1. Human Rights in Healthcare Betsi Cadwaladr University Health Board
Anne-Marie Rowlands: Deputy Director of Nursing
Sally Hughes-Jones: Head of Equality and Human Rights
Julie Smith: Associate Chief of Staff Nursing

2. About BCU Health Board Largest health organisation in Wales
Primary, community, mental health & acute hospital services for a population of around 676,000
Workforce around16,000 staff
Budget around £1.2 billion

3. Acute and Community services
3 district general hospitals
22 other acute and community hospitals
90 health centres, clinics, community health team bases and mental health units
121 GP practices and NHS services provided by North Wales’ dentists, opticians and pharmacies.

4. Our Strategic Direction
“Anyone coming in contact with a public service should be treated with respect and dignity, have their health need assessed, be helped and not handed off to someone else, receive a responsive, safe and high quality service that continually improves, is easy to access and understand” (Strategic Directions 2009)

5. Our Positive Obligation
Positive obligations on public authorities to take a proactive approach to human rights.
FREDA principles (Fairness, Respect, Equality, Dignity, Autonomy) underpin Human Rights and public service ethos.
Supports BCU Strategic Equality Plan & our organisational values

6. Human Rights Based Approach
Empowers service users and staff
Protects vulnerable people
Improves experience
Improves outcomes
Bring human rights to life by applying the principles to a clinical pathway

7. Leading & Defining the Project
Championed at Board level by the Director of Nursing, Midwifery and Patient Services
Deputy Director of Nursing, whose portfolio includes nutrition
Head of Equality and Human Rights
Associate Chief of Staff Nursing, lead for transformational group

8. Why Human Rights, Nutrition and Hydration?
Patient Association, Care Quality Commission, Ombudsman, Age Concern
No specific guidance – direct link nutrition, hydration, human rights & obligations of service providers
Evidence, guidance and best practice
BCU – huge organisation – different ways of working

9. Quality Patient Care Ward staffing/ nurse : patient ratio review
Supernumerary ward sisters/charge nurses
Introduction of matrons
Strategic nutritional and catering group
Saving 1000 Lives – Intentional rounding
Striving for excellence– ‘good is not good enough’

10. Project Aims Development of a practical toolkit
Directly links nutrition, hydration, human rights & obligations of service providers
Increase knowledge and awareness of human rights, nutrition and hydration
Embed dignity and human rights within everyday ward routine
Place the patient at the centre of care.

11. Achieving the Aims Multidisciplinary project steering group
Redefined the role of nutritional sub group
BIHR Human Rights training
Brainstorming session - practical starting point
Project plan & driver diagram agreed
Draft toolkit developed

12. Engagement and Involvement
Communication & press briefing
Stakeholder event - ward staff, dietetics, Speech and Language, education, catering, service users, specialist nurses
BIHR training, questionnaire, workshop
Draft toolkit –questions posed – positives and negatives? what would you change? barriers to implementation?

13. Outcome of Stakeholder Event
Event ideas and feedback discussed
Changes to toolkit made
6 pilot wards identified (mix of acute medical, care of the elderly, acute surgical, acute orthopaedic)
BIHR training for pilot wards, matrons and senior nursing team

14. Transformational sub group
Reporting to Human Rights steering group
Monthly meetings
Leads identified to support pilot wards
Focus on establishing the baseline, identifying areas for change
Testing (and changing) the toolkit

15. Drivers to Succeed Over arching aim
Primary Driver (Patients receive the required level of support with eating & drinking)
Secondary Drivers (Safety, Environment etc.)
Interventions
Cornerstone of the toolkit

16. Ensure appropriate environment of care including access to equipment.
Drivers & Key Components of Nutrition & Hydration in relation to Ward Routine
Environment
Ensure appropriate environment of care including access to equipment.
Safety
Identify vulnerable patients and those at risk at the beginning of every shift.
Establish an alert system.
Choice
Enable and promote choice and ensure 24 hour access to food and drinks.
Putting Human Rights at the Heart of Hydration and Nutrition
Meal times
Ensure mealtimes are protected. Enable and promote appropriate involvement of carers and volunteers
Empower patients and their families.
Ensure and enable regular communication. Ensure patients autonomy and dignity is respected.
Audit compliance and measure improvement
MUST audit and fundamentals of care audits. Identify, monitor and learn from concerns.

17. Principles of Improvement Methodology
Initiative to improve patients nutrition and hydration in various areas of practice using PDSA cycle methodology with fast cycling
Measure it > change it > re-measure it > change it
Until you get it right!
Aims to introduce effective processes and systems for staff in ward environments
Aims for culture change!

18. Methodology

19. East Central West Measurements Human Rights Strategic Group
In Patient Transformational Group
East Central West
Mealtimes & Environment
Patient Choice
Patient Safety & Empowerment
Measurements

20. How did we do it ? East pilot areas
Patient safety and empowerment work streams in line with improvement methodology
Wards and teams identified
Operational definitions for measurements developed
Baseline measurements undertaken
PSDA cycles - process redesign
We stacked the odds in our favour!!

21. Patient Safety 3 dimensions of patients safety
Identification of patients at risk during safety briefing (measure 1)
(Safety briefing – measure 2)
Delegation of Nursing orders (measure 3)

22. Methodology
Baseline measurement on pilot ward showed identification of patients at risk at safety briefing at 59%
Target compliance = 95%

23. Methodology (2) Changes introduced
Raise awareness of human rights approach and toolkit development – matrons meeting/staff meetings
All Wales e learning directive for all nurses to complete
Posters for SBAR
Symbols
Letters to nurses in charge outlining roles and responsibilities
Red jugs/lids
At a glance board
Roles and responsibilities e.g. For house keepers for data collection, Change ward routine in relation to undertaking distribution of red jugs/symbols

24. Example of reliable design evolution
Implement a system to ensure patients at risk are identified at safety briefs
Who - All team leaders
What – ensure at risk patients are identified at safety briefing
When – during safety briefings (3x daily)
Where - Pilot ward
How -
Design – brief the nurses regarding responsibilities of identifying patients at risk
Redesign – re introduce safety briefing into ward 3 times daily
Redesign – develop a poster to be clearly displayed at nurses station prompting safety brief times
Redesign - change the pm SB time to accommodate shift patterns
Redesign – introduction of symbols relating to patients at risk

25. Reliable Process Design
Safety Briefing
PM …… AM
Nights ……..
Don’t forget
Don’t Forget

26. Results – weekly data

27. Results – monthly data Introduced symbols/posters Re affirmed R&R
No SB (nights)

28. Delegation of need

29. Empowerment

30. Conclusion
Through repeated testing and process redesign, reliability and sustainability achievable
Lessons learnt –
At the beginning state who, what, where and when (prevents defects being the people you forgot to include!
Keep it simple
Spread only when processes reliable

31. Next Steps Project steering group meeting Dec 12
Agree implementation plan
Development of ward resource file/website
Communication within organisation
Strategic Nursing and Midwifery Committee
Improving Service User Experience Committee
Evaluation of impact
Sharing across Wales and wider

32. Thank You
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