1. Powys teaching Health Board
10th June 2011
Powys teaching Health Board
Presenter: Dr Brendan Lloyd

2. Area: Understanding Mortality
Aim
Drivers
Interventions
Tests of Change
Continue participation in DH Death Certification Pilot
Independent medical review of all Powys in-patient deaths
Provide assurance to Board regarding local services and the HSMR of provider hospitals
Mortality
HSMR
Palliative Care
Collect HSMR data from both Welsh & English providers – monitor through Quality & Safety committee
Improve quality & choices for Powys residents
HSMR data features in all Quality Reports
Increase choices available to Powys residents through extended palliative care, nursing and social service teams
Increase choices for Powys residents in line with Last Days of Life pathway

3. Outcomes
The findings from 401 case reviews (all Powys in-patient deaths September 2009 to present) :
None of these deaths were preventable
A small number of these deaths whilst sudden, were still considered expected
Scrutiny did not result in any ‘cause for concern’ DATIX reports about poor or insufficient care
The quality/accuracy of the Medical Certificate of Cause of Death has improved

4. Reduce Harm and Mortality
Next steps
Aim
Drivers
Interventions
Tests of Change
Reduce Harm and Mortality
604 Powys residents are dying in hospitals outside of Powys – why?
Map place of death for all Powys residents
Better understanding of reasons why so many Powys residents die in DGH’s outside of Powys
Audit records of Powys residents who die in provider hospitals outside of Powys
People who choose die at home or in a local hospital should have care planned to enable this to happen
Actions to reduce harm and mortality are focused and based upon evidence

5. Area: VTE Prevention Aim Drivers Interventions Tests of Change
Introduction of Powys wide VTE risk assessment form
Monthly audit of all Powys in-patients
To prevent the occurrence of Venous Thrombo- embolism in all Powys in- patients
Provision of prophylactic drug therapy to prevent VTE

6. Area: Pressure Ulcer Prevention
Aim
Drivers
Interventions
Tests of Change
Improved clinical assessment of skin integrity in all care settings
Implement a standardised clinical assessment tool for risk of pressure ulcers in all care settings
SKIN bundle assessment and care package now in place on Brecon, Bronllys, Llandiloes and Welshpool wards (40% of total wards)
Reduce number and severity of pressure ulcers across hospital, community and care home sector
Improved clinical care of patients at medium and high risk of pressure ulcers
Implement a pressure ulcer care bundle that can be used in various settings
Welshpool District Nursing team developing bundle for use in the community
Improve whole systems care – incorporating community hospitals, community and care homes
Explanation of the SKIN bundle concept given to Residential Home Link Nurses in March
One home, Cwrt Enfys has volunteered to pilot the SKIN bundle approach there

7. Thank You