Documented elements of SSKIN bundle 1.?Timely risk assessment / review 2.?Timely nutrition assessment / review 3.? Timely preventative care actions. 4.? Timely evaluation Outcome measure - educate and re-audit in 6 months. Private and confidential11

Best practice & reflective learning – New & Old Audit questions. 1.All patients should be assessed for risk of developing a pressure ulcer (80%) Waterlow as a minimum. 2. All pressure ulcers of grade 2 or above should be reported as a clinical incident – (90%) 3. Where a pressure ulcer has been identified, an individual care plan for management should be documented – (80%) 4. Patients with pressure ulcers should have appropriate pressure relieving equipment – (80%) 5. Patients with pressure ulcers should have a nutritional assessment undertaken – (70%) 6. patients should have a turning / position change recommendations. NICE 2014 Private and confidential 12

Initial Audit results The audit data supported the previous anecdotal beliefs, namely – –The majority of cases come from home carers (69%) and residential homes (24%) –Patients with category 3 & 4 PUs were much more likely to be incontinent than those with category 2 (88% vs 47%) –Most category 3 or 4 PU Patients had impaired mobility compared to a third of category 2 PU patients who were defined as mobile. Private and confidential 13

RCA analysis table Private and confidential 14

Goals 2015 Reduce the severity of damage and the overall number of pressure ulcers Real time costs - Increased awareness of pressure damage Back on the agenda – safety thermometer, CQUINS Need to keep improving and developing Private and confidential 15

Evidenced based Education.

Education Delivery Feedback has been incredibly positive with an average score of 4.95 for the training and content(where 5 is Excellent) from 115 questionnaires. Virgin Care HCAs and APs demonstrated very high levels of knowledge around PUs and wound care in general. The amount of training provided for wound care and PUs to carers previously has been very limited and this was reflected in their level of knowledge in comparison to HCAs. Additional training regarding role & responsibilities with regards to prevention of PUs has also been delivered alongside to Virgin care HCAs and APs. l17

Referred to DN team due to PU

Was Patient Receiving Social Care Package

Has Patient had a Previous PU

Patient Mobility 12.5% of catagory 3&4 Patients were Mobile 32% of catagory 2 Patients were Mobile

Total Pressure Ulcers

Percentage of Patients with PUs

On DN Caseload When Acquired

Outcomes from Partnership working with Molnlycke joint project. Training delivered to 10 residential Homes & 6 care agencies staff identified as involved in the Community patients journey. Staff from care Agencies/ Residential homes reported little to no training in PU prevention. Trainer observation - V.C. Staffs participation & high knowledge level was tangible. Incidence figures from Patients resident in Residential homes significantly reduced on re- audit 3 months post training. SI – analysis of root cause undertaken – all patients had the same pre-disposing risk factors recognised by current National Research being undertaken as a significant risk in the Pu population. (We were the same). High incidence of patients in SI cohort recognised as requiring different & specific preventative approaches. 98% of patients had a Waterlow risk assessment and 100% had an individual care plan.

Recommendations from partnership working with Molnlycke joint Project. Roll out of PU Updates based on learning from RCA cases and yearly update on accurate categorising for trained staff – TV Service. Yearly Pu update training for HCA’s & Associate Practitioners by Learning & Development. Training to outside organisations to continue – funding permitted. Resource for additional TVN support with - high risk individuals ( For Specialists.) Hydration - monitoring awareness of need to improve. RCA analysis to be on-going and included in 6 monthly board report. Cluster review - TV lead to monitor locality teams incidence – Monthly CIRIS report to include this. Commenced May Resource for bespoke training Business case for More TVN time = Greater prevention.

Private and confidential 27 Where do we go from here? Thank you For Listening!