Learning Session 6

1. Learning Session 6 National Waiting Times Centre BoardGolden Jubilee National Hospital

2. Where are you with respect the programme goals and process reliability? • Seen statistically significant improvement but haven’t yet met goals of demonstrated reliability Examples • GTT & Leadership walkrounds • On Time Antibiotics & Surgical Pause • Safety Briefs, Hand Hygiene & C. Diff rates • CV Bundles

3. Leadership Walkrounds

4. Global Trigger Tool

5. On Time Antibiotics

6. PeriOp Briefings

7. Safety Briefings

8. Hand Hygiene

9. Days between C.Diff cases

10. CV Bundle Compliance

11. Our Success Success 1 (MM) INR Reporting Success 3 (Peri Op) Surgical Pause • Success 2 (GW) • Safety Briefs • Success 4 (Leadership) • Leadership Walkrounds Success 5 (Critical Care) CV Bundles

12. Our Challenges CVL-BSI rate – improvement in rate, yet to achieve 100 days between VAP rate – no significant improvement in rate Normothermia Outreach team Multi Disciplinary Engagement

13. Barriers and Challenges. • Tendency on occasion to spread too quickly without ensuring reliable process in place. • Further development required to ‘mature’ measurement strategy. • Elements of recovery need to be fully tested in coming months. • Medical Engagement improving and further education and support will help further. • Continue to build capacity and integrate SPSP into our overall approach to quality. • Fully embed across the Board.

14. What we’re trying.. • Local Health Board Coordinator (LHBC) has undertaken a hands on approach to programme management. • One year pilot – started Feb 1st 2010 – omens are good! • Extranet Data set has been fully reviewed and updated • Local data management strategy is being improved with increased responsibility to team leads for data management. • The effectiveness of the SPSP steering group is being reviewed including: • Role of Exec Directors. • Role of team leads. • The use of data – how we report it and use it more effectively.

15. Ongoing work…. • Raising SPSP profile across Board through formal governance structures. • Extranet doesn’t tell the whole story- Adoption of the ‘SPSP way’ is becoming more common – e.g. • Improved very high incident reporting process • Involvement of Lay people - walk rounds. • PDSA becoming less of a ‘mystery’ • At the heart of our approach to adoption of the quality strategy • Introduction of Electronic handover tool. • Reflected in NHS QIS CGRM feedback.

16. Perioperative Workstream Team Members Attending Helen Kerrigan – Team Lead, SCN Rosie McGuire- Anaesthetic Nurse Alan Wilson- General Team Leader Lorna Morrisson – Orthopaedic Scrub Nurse Shona Patterson – Clinical leader- Anaes/Pacu Bernadette Brady- Recovery Nurse Other Carl Hope- General Manager- Surgical services XX – Consultant Orthopaedic Surgeon National Waiting Times Centre Board Golden Jubilee National Hospital

17. Scottish Patient Safety Programme Peri op Current Work: Drivers and Changes Secondary Drivers Primary Drivers Outcomes Process Changes Antibiotic Protocol in place and implemented in all areas Provide appropriate reliable and timely care to patients to prevent SSI • Ensure proper prescribing of prophylactic Antibiotics. • Avoid hair removal if possible – do not use razor. • Maintain normal blood glucose • Ensure normal body temperature. • Undergo team training • Use briefings • DVT Prophylaxis • Continuation of beta blockers Policy developed and testing commenced Testing in endoscopy theatres Improved peri-operative outcomes (Reduced peri-operative adverse incidents, infections and cardiovascular events Create a team culture attuned to detecting and rectifying intra operative errors. Testing in general theatres Human factors and MDT patient safety training taking place monthly Surgical pause implemented in all areas. Prevent Peri operative cardiovascular events. DVT Prophylaxis implemented in all areas Beta Blockade testing in ophthalmic theatres

18. Peri Operative Secondary Driver:Prophylactic Antibiotics D DATA FEEDBACK TO FRONTLINE STAFF: 1.VAP Rate 2. Percent Compliance VAP Bundle (segmented) 3. Percent compliance with Daily Goals S P A A P S D D S P A A P S D A P S D Ensure antibiotic has been administered within 60 minutes prior to the operation Change 5: Pilot size expanded to Thoracic, Cardiac and General Surgery Theatres. Change 4: Educational sessions arranged for medical and nursing staff. Change 3: Adaptations made to protocol. Change 2: Protocol introduced to standardise antibiotic used. Change 1: Test commenced in Orthopedic Theatres.

19. Keys to Success (Peri Op) Change 1 – Test commenced in Orthopedic Theatres • Started small. • Deciding how to measure data Change 2 – Protocol Introduced • Overcoming the difficulty of engaging the multi-disciplinary team • Test often! Change 3 - Adaptations made to protocol • Much discussion and input from surgeons, anaesthetists, microbiologist and pharmacy. • Communicating the final protocol to all relevant staff Change 4 - Educational sessions arranged for medical and nursing staff. • Open sessions to discuss the drugs used, prescribing and administration methods. Change 5 –Pilot size expanded to Thoracic, Cardiac and General Surgery Theatres. • Corporate support for the implementation of the protocol. • Involving clinicians at all change tests

20. Worst Bit – Peri Op Christmas Break Discontinuation of Bear Paws Introduction of Bear Paws

21. Best Bit – Peri -Op New format testing in cardiac theatres New staff not completing Pause forms Successful spread to whole department

22. Our Progress – Peri OpImproving Communication • Surgical Pause & Brief fully embedded in daily practice within all operating theatres • Different specialities have developed their own format • Pre-op & PACU (recovery) have modified a ‘ward’ safety brief for use in their area • Data being collected shows the process is reliable

23. Our Progress – Peri Op Surgical Site Infection Rates Any hair removal is by clipping only and razors have been completely removed from theatre and the wards Data collected indicates a reliable process and supports spread Standardised Antibiotic Prophylaxis Protocol has been produced for all surgical specialities Data collection indicates good compliance in all areas except for general surgery Process for achieving normothermia has undergone PDSA testing and changing for several months with little improvement and is now being tested in another specialty

24. Our Progress – Peri OpPost-op Complications Protocol for Blood glucose control has been created and PDSA testing is under way Data collection and spread will commence within the next month Process for DVT Prophylaxis was well established and data collection indicated good compliance New SIGN guidelines has prompted a review of the process and PDSA retesting This has affected compliance in this bundle Beta-Blockade protocols are being PDSA tested in one area

25. What We Have Done WellPeri Op All theatre nursing staff and majority of medical staff are involved with SPSP (to some extent!) Periop SPSP Meetings are well attended Staff are much better at communicating with each other (particularly junior staff) Improved relationships with other clinical areas and collaborative working (CVC & PVC bundles)

26. What We Need To Work OnPeri Op Implementation, refinement, and spread of remaining bundles (beta-blockade, blood glucose, DVT prophylaxis and normothermia) Investigate ways to measure tangible effects of the bundles (review and compare adverse incidents reports, review discharge documentation for evidence of post-op complications) Increase the engagement of medical staff Improve feed back mechanism for staff and patients

27. In Summary – Peri Op SPSP as a whole is well established in our department We are aware of what we are doing well and what we need to work on There have been many indirect benefits produced from the Periop SPSP SPSP and the Productive Operating Theatre Programme will compliment each other well

28. Critical Care Workstream Team Members Attending National Waiting Times Centre Board Golden Jubilee National Hospital Alison Hunter – Senior Charge Nurse Megan Bateson - Nurse Susan Rafferty - Nurse Mary Black - Nurse Ken McKinlay – Consultant Anaesthetist Carol McEwan - Nurse

29. Scottish Patient Safety Programme Critical Care Current Work: Drivers and Changes Outcomes Primary Drivers Process Changes Secondary Drivers Reduce complications from ventilators Reduce complications from CVCs Optimal glucose control Prevent healthcare associated infections and cross contamination Proper sepsis recognition and treatment Reliable planning, communication and collaboration of multi disciplinary team Preventing VAP bundle - implemented Provide reliable, timely, care to critical care patients using evidence-based therapies CVC insertion & maintenance bundle – implemented Improve Critical Care Outcomes (Reduce mortality, infections and other adverse events) Daily MDT rounds SBAR for nursing handovers Create a collaborative team and safety culture Redesigned Daily Goals

30. Secondary Driver:Reliable planning, communication and collaborationof multi disciplinary team D DATA FEEDBACK TO FRONTLINE STAFF: 1.VAP Rate 2. Percent Compliance VAP Bundle (segmented) 3. Percent compliance with Daily Goals S P A A P S D D S P A A P S D A P S D DAILY GOALS Failed at first attempt. Redesigned, simplified,relaunched Jan 10 Change 4: Testing afternoon mini – round for Goals review/update Change 3: Bedside nurse/team leader redundancy Change 2: Redesign goal sheet (coloured paper format) & test 1-4-5 Change 1: Ask 5 staff how, what & when of Daily Goals

31. Daily Goals- Critical Care Change 1 – Abandon and relaunch • Ask 5 ( or 15 ) what goals they value & how we set them Change 2 – Redesign & testing • Removed from electronic record • Test simplified paper format Change 3 – Nurses as redundancy • Prompting • Scribing (where necessary) Change 4 – Afternoon mini round • Focus on communication between consultant, team leader & bedside nurse

32. What hasn’t worked ….Daily Goals 1 Critical Care Workstream • Spreading before reliability • Making it too complicated • Too many goals • Electronic format • Using nagging as an implementation strategy • Presuming MDT will perceive the benefits

33. DAILY GOALS Mark 1 – no PM review, no specific targets Mark 2 – segmented for sedation break, weaning targets & PM review (ALL OR NOTHING) Critical Care Workstream

34. Where are you with respect to the programme goals and process reliability? Critical Care Workstream Seen statistically significant improvement but haven’t yet met goals of demonstrated reliability CV bundles – process & outcomes

35. CVL-BSI Process & Outcomes Insertion Bundle - approx. 90% compliance last 3 months – stable/improving Maintenance Bundle – best performance 90% in January – now fallen to < 80% CVL-BSI rate – shift in performance – yet to achieve goals Critical Care Workstream

36. THE BEST BIT- Critical Care

37. THE WORST BITCritical Care

38. STAFF INFORMATIONCritical Care

39. INFORMATION FOR FAMILIESCritical Care

40. FAMILIES (contd) – Critical Care

41. OUR LEARNINGCritical Care Testing, testing Run, don’t walk vs. Reliable process Quick wins build enthusiasm & confidence Some consensus comes with time, testing & data Real engagement needs work Ongoing measurement

42. Eleanor Lang –Lead Nurse Quality and Performance Jacqui Brown- Clinical Educator- orthopaedics Susan McLaughlin – Clinical Educator- cardiothoracic Angela Chesney – Charge Nurse Carole Dempsey- Staff Nurse Irene McGachy – Senior Staff Nurse Suzanne Duffy – Staff Nurse National Waiting Times Centre Board Golden Jubilee National Hospital General Ward Workstream Team Members Attending

43. Scottish Patient Safety Programme General Ward Current Work: Drivers and Changes Primary Drivers Secondary Drivers Process Changes Outcomes MEWS chart – implemented in 6 in patient wards, monitoring actions taken following higher MEWs scores with senior nurses. Early identification of patient deterioration (MEWS)-   Early response system to respond to deterioration Prevent pressure ulcers Involve patients in planning Prevent healthcare associated infections Reliable planning, communication and collaboration of multi disciplinary team Provide reliable, timely, care using evidence-based therapies Early response system – intervention algorithm implemented Improved general ward outcomes (Reduced infections, crash calls, pressure ulcers, AE in CHF and AMI patients) PVC bundle- implemented in 5 wards- compliance with completing the bundle has been challenging improving Ensure patient and family centered care Hand Hygiene in place and embedded in all clinical areas. Amalgamating extranet report. Create a collaborative team and safety culture Safety Briefings implemented in all wards, OPD and day units. Compliance is good. SBAR – shift handovers in place in 2 wards. Monitoring quality of handovers in 1 ward. Testing patient transfers using SBAR in HDU- wards

44. Secondary Drivers:implementation of SBAR in handovers DATA FEEDBACK TO FRONTLINE STAFF: 1.Crash Call Rate 2. Percent Compliance w EWS 3. Percent compliance with EBAR 4. Percent of patients with appropriate interventions D S P A A P S D D S P A A P S D A P S D SBAR chart devised and includes all relevant information in pilot population segmented type of surgery and one HDU. Change 4: on to 6th test of form using rapid testing principles and continues with smaller segment Change 3: redesign of chart and continued testing including staff comments Change 2: rapid tests of redesigned SBAR handover chart completing PDSAs Change 1: new SBAR chart devised and tested on one patient transfer form HDU to ward with Charge Nurse

45. Keys to Success Change 1 –Key senior nursing staff at monthly general ward meetings • General ward group meet monthly- cross directorate. • Support from executive lead and SPSP administrator keeps this group meeting regularly reviewing progress and challenges. • This group allows all staff to see what has been implemented where and plan for testing and implementation of other parts of the general ward drivers. Change 2- Educational sessions for nursing staff. • Supported by clinical educators- ongoing short training sessions for ward staff at the clinical areas where staffing allows for this. • Recent awareness week on SPSP general ward work help in canteen- held in April. Change 3 – Template introduced to reinforce use of SBAR in ward handovers during testing and implementation. • Template designed by ward team and reviewed and redesigned during testing phase.

46. Success, Safety briefings (General Ward) • Using same folder in all areas • Encouraging all ward team to use this information • Dips in compliance annotated and SCN informed re taking action • In all general ward areas, out patients and day care areas • Positively received by nursing staff • Varying types of format in use has helped staff engagement

47. 11 out of 12 areas reporting safety briefings

48. In progress…General Ward • Starting to collect data on MEWS actions taken • Due to upload this data to extranet in May • More testing of use of SBAR for handovers and patient transfers planned • Continue to establish the General ward group

49. In progress – General Ward • Starting to test and implement SBAR • Shift to shift handovers in place in 2 wards….spread is planned • Starting to measure and record quality of SBAR handovers in 1 ward- plan to start measuring quality on second ward in May • HDU1 to cardiothoracic ward- rapid testing of SBAR sheet in progress with HDU Charge Nurse

50. Our challenges – General Ward • PVC bundle compliance variable in some areas • Testing and adapting complete • Performance issue • Low rates of infection….relevance of this difficult for staff to see.