1. Insert name of presentation on Master Slide Aneurin Bevan Health Board 11 May 2010 Reducing Mortality and Harm

2. Insert name of presentation on Master Slide ABHB and Patient Safety Quality and Patient Safety are within and integral to the top priorities for ABHB ABHB is developing an approach to patient safety, which will incorporate 1000 Lives + and is summarised on the next pages, and then described in more detail in the story board.

3. Insert name of presentation on Master Slide Aneurin Bevan Health Board Approach to Patient Safety (1 of 3) Set high level aims for Patient Safety: reductions in mortality (RAMI) and harm (GTT) Develop Driver Diagrams for mortality and harm, with a whole systems approach, to summarise the work and demonstrate how the high level aims connect to the interventions at front line team level

4. Insert name of presentation on Master Slide Aneurin Bevan Health Board Approach to Patient Safety (2 of 3) Put measures in place for each of the primary drivers (process and outcome), which then form part of the Quality Dashboard Implement Primary Drivers through front line teams with task and finish groups Monitor impact of implementation of interventions, and review reliability of processes and revisit implementation where necessary

5. Insert name of presentation on Master Slide Aneurin Bevan Health Board Approach to Patient Safety (3 of 3) Develop the capacity and capability of staff through out the organisation for patient safety through an “Improvement network” that everyone is a part of, but a core group of staff have the knowledge, skills and experience to run PDSA cycles

6. Insert name of presentation on Master Slide Targets for Reduction in Mortality and Harm – 3 year plan Mortality RAMI in line with top performing UK organisations Eliminate seasonal and weekly variation in RAMI Harm Establish the Global Trigger Tool as a measure of harm across the organisation (acute and GMS) <10 episodes of harm per 1000 bed days in acute care (<1%)

7. Insert name of presentation on Master Slide ABHB – Current RAMI Coding Completeness: November 09 = 96% December 09 = 92.6%

8. Insert name of presentation on Master Slide Using RAMI as a measure of standardised mortality ABHB has improved its coding of discharges and deaths to ensure it is accurate and complete, as this has an impact on the RAMI The run charts for RAMI and Unadjusted Mortality are monitored and discussed monthly at the Mortality Group A case note review of “box 4” deaths will start shortly to identify key areas for improvement

9. Insert name of presentation on Master Slide Using RAMI as a measure of standardised mortality Areas for improvement are also identified through learning from incidents, complaints and claims, and through sharing ideas with other organisations working to improve patient safety (steal shamelessly or pinch with pride!) The interventions identified to address the areas for improvement will be added to the driver diagrams

10. Insert name of presentation on Master Slide ABHB – Current Adverse Event Rate RGH Key A = SPI tool, B = UK Tool, C = 1000 Lives Tool (A & B have fewer triggers) AA BB C AA C

11. Insert name of presentation on Master Slide ABHB – Current Adverse Event Rate NHH

12. Insert name of presentation on Master Slide Using GTT as a measure of adverse event rate A lot of work has been undertaken on the GTT over the last 6 months Driver Diagram was used to summarise what needed to be done (see next slide) Update Training has been held for all GTT reviewers GTT and the data on adverse event rates has been presented at high level Committees in order to raise its profile PCTT to be piloted over the next 6 months

13. Insert name of presentation on Master Slide OutcomesPrimary DriversSecondary Drivers Aneurin Bevan Health Board GTT Driver Diagram Reliable measure that demonstrates improved patient safety over time & provides qualitative data on types of incidents Ensure GTT Audit Measurement Consistency & Reliability Increase Profile/Gain Will for GTT Audit as 1000 Lives Campaign/SPN Measure Use of Qualitative Information Gain Leadership Commitment – Explain GTT Measure, high level feedback to exec team Gain divisional/frontline staff understanding – Explain GTT audit measure, feedback of quantitative/qualitative data split by domain Checklist for auditors including issues highlighted and clarifying basic methodology Clean data of basic errors on GTT audit spreadsheet – ensure consistent sampling Audit of high category graded events ie. G, H & I events Involvement of all auditors, eg. Pharmacy in RGH, Medical input, Nursing input Clarify included events or triggers eg. at home, in hosp, blame? Ensure correct tool is being used at both sites – add to GTT tool month/year, auditor name, question re. patient admitted with event Write a brief protocol for GTT Audit at GHNT/ABHB including roles, support, methodology, sampling, definitions, feedback/use information, mechanism for learning from audit. Time for systematic analysis of data using GTT Spreadsheet including evaluation of overall GTT scores, trends for triggers/events, trends for different domains. Turning data into info. Engage Medical staff - feedback of data such as readmissions, surgical complications Strategy for learning from GTT data – discuss with stakeholders Feedback any system-wide issues identified to Trust Learning Committee Feedback of events related to individual areas/divisions GTT Audit training for auditors and for staff supporting GTT audit Ward level feedback – regular feedback to ward areas

14. Insert name of presentation on Master Slide Driver Diagrams in ABHB ABHB is developing Driver Diagrams for mortality and harm to summarise the work underway and planned and demonstrate how the high level aims connect to the interventions at front line team level The driver diagrams will cover the whole system There are overall driver diagrams to show the drivers for the whole ABHB, but driver diagrams are also being developed to focus on each Division, community and primary care. In addition the driver diagrams can be re- worked to show all the work and where it is taking place for each primary driver The driver diagrams shown below are still being developed, and will continue to change as new issues are identified and interventions to address them are established

15. Insert name of presentation on Master Slide ABHB MORTALITY DRIVER DIAGRAM ObjectivePrimary Drivers (What)Secondary Drivers (How) Action Reduce Unexpected Deaths * Prevent Deterioration of Patients (RRAILLS) * Prevent HCAI MRSA C Diff VAP CLC SSI * Prevent Hospital Acquired Thrombosis * Improve Management of High Risk Medications Insulin Warfarin Improve Team Working CHF Stroke Appropriate Response to MEWs Triggering Appropriate DNARs in Place Recognition and Management of SEPSIS Hand Hygiene Environmental Measures Antibiotic Stewardship VAP Bundle CLC Initiation and Maintenance Bundles Normothermia Glycaemic Control Antibiotic Prophylaxis Appropriate Hair Removal DVT Risk Assessment and Appropriate DVT Prophylaxis * Improve Management of Chronic Conditions Monitoring and Intervention for high INRS Warfarin Chart and Risk Assessment Safety Briefings SBAR WHO Checklist One MEWS Chart MEWS Chart signed by trained staff Observation Policy Appropriate handover/SBAR Outreach Team Hospital at Night SEPSIS 6 SEPSIS Resus Bundle SEPSIS Management Bundle CHF: 6 Campaign Interventions Timely Management of TIA Acute Stroke Care – First Week Early Recovery and Rehabilitation Priority for ABHB * 1000 Lives Plus MEWs (and MEOWs and Community Hospitals)

16. Insert name of presentation on Master Slide *Reduce Patient Falls in Hospital and Intermediate Care *Reduce Pressure Damage *Reduce Medication Errors Risk Assessment TCAB *Reduce HCAI Risk Assessment TCAB Medicine Reconciliation Missed Doses Positive Patient ID Peripheral Lines Bundle CAUTI Initiation and Maintenance Bundles SA UTIs Falls Bundle Hourly Rounds Skin Bundle Hourly Rounds Reduce harm by 10% every year Priority for ABHB * 1000 Lives Plus ABHB HARM DRIVER DIAGRAM Objective Location Primary Drivers Secondary Drivers Action

17. Insert name of presentation on Master Slide Driver Diagrams and the Quality Dashboard The standardised Mortality and the Adverse Event Rate are two of the high level measures in the quality dashboard The dashboard is being developed so that each primary driver in the mortality and harm driver diagrams has both a process and outcome measure (where possible) Ward and Department dashboards will have measures that build to give the measures for the primary drivers

18. Insert name of presentation on Master Slide Primary Drivers in the Mortality Driver Diagram Prevent Deteriorating Patient/ RRAILLS Prevent HCAI Prevent HAT Improve Management of High Risk Medications Improve Teamworking Improve Management of Chronic conditions

19. Insert name of presentation on Master Slide Preventing the Deterioration of Patients (RRAILLS) There is a Working Group co-ordinating the work on the deteriorating patient, as this is an issue that the Learning Group has identified from Incidents, Complaints and Claims The Working Group is co-ordinating the Policy on Observation frequencies and MEWS, the implementation of an ABHB obs/MEWS chart for acute care. Work is ongoing on MEOWS and a suitable tool for the Community Hospitals, training, the outreach team and the use of the SBAR when the ward hands over patients who are triggering on MEWS to either the outreach team, the doctors or the Nurse Practitioners Key measures are shown below

20. Insert name of presentation on Master Slide Preventing the Deterioration of Patients (RRAILLS) – outcome measure

21. Insert name of presentation on Master Slide Preventing the Deterioration of Patients (RRAILLS) – process measure

22. Insert name of presentation on Master Slide Preventing HCAI - MRSA Work on this issue continues, with the hand hygiene driver continuing to spread There are now 33 wards within RGH, 16 wards in NHH, 4 wards in CDMH and 4 Community Hospitals This is one of a whole range of measures introduced to prevent and control MRSA

23. Insert name of presentation on Master Slide Preventing HCAI – MRSA process

24. Insert name of presentation on Master Slide Preventing HCAI – MRSA process

25. Insert name of presentation on Master Slide Preventing HCAI – MRSA outcome

26. Insert name of presentation on Master Slide Preventing HCAI – C. Diff. The IPaC Team are working with the Anti-biotic Pharmacist to pilot and spread compliance with the ABHB guidance on prescribing antibiotics The individual components are measured: % antibiotics compliance with formulary, % antibiotic duration specified, % duration adhered to Specific ward rounds are undertaken to review the prescribing of antibiotics for patients on the ward The anti-biotic pharmacist feeds back to junior doctors when the formulary and other guidance has not been adhered to

27. Insert name of presentation on Master Slide Preventing HCAI – C. Diff. process

28. Insert name of presentation on Master Slide Preventing HCAI – C. Diff. Outcome

29. Insert name of presentation on Master Slide Preventing VAP – NHH Outcome The increase in VAP cases at RGH is being investigated with WHAIP who provide the data, as it is not thought to be correct. The run chart will then be changed to reflect the true situation The implementation of the bundle will be reviewed if there has been an increase in the VAP rate to ensure it is robust

30. Insert name of presentation on Master Slide Preventing VAP – process

31. Insert name of presentation on Master Slide Preventing VAP – Outcome

32. Insert name of presentation on Master Slide Preventing CLC infections - Process

33. Insert name of presentation on Master Slide Preventing CLC infections - Process

34. Insert name of presentation on Master Slide Preventing CLC infections - Outcome

35. Insert name of presentation on Master Slide Preventing SSIs - NHH

36. Insert name of presentation on Master Slide Preventing SSIs - RGH

37. Insert name of presentation on Master Slide Preventing Hospital Acquired thrombosis ABHB has set up a Steering Group to lead this work A multi-disciplinary team is attending the HAT Learning Sets It has been agreed to look at elective surgical patients first, with three initial actions: PDSA cycles on using the risk assessment form for one surgeon in one pre-assessment clinic, general awareness raising about the risk assessment form and process, and the development of process, outcome and balancing measures for HAT The numbers of patients receiving DVT prophylaxis is shown below, taken from the theatre management system, ORMIS

38. Insert name of presentation on Master Slide Preventing Hospital Acquired thrombosis - process

39. Insert name of presentation on Master Slide High Risk Medications - Warfarin Pharmacy staff are identifying patients in hospital with an INR>5, and these patients are followed up on the same day to correct their INR level Feedback is given to primary care, where appropriate A team of pharmacists from the hospital and the localities is working to improve the use of the Warfarin Risk Assessment form. They are tracking a small group of patients through the system to check it is completed when a patient is started on Warfarin, and is then sent to the GP, and is updated whenever there is a transition in care, and at lest annually

40. Insert name of presentation on Master Slide High Risk Medications - Warfarin

41. Insert name of presentation on Master Slide Improving Team Working Safety Briefings – these are well used across the wards in RGH, NHH and CDMH, and usually form part of the handover. There is a standard format, which the ward can adapt to include safety issues that are pertinent in that area SBAR – this is used at handover of a deteriorating patient to the outreach team, a doctor or a nurse practitioner. However, the measurement of their use has been problematic and is being revisited Other measures – these include the WHO checklist and the multi-disciplinary ward rounds and goal setting on critical care.

42. Insert name of presentation on Master Slide Team Working – Safety Briefings

43. Insert name of presentation on Master Slide Improving the management of chronic conditions - CHF To date, the measurement has focussed on the patients at NHH who are referred to the Cardiac Rehabilitation Team Cardiac Rehabilitation Team are working with the Clinical Audit Department to audit CHD patients referred and not referred to Cardiac Rehabilitation Team.

44. Insert name of presentation on Master Slide Improving the management of chronic conditions - CHF

45. Insert name of presentation on Master Slide Improving the management of chronic conditions - CHF

46. Insert name of presentation on Master Slide Improving the management of chronic conditions - Stroke One of the key objectives of the ABHB Stroke Delivery Board is the implementation of the acute care bundles (first week) and the bundles for TIA and Rehabilitation Adherence to the acute care bundles is monitored through the AWSSIC data base which is populated by the team of Stroke Clinical Specialist Nurses based in the 2 Stroke Units

47. Insert name of presentation on Master Slide Primary Drivers in the Harm Driver Diagram Reduce Patient Falls Reduce Pressure damage Reduce Medication Errors Reduce HCAI

48. Insert name of presentation on Master Slide Reducing Patient Falls and Pressure Damage ABHB Nurses started to implement certain elements of Transforming Care whilst it was being piloted through the 1000 Lives Campaign. This was very successful. Transforming Care was formally launched in ABHB on 8 April 2010

49. Insert name of presentation on Master Slide Reducing Patient Falls and Pressure Damage ABHB will send a full team to the Preventing Hospital Acquired Pressure Ulcers Event, and implement the skin bundle through piloting and spread ABHB will also implement the Falls Bundle ABHB also believes that the Hourly Rounds can play a large part in reducing falls

50. Insert name of presentation on Master Slide Reducing Medication Errors ABHB has a Medications Safety Group that reviews all the medication incidents reported to ensure that appropriate actions are taken for individual incidents, and to identify trends that require a co-ordinated approach These can link to the medication related NPSA alerts

51. Insert name of presentation on Master Slide Reducing Medication Errors The Medications Safety Group has promoted the introduction of the Medication Incident Reporting Form. This will now be implemented through the introduction of Web-based Datix

52. Insert name of presentation on Master Slide Reducing Medication Errors The work to improve medicines reconciliation has continued The results at Nevill Hall have been reported before the intervention by the Pharmacist. A data series for medicines reconciliation at NHH after the pharmacist intervention will be included

53. Insert name of presentation on Master Slide Reducing Medication Errors

54. Insert name of presentation on Master Slide Reducing HCAI - CAUTI A Working Group with membership from acute care and the localities is meeting to introduce the Catheter Associated Urinary Tract Infection Insertion and Maintenance Bundles The bundles are being piloted on 2 acute wards at both NHH and RGH. The pilot at NHH is progressing well, and the pilot at RGH is being revisited to re- invigorate its introduction

55. Insert name of presentation on Master Slide Reducing HCAI - CAUTI The Working Group is planning to introduce the maintenance bundle into Nursing Homes Homes have been identified across the localities, appropriate paper work is being developed and a training package is being designed for the launch day in late May

56. Insert name of presentation on Master Slide Reducing HCAI – Staphylococcus Aureus The IPaC team will identify a reduction target and implement a care bundle Peripheral Lines) to reduce the number of SA bacteraemias across the acute sites

57. Insert name of presentation on Master Slide Work in the Localities/ Primary Care Staff in the Localities continue to be enthusiastic supporters of the patient safety work Much of the effort in the last 6 months has been to take forward interventions that benefit from whole systems working, such as the work on CAUTI and the work to improve the use of the risk assessment form for Warfarin

58. Insert name of presentation on Master Slide Work in the Localities/ Primary Care The membership of the 1000 Lives frontline Team Meeting has been reviewed and now includes staff from the Localities The Localities 1000 Lives Team continues to meet to ensure that the work that is in place is maintained, and to develop an action plan to continue to make the innovative changes that have characterised the work to date

59. Insert name of presentation on Master Slide Work in the Localities/ Primary Care The PCTT will be piloted in primary care in Gwent over the next 6 months Leadership walkarounds have spread to Community Hospitals and Mental Health and will spread to Primary Care in the next month