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					Learning Session 6

NHS Borders
NHS Borders Aims and
Programme Goals

   •   Mortality: 15% reduction
   •   Adverse Events: 30% reduction
   •   Ventilator Associated Pneumonia: 0 or 300 days between
 a •   Central Line Bloodstream Infection: 0 or 300 days between
 a •   Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range
   •   Staph Aureus Bacteraemias: 30% reduction
   •   Crash Calls: 30% reduction
   •   Harm from Anti-coagulation: Reduction in INRs > 6
 a •   Surgical Site Infections: 50% reduction in population of choice
   •   All process measures will be > 95% reliable
    Where are you with respect
    the programme goals and
    process reliability?
                                             Sept 08 - Different Protocol introduced
                                             Oct 08 to Jan 09 – Testing – Protocol very complex and
                                             not successful despite education of staff throughout.
                                             Decision to revert to original protocol with some
                                             amendments
                                             Mar 09 Revised protocol testing + staff education
                                             Compliance gradually improving
                                             Sept 09 - Data now taken from Ward Watcher




        Jan – 29 lists, 29 briefs,
              29 debriefs,
        133 patients, 132 pauses

        Feb – 34 lists, 34 briefs,
     33 debriefs (main theatre list),
       168 patients, 168 pauses

        Mar – 40 lists, 40 briefs,
39 debriefs (nurse in charge not present),
        176 patients, 176 pauses
Where are you with respect the
programme goals and process
reliability?


                                       The prophylactic
                                          antibiotics
                                       process is not at
                                        95% reliability




                                       Medicines
                                 Management where
                                 the reliability of the
                                  process has been
                                  difficult to achieve
Where are you with respect the
programme goals and process
reliability?

          Kaizen Event                         Lack of team leader affecting the regularity of
        interrupted data                          team meetings. Plus, person dependent
            collection                           system for collecting this data resulting in
                                                         intermittent data collection




                                                               Ward refurbishment


                                                      Added to Safety Briefing


           Data not discussed by the team due to infrequent
           meetings and no team leader replacement
NHS Borders - Our Success

                                              Safety Briefings
                              It was evident that the tins of cleansing foam
                                  for patient hygiene were being shared                 Time
  Revised, re-designed
                                 between patients and stored at sinks in 6         Management in
   software system for
                               bedded bays. An alert was put on the safety           theatres –
   theatres to includes
                               briefing for two weeks and the foam is now          improved flow
  process measures for
     SPSP activities         being stored in patient locker for individual use



                                             Safety Briefings
                                       Patient with current history of
                                 inappropriate behaviour towards staff.
                                 Safety briefing noted that all staff must
                                    attend in two’s at all times without
                                  exception. All staff briefed in morning        All ITU measures
                                and at change of shift, safety briefing on         now on Ward
      Regular review of                                                          Watcher – reliable
                                   display in sister’s office available to
    cardiac arrest calls –                                                         real time data
                                    female domestic, Physio, OT etc.
     reducing erroneous
    calls where there is a
       DNAR in notes
                                           Safety Briefings
                                Magnesium for IV infusion supplied from
                              pharmacy was a different preparation to that
                             normally supplied. Pharmacist advised staff to
                                   include this on the safety briefing
NHS Borders –
Our Challenges

                                                                          Reducing
    Medicines                                Time, resources
                                                                        variation and
  Management –                                 and capacity
                                                                         encouraging
   Lack of MDT                                                         standardisation
    team work            Lack of team
                         meetings to aid
                         analysis and
                         ownership of data

                                              Person                    Using the data
    Integration with
                                             Dependent                 and encouraging
  other improvement
                                              Systems                     ownership
   initiatives without
    losing focus on
        Model For
     Improvement

                         Spread – keeping            Data Collection
                          the tempo high
What we’ve tried

 •Testing a new data collection system for all General Ward
 reports
 •Compliance with the CLI bundle and Daily Goals
 documentation in Critical Care
 •In Peri-op testing new ways of collecting data with revised
 and redesigned computerised theatre system
 •Medicine Management – engaging of clinicians - we now
 have commitment from Medical Head of Service which has
 resulted in an upward trend
   Scottish Patient Safety Programme General Ward Current Work:
   Drivers and Changes
   Outcomes      Primary Drivers   Secondary Drivers   Process Changes

                                                Early identification of patient   SEWS observation
                                                deterioration (EWS)               chart - implemented
                          Provide reliable,
                          timely, care using
                          evidence-based        Early response system to          Early response
                          therapies             respond to deterioration          system – intervention
                                                                                  algorithm
                                                                                  implemented
                                               Prevent healthcare associated
Improved general                               infections
                                                                                  PVC bundle -
ward outcomes                                                                     prescription chart -
(Reduced infections,                                                              testing
crash calls,                                                                      documentation and
pressure                                                                          removal date sticker
ulcers, AE in CHF and                                                             - implementing
AMI patients)


                        Create a
                        collaborative          Reliable planning,                  SBAR – with calls
                        team                   communication and                   to outreach team –
                        and safety culture     collaboration of multi              implemented and
                                               disciplinary team                   spreading
Secondary Drivers:
Surgical Pause in Day Procedure Unit



                                            Change 4: Prompt card now
                                            used routinely

                             A P
                                       Change 3: Introduced laminated
                             S D       surgical pause card and completion
                                       of pause using computer screen

                         Change 2: SBAR used to identify non-
                         compliance issues and repeat PDSA for surgical
      AP                 pauses. The data recorded on debriefing form
      S D                and reported back to Theatre Safety Group

        Change 1: Surgical Pause process not sustained.
        Problems occurring with Doctors not listening and
        inadequate preparation of patient. Decision taken
        to retest the surgical pause
Keys to Success

•   Change 1 – Reverting
    back to the use of
    PDSA cycles
•   Change 2 – Education      •Beta Blocker Plan?
    with Junior medical
    staff and feedback to


                             PAUSE
    the Theatre Safety
    Group
•   Change 3 –
    Introduction of
    laminated Pause card
                             •Display Consent Form
•   Change 4 – Adoption of
                             •Allergy Status
    the prompt as routine
    process                  •Antibiotic Prophylaxis
                             •VTE Prophylaxis
NHS Borders
Medication Reconciliation
                                                                          Recommendations
                                                                          1. Attend medical unit meeting
      Use of Action Codes:                                                in May to feedback individual
      C = Continue                                                        results and highlight medicines
      S = Stop                                                            reconciliation again.
      W= With hold                                                        2. Brief consultants, specialist
       = Increase dose                                                   registrars about results, and
       = Decrease dose                                                   again about action code
                                                Kaizen event              recording. Continue to use
                                                                          existing patient record.
                                                                          3. Run briefing sessions on
                                                                          ward 4 for nurses to feedback
                                                                          results and increase
     5. Carry on with monthly audits. Summarise again in July 2010.       awareness.
      6. Ensure that any revision to patient record includes a revised
                            medicine reconciliation sheet.                4. Make HAN team aware of
  7. Work with team sponsor and Lead Medical Clinician to highlight the   results and process out of
                importance of this work and achieving the aims of the     hours.
                                       program.
NHS Borders
INR Rates


  Ranges from 2.54 – 6.29               Ranges from 0.35 – 2.62               Ranges from 0.45 – 2.25




      • Discussion of the data with Medical staff following presentation at Grand Round in March
                                 •FMEA on Warfarin discharge in April
                     •Working with other teams on high risk medicines eg Insulin
               •Keen to redesign the discharge process with Insulin using PDSA cycles


                    Data from June 09 onwards is Inpatients only
  NHS Borders
  Calls to Outreach Team


            SIRS forms spread                                                                                   Crash Call
                                            SIRS form amended again and tested prior                            down to 4
               to all medical
                                                      to being sent to print
                   wards
                                                                                                                Crash Call
                                                                                                                 up to 8
                              SIRS SBAR
  SIRS forms                cards introduced
                                                                                                                Crash Call
   reviewed,                                                                                                    down to 7
  tested and
redesigned x 4              Seasonal change, fewer
                                                                 Reduced                                        Crash Call
                           corresponding crash calls
                                                               numbers due                                       up to 15
                             over this time period
                                                               to consultant
                                                               on AL, mainly                                    Crash Call
                                                               surgical staff             Number of calls to    down to 4
                                                                                         cardiac arrest team
                                                                                       increased in month Aug   Crash Call
     Sustained training programme in recognition of the deteriorating patient                    09              up to 11
Help Needed Please!
                                         Encouraging staff
               Measuring                 to recognise the
               the quality                interconnection                  Tips on
                  and                    between process                  engaging
               percent of                and outcome for                 Physicians
               staff using                     patient
                 SBAR
Ideas for
education
of all staff
                             Database
                              for walk                Helping staff to
                               rounds                     see the
                                                     connections and
                                                      advantages of
                                                        integrated
                                                          working
And Lastly

•   Borders Improvement and Support Team (BIST) has been set up to:
•   Co-ordinate redesign work across NHS Borders
•   Support anyone wanting to make changes to their service or the way they work
•   Lead on redesigning services in a range of key areas
•   It brings together the following:
           18 weeks Referral to Treatment
            Long-Term Conditions Collaborative & Network
            Managed Care Networks
            • Mental Health Collaborative
            • Leading Better Care/Releasing Time to Care
The Programme Manager Team Sponsors, Team Leaders and some of the teams
   staff have been closely involved with the LEAN projects currently ongoing at
   BGH. The measures for the SPSP have been incorporated into the Project
   Charters for the LEAN re-design projects. SPSP contributes to the Continuous
   Improvement Monthly Report and the Strategic Change Programme Project
   Board Meeting

				
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