1. Patient Safety Collaborative Pressure Ulcer Harm Reduction Dr Paul Durrands Chief Operating Officer, Oxford AHSN

2. What and where http://www.oxfordahsn.org/our-work/wealth-creation/obn-map/ Oxford AHSN Life Sciences map link: Oxford AHSN – 1 of 15 AHSNs 3.3M population Annual NHS spend circa £5bn NHS employees 65,000 326 GP practices, 2,000 GPs 11 Trusts 12 Clinical Commissioning Groups Four Local Enterprise Partnerships 12 Councils Nine Universities Major international companies 620 healthcare and life science organisations

3. Oxford AHSN governance structure We welcome new partners Great Western Hospitals NHS FT is working with our clinical networks, R&D and Clinical Innovation Adoption programmes. Bedford Hospital NHS Trust is working with the Imaging Network, has EBH Fellowship and was an OBN/AHSN Award winner. Frimley Health is engaged in Best Care, Clinical Innovation Adoption programme, Patient Safety and the Partnership Board.

4. Patient Safety Professor Charles Vincent leads the Patient Safety Collaborative, launched in October 2014. Charles trained as a clinical psychologist and has worked in the field of the causes of harm to patients and the consequences for patients and staff for many years. The Patient Safety Collaborative (PSC) was launched in October 2014 – part of a network of 15 covering England. It will focus initially on a small number of clinical programmes but also act as an umbrella and coordinating centre for the many important patient safety initiatives – both practice and research – within Berkshire, Buckinghamshire, Oxfordshire and Bedford. The principal aims of the PSC are to: Develop safety from its present narrow focus on hospital medicine to embrace the entire patient pathway Develop and sustain clinical safety improvement programmes within the Oxford AHSN Develop initiatives to build safer clinical systems across the Oxford AHSN Collaborate and support sister safety programmes both nationally and internationally. Early priorities include the active engagement of patients and carers; the development of a safety information system, the establishment and support of programmes on acute kidney injury, medication safety, pressure ulcers, safety in mental health and sepsis, and developing capacity and capability in leadership for safety improvement. PSC has appointed Jill Bailey as Head of Patient Safety

5. Reducing harm from pressure ulcers Pressure ulcers cause patients to suffer harms such as pain and infection and in extreme cases can result in plastic surgery, amputation or even death. There is a considerable financial cost to the whole health economy as well as an increased use of resource and prolonged length of stay Most of the harm associated with pressure ulcers is known to be avoidable with good care

6. Oxford AHSN Patient Safety Collaborative Pressure ulcer harm reduction: Progress so far Chair: Debra Jackson Professor of Nursing, Faculty of Health & Life Sciences, Oxford Brookes University, Professor, Nursing Research, Oxford University Hospitals NHS Trust Clinical Leads: Ria Betteridge Consultant Nurse, Tissue Viability Oxford University Hospitals NHS Trust and Sarah Gardner Clinical lead Tissue viability service Oxford Health NHS FT

7. Oxford AHSN PSC Pressure ulcer harm reduction: progress so far Membership from: Buckinghamshire Healthcare NHS Trust, Berkshire Healthcare NHS FT, Oxford Health, Oxford University Hospitals, Royal Berkshire NHS FT, Bedford Hospital NHS Trust, Milton Keynes NHS FT, Oxfordshire Clinical Commissioning Group, Oxfordshire County Council, Nursing/ Care Home sector Support is provided by the Patient Safety Academy, the AHSN informatics team and the Patient Safety Collaborative

8. AHSN PSC Pressure ulcer harm reduction: progress so far Project group set up with monthly meetings planned for the first six months Scoping work completed to understand the good work and progress which has already been made in the area of pressure ulcer reduction in the region Project documents complete [PID, TORs, plan] Final Driver Diagram completed

9. AHSN PSC Pressure ulcer harm reduction: progress so far First cut of data from Safety Thermometer complete First cut of incident data from OUH and OH underway Literature review is underway Patient and carer involvement underway The workstream members will begin the Quality Improvement work in their organisations by the end of the year. Preparations underway to facilitate this.

10. Quality Improvement Approach Following extensive discussion, the Aim of the work stream has been decided: ‘To ensure 100% of people receiving care in the participating sites will remain free from harm as a result of acquired pressure damage by 31 st March 2018’ With a secondary aim to: ‘Establish best care guidelines using improvement methodology’

11. Quality Improvement Training NHSIQ and the Patient Safety Collaborative will be providing a six day course in Quality Improvement to support the improvement work streams The pressure ulcer group will take at least 20 places on this course As well as supporting the pressure ulcer work stream, this will support the growth of Quality Improvement capability in the Oxford AHSN region

12. The AHSN commitment to the PSF legacy A commitment to take forward the ethos of whole systems approaches enshrined in the SSKINntelligence programme and to include nursing / care homes in our work A commitment to dedicate the money specifically for work in reducing pressure ulcers and for training and support to clinicians A commitment across the entire Oxford AHSN region We will endeavour to run nursing research parallel to the Quality Improvement work