1. www.virgincare.co.uk HQIP Partnership Working Award Clinical Audit Manager (Community Services, Surrey) Tissue Viability Nurse Specialist (Community Services, Surrey) Community Hospital Matron (Community Services, Surrey) Tutor in Community Nursing at Surrey University Private and confidential1

2. www.virgincare.co.uk Aims – how the session is planned Explanation of award category Describe clinical audit project Key reflection on success in partnership working Achieving an ‘outcomes’ focus Critical success factors Discussion The broader national context Private and confidential 2

3. www.virgincare.co.uk ‘part·ner·ship’ (n) A collaborative relationship... based on trust, equality and mutual understanding for the achievement of a specified goal (World Health Organisation, 2009) Arrangements typically involve joint working to achieve common goals, with partners sharing risks and rewards. (Audit Commission, 2012) Private and confidential 3

4. www.virgincare.co.uk HQIP Partnership working award category Projects submitted for this category must be: –Jointly carried out with other organisations –Could include working across NHS sectors –Trusts from the same sector –Social care, industry and/or independent healthcare organisations such as charities or private healthcare Private and confidential 4

5. www.virgincare.co.uk Our entry ‘...Relentless pursuit of continuous quality improvement in the prevention and management of pressure damage, to eliminate avoidable harm, distress and discomfort, experienced disproportionately by older people in community settings’ Fulfils essential criteria for clinical audit Florence Nightingale wrote in 1859 “If he has a bedsore, it’s generally not the fault of the disease, but of the nursing” Private and confidential 5

6. www.virgincare.co.uk What is a pressure ulcer? “Localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.” (EPUAP 2009) Pressure damage is associated with: longer hospitalisation Increased complications and dependency Increased vulnerability to infection Pain, discomfort/infringement of dignity Increased cost A significant proportion are avoidable Private and confidential 6

7. www.virgincare.co.uk Private and confidential 7

8. www.virgincare.co.uk Pressure ulcer productivity calculator Department of Health (June 2010) Based on 2008/9 prices –Category 1 = £1,000 –Category 2 = £6,000 –Category 3 = £10,000 –Category 4 = £14,000 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_116669 Private and confidential 8

9. www.virgincare.co.uk Clinical audit aims Improve prevention Minimise skin damage Benchmark to drive improvement over time Reduce inconsistency Eradicate avoidable pressure damage NHS Outcomes Framework: Domain 4 – Ensuring a positive experience Domain 5 – Safe environment Private and confidential 9

10. www.virgincare.co.uk Audit methodology On ‘audit’ day, all patients with pressure ulcers included Process measures: Documented 1.Timely Waterlow risk assessment/review 2.Timely nutrition assessment/review 3.Individual care plan 4.Pressure relieving equipment 5.Incident form submitted (category 2, 3 and 4) Prevalence Outcome measure Private and confidential 10

11. www.virgincare.co.uk Examples of key players in this partnership Patients and carers General Practitioners Tissue viability nurse specialists Community Hospital wards – multidisciplinary Community nursing teams Care homes (residential and nursing) Acute hospital wards – multidisciplinary Social care Wound care companies Safeguarding Private and confidential 11

12. www.virgincare.co.uk Patient pathway Own home Acute hospital Community hospital Intermediate care Step up/step down Nursing home Residential home Community nursing team Private and confidential 12 Home

13. www.virgincare.co.uk Resulting culture Unavoidable complication of immobility? Inevitable consequence? Difficult to influence? Reactive management versus proactive prevention Private and confidential 13

14. www.virgincare.co.uk Successful partnerships depend on 1) Effective communication and leadership 2) Measurable outcomes 3) Sustained clinician engagement 4) Positive culture 5) Focussed education 6) Shared responsibility 7) Jointly devised solutions 8) Sustainability and ongoing improvements Private and confidential 14

15. www.virgincare.co.uk Focus on each element of partnership working In each aspect we: –reviewed our processes and systems –strived to work in collaboration with others –talked and shared ideas –were brave and changed the way we did things Examples from each of the elements of partnership working that we hope will resonate with you Allow time for questions and sharing of other examples/ideas Private and confidential 15

16. www.virgincare.co.uk Communication Raising awareness Discussing progress Cooperation Sharing/transparency Comparative benchmarking –Over time –Between participants Private and confidential 16

17. www.virgincare.co.uk Measurable outcomes Improved quality – experience and safe care Incidence reduced Prevalence reduced Experience of pain and discomfort reduced Time saved to be used more appropriately Costs reduced Length of stay reduced Sustainability – continue to monitor over time Private and confidential 17

18. www.virgincare.co.uk Sustained clinician engagement Engagement of all – assessment tools Consistency Embedding changes into routine practice Changed incident reporting form Private and confidential 18

19. www.virgincare.co.uk Culture Raised awareness of pressure damage From ‘treatment’ focus to one of ‘prevention’ ‘Unavoidable’ to ‘unacceptable’ Positive incident reporting – how? Transparency – an open culture Reflection on shared problem Joint ownership of need for eradication Shared drivers for change Acceptance of ability to influence Private and confidential 19

20. www.virgincare.co.uk Focused education Internal and external Collaboration – bring clarity to quality One size does not fit all Targeted education based on identified need Skills sharing Ongoing targeted support Implementation of best evidence Private and confidential 20

21. www.virgincare.co.uk Shared responsibility Pressure ulcer pathway –Prevention, treatment and reporting –Responsibility, ownership and equality at each level –Visible focus for action Private and confidential 21

22. www.virgincare.co.uk Jointly devised solution Safe Care Steering Group Community SSKIN bundle –five best practice elements Use of SKIN bundle to support local incident reporting Serious incidents –Root Cause Analysis (RCA) –RCA panels and action plans –Shared learning Private and confidential 22

23. www.virgincare.co.uk Sustainability Private and confidential 23 Incident reporting triggers routine clinical audit Ongoing measurement Triangulation of data Education Review of tissue viability specialist resource

24. www.virgincare.co.uk Template discussion Sharing of: –thoughts –solutions –innovation –one action you will take Private and confidential 24

25. www.virgincare.co.uk National Safe Care CQUIN (May 2012) Rationale ‘Whilst some 10-12% of all patients suffer from pressure ulcers, a substantial proportion of these can be avoided More older people and more vulnerable patients suffer from pressure ulcers in community settings. The gap between the best and worst performers is substantial Simple inexpensive nursing interventions can dramatically reduce prevalence’ Private and confidential 25

26. www.virgincare.co.uk ‘Safety Thermometer’ CQUIN improvement goal 2013/14 Pressure ulcers originate across and outside of the health and social care system No distinction should be made between ‘old’ (present on admission) and ‘new’ (developed post-admission) pressure ulcers for the improvement CQUIN Organisations should work with partners across the health and social care system to address the causes and reduce their prevalence, regardless of source’ Commissioning for quality and innovation (CQUIN): 2013.14 guidance Draft – December 2012. NHS Commissioning Board Private and confidential 26

27. www.virgincare.co.uk Best practice evidence and drivers The management of pressure ulcers in primary and secondary care – NICE CG 29 (2005) Pressure ulcer treatment – EPUAP (2009) Essence of Care – DH (2010) SSkin Care Bundle – Health Improvement Scotland (April 2011) Achieving consensus in pressure ulcer reporting – Tissue Viability Society (2012) National monthly Safety thermometer census and Safe Smarter Care ‘harms’ measurement – CQUIN (2012) Private and confidential 27

28. www.virgincare.co.uk Best ‘clinical audit’ practice and pressure damage High quality care in pressure ulcer prevention depends on simple but consistent nursing (and other clinician) interventions to prevent ‘harm’ Clinical audit measures consistency across teams, settings and over time (re-audit) Critical success factors: CIREM research –strong likelihood of effective clinical audit –high impact on patient outcomes Private and confidential 28

29. www.virgincare.co.uk 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 confidential 29 HQIP Clinical audit: ten simple rules for NHS Boards: ‘Ensure with others that clinical audit crosses care boundaries and encompasses the whole patient pathway’

30. www.virgincare.co.uk Questions Food for thought on closing: –‘Some is not a number’ –‘Soon is not a time’ –Our partnership audit has given us clarity –Joint and clear expectation for continual improvement –‘Our contribution will be what did not happen to them’ ‘The 5 million lives campaign: Institute for healthcare improvement 2006-8’ Private and confidential 30