1 / 26

educating and empowering frontline staff to recognise and respond ...

Olivia
Download Presentation

educating and empowering frontline staff to recognise and respond ...

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Educating and empowering frontline staff to recognise and respond appropriately to the deteriorating patient John Lewandowski Clinical Educator Team Leader My name is John Lewandowski and I lead a team of educators in our Trust who are responsible for rolling out the NICE competencies for acute illness across our two sites. This presentation will cover how we did that This is only a small and specific part of an overall Trust strategy to reduce mortality (e.g. Infection control, nutrition, medication safety, falls, tissue viability and so on). However, our role and that of the competencies does overlap with many of these inititiatives This slide set may have some slight changes from the one in your pack so just be aware My name is John Lewandowski and I lead a team of educators in our Trust who are responsible for rolling out the NICE competencies for acute illness across our two sites. This presentation will cover how we did that This is only a small and specific part of an overall Trust strategy to reduce mortality (e.g. Infection control, nutrition, medication safety, falls, tissue viability and so on). However, our role and that of the competencies does overlap with many of these inititiatives This slide set may have some slight changes from the one in your pack so just be aware

    2. This bold target was set back in 1998 And I want to show you how we have been and still are part of that I will cover three broad themes of how we moved forward This bold target was set back in 1998 And I want to show you how we have been and still are part of that I will cover three broad themes of how we moved forward

    3. Overview You cant deliver competencies without a supportive framework and thats the first point I will explore Co-ordinated strategy essential in facilitating the way for success in competency development and delivery Without clinical leadership, staff support and correct underlying mechanisms and processes, then the educational principles that are laid out in the competencies will not necessarily be adopted by front line staff and staff will not be empowered 2. Developing & assessing competence in practice Second point is the nuts & bolts of how competencies (Drawn from NICE 50) were drawn up and delivered across our Trust. 3. Competence and practice development The third thing to explore will be to highlight that you cant have competencies without supportive practice development and the compliance of ward staff and managers. Its not just about jumping through hoops. Staff can see the link between competencies and policy So, focusing on the first element... You cant deliver competencies without a supportive framework and thats the first point I will explore Co-ordinated strategy essential in facilitating the way for success in competency development and delivery Without clinical leadership, staff support and correct underlying mechanisms and processes, then the educational principles that are laid out in the competencies will not necessarily be adopted by front line staff and staff will not be empowered 2. Developing & assessing competence in practice Second point is the nuts & bolts of how competencies (Drawn from NICE 50) were drawn up and delivered across our Trust. 3. Competence and practice development The third thing to explore will be to highlight that you cant have competencies without supportive practice development and the compliance of ward staff and managers. Its not just about jumping through hoops. Staff can see the link between competencies and policy So, focusing on the first element...

    4. 1: Coordinated & Supportive Strategy Strong clinical leadership is the first of three aspects I would like to discuss regarding our co-ordinated and supportive strategy Our Trust has a strong board to ward philosophy to enhance clear lines of communication and responsibility. Mechanisms to reflect this include: Quarterly reports We have a greater interface between board and ward with a much greater focus on quality which is taken very seriously QR include key information on falls, pressure sores, clinical incidents, complaints, clostridium difficile and MRSA. EWS audits included. Some discussion at the moment of adding chart checker (PDSA) and whether we should add cardiac arrest rates 2. LIPS leading improvement in patient safety We have a patient safety lead who is engaging re: patient safety first as well as GTT mortality reviews & trigger events = adverse incidents (e.g. Lack of EWS, return to theatre, arrest etc) 3. Patient Safety First Campaign The work undertaken by my team has been supported by the wider work going on to reduce harm as part of the Patient Safety First Campaign which the Trust is actively participated in. We have a patient safety lead for LIPS who engages with this 4. QRP example on the next slide Our nursing director is an active lead for the QRP doing the rounds etc 5. Also: We have a steering group for acute illness Strong clinical leadership is the first of three aspects I would like to discuss regarding our co-ordinated and supportive strategy Our Trust has a strong board to ward philosophy to enhance clear lines of communication and responsibility. Mechanisms to reflect this include: Quarterly reports We have a greater interface between board and ward with a much greater focus on quality which is taken very seriously QR include key information on falls, pressure sores, clinical incidents, complaints, clostridium difficile and MRSA. EWS audits included. Some discussion at the moment of adding chart checker (PDSA) and whether we should add cardiac arrest rates 2. LIPS leading improvement in patient safety We have a patient safety lead who is engaging re: patient safety first as well as GTT mortality reviews & trigger events = adverse incidents (e.g. Lack of EWS, return to theatre, arrest etc) 3. Patient Safety First Campaign The work undertaken by my team has been supported by the wider work going on to reduce harm as part of the Patient Safety First Campaign which the Trust is actively participated in. We have a patient safety lead for LIPS who engages with this 4. QRP example on the next slide Our nursing director is an active lead for the QRP doing the rounds etc 5. Also: We have a steering group for acute illness

    5. Quality Review Sharing good practice how do we feed back and share the results? Well, this is one of the other themes for having a co ordinated and supportive strategySharing good practice how do we feed back and share the results? Well, this is one of the other themes for having a co ordinated and supportive strategy

    6. 1: Coordinated & Supportive Strategy Share Good practice/Recognition and Performance Why does it work and what works? e.g. Learning from and within other teams (e.g. QRP, stop the clock/non essential tasks) 2. Take responsibility e.g. Linked to acute competencies part of KSF 3. Learn from patients e.g. key component of QRP. Incident reporting & action planning. Direct link to the CLIP report (complaints & litigation, incidents, PALS). Case discussions 4. Measure for improvement Will discuss our audit results more at the finish but one fine example of this is the QRP results I showed you 5. Engage front line staff Engage front-line staff to take measures to keep healthcare environments safe and efficient. Productive ward. Patient safety first. QRP results Competitive audits. Educators policy changes also involve staff 6. Executive team support Executive support for the clinical educator team, background framework, competencies and practice development TRANSITION STATEMENT There are other practical tools and mechanisms in place that facilitated our introduction Share Good practice/Recognition and Performance Why does it work and what works? e.g. Learning from and within other teams (e.g. QRP, stop the clock/non essential tasks) 2. Take responsibility e.g. Linked to acute competencies part of KSF 3. Learn from patients e.g. key component of QRP. Incident reporting & action planning. Direct link to the CLIP report (complaints & litigation, incidents, PALS). Case discussions 4. Measure for improvement Will discuss our audit results more at the finish but one fine example of this is the QRP results I showed you 5. Engage front line staff Engage front-line staff to take measures to keep healthcare environments safe and efficient. Productive ward. Patient safety first. QRP results Competitive audits. Educators policy changes also involve staff 6. Executive team support Executive support for the clinical educator team, background framework, competencies and practice development TRANSITION STATEMENT There are other practical tools and mechanisms in place that facilitated our introduction

    7. c. Other supportive mechanisms & tools: 24/7 Critical Care Outreach Aggregate EWS/MEWS EWS/NICE 50 Audits Introduction of SBAR SUI panel Escalation policy 1: Coordinated & Supportive Strategy Has tended to be over reliance on outreach so where is the time for them to teach? Aggregate scoring mechanism includes appropriate standards (e.g. Minimum obs, prescription of obs etc). Includes Maternity EWS NICE 50 audit is huge single snapshot SBAR is from NHS Institute SUI and what we can learn (includes failure to rescue. Feeds back action plans and if necessary what can be learned for the whole Trust) Escalation added into our policies: If necessary, an individual can escalate concerns if they are not getting the required support, ultimately to the director of nursing or the medical director this gives the right message to staff regarding the importance of not taking no for an answer. It empowers multi disciplinary staff to make the right decision at the right time so failure to rescue is minimised So, moving onto our second main theme what about the nuts and bolts of the competencies and is it worth doing them?Has tended to be over reliance on outreach so where is the time for them to teach? Aggregate scoring mechanism includes appropriate standards (e.g. Minimum obs, prescription of obs etc). Includes Maternity EWS NICE 50 audit is huge single snapshot SBAR is from NHS Institute SUI and what we can learn (includes failure to rescue. Feeds back action plans and if necessary what can be learned for the whole Trust) Escalation added into our policies: If necessary, an individual can escalate concerns if they are not getting the required support, ultimately to the director of nursing or the medical director this gives the right message to staff regarding the importance of not taking no for an answer. It empowers multi disciplinary staff to make the right decision at the right time so failure to rescue is minimised So, moving onto our second main theme what about the nuts and bolts of the competencies and is it worth doing them?

    8. Introduction Before I talk about the advantages of competence I want to point out that we have real witnessed practical experience of how the advantages cited within the competency framework are real. For staff, it IS more than just jumping through hoopsMy team and I saw clear example of all of these as a direct consequence of our work 1. We can empower staff if competencies are supported by the right policies and processes. They can help staff to be more assertive and confident 2. Helps inter-professional working Sets clear pathways of responsibility (CG100 flyers nursing vs doctor responsibility etc) 3. Enhance accountability You know what is expected of you. Embedded within the competency documents which staff need to sign 4. Assist service planning, workforce development & role re-design Adapted competencies are a result of and also influence Examples include Surgical close obs and stroke service who relied on us to support staff in these new areas 5. Adds to appraisals/clinical supervision/KSF We have a lot of practical experience of this now and with staff who are at risk of capability 6. Integrates well with existing education & training Not about re inventing the wheel (e.g. enhances preceptorship training & AP training) Introduction Before I talk about the advantages of competence I want to point out that we have real witnessed practical experience of how the advantages cited within the competency framework are real. For staff, it IS more than just jumping through hoopsMy team and I saw clear example of all of these as a direct consequence of our work 1. We can empower staff if competencies are supported by the right policies and processes. They can help staff to be more assertive and confident 2. Helps inter-professional working Sets clear pathways of responsibility (CG100 flyers nursing vs doctor responsibility etc) 3. Enhance accountability You know what is expected of you. Embedded within the competency documents which staff need to sign 4. Assist service planning, workforce development & role re-design Adapted competencies are a result of and also influence Examples include Surgical close obs and stroke service who relied on us to support staff in these new areas 5. Adds to appraisals/clinical supervision/KSF We have a lot of practical experience of this now and with staff who are at risk of capability 6. Integrates well with existing education & training Not about re inventing the wheel (e.g. enhances preceptorship training & AP training)

    9. Funds 5.5 WTE staff for a period of 2 years supported by research team (1 lead and 4.5 WTE team) 2. Clinical Educators Practice based/peripatetic (more on this later) 3. NICE 50/NPSA Competencies based on NICE 50, NPSA and NICE Competency framework These acute competencies are for ALL staff caring for in patient adults 4. Aim at the outset for 90% target training Staff caring for in patient adults is the target Funds 5.5 WTE staff for a period of 2 years supported by research team (1 lead and 4.5 WTE team) 2. Clinical Educators Practice based/peripatetic (more on this later) 3. NICE 50/NPSA Competencies based on NICE 50, NPSA and NICE Competency framework These acute competencies are for ALL staff caring for in patient adults 4. Aim at the outset for 90% target training Staff caring for in patient adults is the target

    10. Point 1 amended per discipline & area (talk about what a recorder does VS recogniser) We limited focus on specific staff caring for in patient adults. This included OTs, Physio, midwives, nursing staff and doctors. Having specifically amended competencies enabled each discipline and specialist area to own the competencies as they were more relevant and applicable. Who are recorders etc Point 2 KSF linked & mandatory (nursing staff, HCA and Midwives are done peri patetically) The staff are made clear that they understand it is KSF linked inability to complete interrupts ability to proceed on gateway. Immediately made mandatory once they are rolled out within a specific area and now delivered to staff on induction. Booklet for doctors Point 3 a word on primary and secondary responders part of their foundation training (urgent stuff right at the start) Primary Responder is mapped to Foundation level 1 competencies as is Secondary responder to Foundation level 2 (for the rest of the staff the competencies take the form of a booklet) Point 4 PT/OT teach selves Physiotherapist and Occupational Therapist ward champions were trained to undertake training for their own staff with some support from us. Bulk of our work is with nurses, midwives and HCA Point 5 timing & penalty Three months to complete from commencement Commencement slip goes to training who then flag it on system until completion. First failure results in a reminder to ward manager and individual then some further time. Second failure results in a reminder to General manager, ward manager and individual and then slight further time given. Third failure results in reminder also sent to go Governance lead for immediate action Point 1 amended per discipline & area (talk about what a recorder does VS recogniser) We limited focus on specific staff caring for in patient adults. This included OTs, Physio, midwives, nursing staff and doctors. Having specifically amended competencies enabled each discipline and specialist area to own the competencies as they were more relevant and applicable. Who are recorders etc Point 2 KSF linked & mandatory (nursing staff, HCA and Midwives are done peri patetically) The staff are made clear that they understand it is KSF linked inability to complete interrupts ability to proceed on gateway. Immediately made mandatory once they are rolled out within a specific area and now delivered to staff on induction. Booklet for doctors Point 3 a word on primary and secondary responders part of their foundation training (urgent stuff right at the start) Primary Responder is mapped to Foundation level 1 competencies as is Secondary responder to Foundation level 2 (for the rest of the staff the competencies take the form of a booklet) Point 4 PT/OT teach selves Physiotherapist and Occupational Therapist ward champions were trained to undertake training for their own staff with some support from us. Bulk of our work is with nurses, midwives and HCA Point 5 timing & penalty Three months to complete from commencement Commencement slip goes to training who then flag it on system until completion. First failure results in a reminder to ward manager and individual then some further time. Second failure results in a reminder to General manager, ward manager and individual and then slight further time given. Third failure results in reminder also sent to go Governance lead for immediate action

    11. Point1 - Manager brief Ward manager is seen several weeks before and during this interview (if necessary PDSA): Explanation of what is expected. List of key staff requested (at least 1 per 5 staff). Multiple copies of relevant competencies to be printed and an area to keep them safe (staff can mislay resulting in delay). Ward champions must be senior staff or sisters and must be free to mentor. We also point out as well as the competencies we will evidence specific training and exactly who we have delivered it to (e.g. Track & Trigger Training, Fluid balance, SBAR, ABCDE assessment, Emergency trolley, Escalation policy). If manager is not already we point out the link to the AIM course & NICE 50 competencies and when AIM courses are. Roughly two to three weeks per ward. We then ask manager if there is anything else we can help to train whilst we are at it. Manager doesnt always brief staff so - we now tend to visit an area a few times. We were 24/7 but funding was an issue Point 2 - Ward champions also: Briefed as above & how to deal with staff who are not demonstrating competence. Also given hard copy and electronic resources Point 3 - After the Visit We do deal with serious issues there and then but we do delivering a post visit brief (using Pendletons rules of Feedback) which doesnt just cover the competencies. It also includes feedback on issues relevant to the acutely ill patient (e.g. prioritisation of observations, handovers etc). Managers are set colour coded action plans We did go back to several areas and there were three reasons. A - poor compliance so we had to re action plan and continue until we saw improvement. B - part of SUI planning/response. C if the action plan (above) had serious concernsPoint1 - Manager brief Ward manager is seen several weeks before and during this interview (if necessary PDSA): Explanation of what is expected. List of key staff requested (at least 1 per 5 staff). Multiple copies of relevant competencies to be printed and an area to keep them safe (staff can mislay resulting in delay). Ward champions must be senior staff or sisters and must be free to mentor. We also point out as well as the competencies we will evidence specific training and exactly who we have delivered it to (e.g. Track & Trigger Training, Fluid balance, SBAR, ABCDE assessment, Emergency trolley, Escalation policy). If manager is not already we point out the link to the AIM course & NICE 50 competencies and when AIM courses are. Roughly two to three weeks per ward. We then ask manager if there is anything else we can help to train whilst we are at it. Manager doesnt always brief staff so - we now tend to visit an area a few times. We were 24/7 but funding was an issue Point 2 - Ward champions also: Briefed as above & how to deal with staff who are not demonstrating competence. Also given hard copy and electronic resources Point 3 - After the Visit We do deal with serious issues there and then but we do delivering a post visit brief (using Pendletons rules of Feedback) which doesnt just cover the competencies. It also includes feedback on issues relevant to the acutely ill patient (e.g. prioritisation of observations, handovers etc). Managers are set colour coded action plans We did go back to several areas and there were three reasons. A - poor compliance so we had to re action plan and continue until we saw improvement. B - part of SUI planning/response. C if the action plan (above) had serious concerns

    12. Developing and assessing competence in clinical practice is a challenge Witnessing the reality of practice Keeping back observing. If competent you simply sign off. You get to see practical improvements in real time (e.g. FB) Link cause & effect Ideal for promoting IPE (e.g. EWS ABCDE skills drills) Stop the clock for observations came in as a result of linking cause & effect (e.g. Delayed obs) Thinking about underpinning theory or logic (ritualistic practice e.g. bed baths more important than obs) Thinking about why or how things happen the way they do (why have you sent that HCA to scan with that patient who has chest pain?) Giving feedback Pendletons rules of effective feedback (both for individual clinicians and managers) Facilitating where you can (e.g. Tell me more about this patient whats missing?) Educating where you see the need but knowing where to step in and lead by example especially if there are safety issues. Visual teaching aids/laminates and practice improvements all support our practice presence Developing and assessing competence in clinical practice is a challenge Witnessing the reality of practice Keeping back observing. If competent you simply sign off. You get to see practical improvements in real time (e.g. FB) Link cause & effect Ideal for promoting IPE (e.g. EWS ABCDE skills drills) Stop the clock for observations came in as a result of linking cause & effect (e.g. Delayed obs) Thinking about underpinning theory or logic (ritualistic practice e.g. bed baths more important than obs) Thinking about why or how things happen the way they do (why have you sent that HCA to scan with that patient who has chest pain?) Giving feedback Pendletons rules of effective feedback (both for individual clinicians and managers) Facilitating where you can (e.g. Tell me more about this patient whats missing?) Educating where you see the need but knowing where to step in and lead by example especially if there are safety issues. Visual teaching aids/laminates and practice improvements all support our practice presence

    13. Peripatetic approach is not just about the bedside but is about other aspects of practice and whether or not they promote safe care of acutely unwell patients Point 1 - Observation of handover and communication (give direct feedback on handover by both docs & nurses) Pendltetons rules of constructive feedback also relates to these important processes as well as direct clinical practice The peripatetic approach helps to empower staff as it is grounded in the real world. What we suggest for practice improvement has to be seen to be realistic and achievable. These two pointers have led to a number of practice improvements that we had to lead on (will discuss shortly) Point 2 Prioritisation and organisation (e.g. drugs round. I ward does all drugs CDs and kardex together, another does them seperately e.g. do the main drugs then do a second CD round) There can be difficulties Peripatetic approach is not just about the bedside but is about other aspects of practice and whether or not they promote safe care of acutely unwell patients Point 1 - Observation of handover and communication (give direct feedback on handover by both docs & nurses) Pendltetons rules of constructive feedback also relates to these important processes as well as direct clinical practice The peripatetic approach helps to empower staff as it is grounded in the real world. What we suggest for practice improvement has to be seen to be realistic and achievable. These two pointers have led to a number of practice improvements that we had to lead on (will discuss shortly) Point 2 Prioritisation and organisation (e.g. drugs round. I ward does all drugs CDs and kardex together, another does them seperately e.g. do the main drugs then do a second CD round) There can be difficulties

    14. Peripatetic approach is useful but not without its challenges. Developing ward champions is a key tactic and you should ensure AIM course is mandatory if not for all staff then certainly at least for ward champions. Build relationships early Point 1 Witnessing issues Witnessing questionable practice/clinical incidents takes tact and where Pendletons rules comes in. A sound knowledge base for educators is essential as well as the need to facilitate appropriate support & de brief. On a different note the witnessing of competency acquisition is sometimes difficult this is when you can utilise scenarios. Skills drills can be useful but are of very limited use in a busy clinical area, (seeing competencies) Point 2 & 3 Time Demands/Pressure on staff/Dealing with meltdown If a member of staff is stressed or does not have time deal with it carefully and know when to back off. If a ward is in meltdown you can offer relevant strategic help and advice but sometimes its best to focus elsewhere and come back but revise your input strategy Point 4- Communication does improve as a result of our input Sometimes reception can be frosty, in all cases this has been when management have been tardy in involving their staff in what we are there for. Now we recognise the need to check areas before you start despite manager prep. Staff are acceptably cautious at first usually but in most cases once they realise why we are there they tend to relax into the process. In some cases, (as we will see we have been able to assist practice development and make their lives easier in the bargain) Important last point Staff can mislay their competencies. They are told at the outset that they are responsible for them and no one else Peripatetic approach is useful but not without its challenges. Developing ward champions is a key tactic and you should ensure AIM course is mandatory if not for all staff then certainly at least for ward champions. Build relationships early Point 1 Witnessing issues Witnessing questionable practice/clinical incidents takes tact and where Pendletons rules comes in. A sound knowledge base for educators is essential as well as the need to facilitate appropriate support & de brief. On a different note the witnessing of competency acquisition is sometimes difficult this is when you can utilise scenarios. Skills drills can be useful but are of very limited use in a busy clinical area, (seeing competencies) Point 2 & 3 Time Demands/Pressure on staff/Dealing with meltdown If a member of staff is stressed or does not have time deal with it carefully and know when to back off. If a ward is in meltdown you can offer relevant strategic help and advice but sometimes its best to focus elsewhere and come back but revise your input strategy Point 4- Communication does improve as a result of our input Sometimes reception can be frosty, in all cases this has been when management have been tardy in involving their staff in what we are there for. Now we recognise the need to check areas before you start despite manager prep. Staff are acceptably cautious at first usually but in most cases once they realise why we are there they tend to relax into the process. In some cases, (as we will see we have been able to assist practice development and make their lives easier in the bargain) Important last point Staff can mislay their competencies. They are told at the outset that they are responsible for them and no one else

    15. Point 1 AIM 9you can always tell who has done an AIM course) AIM course is NHS North West Due to our input AIM course is now held 2-4 times per month and is now a formal part of our approach to management of a patient triggering EWS Point 2 - HCA All HCA staff in the Trust must now also evidence they have attended specific Trust training on observations Point 3 Bank/Agency We identified and responded to the risk here. All bank staff must have received training on observations. Key members of our local staff agency were trained in what we expected and all of agency staff have now received formal training on our charts and how they are used Point 4 - Audit We audit wards post SUI daily whilst we are there to determine immediate improvements as well as routine audits Lets look at some of the practice development we did as additional frame-working for our competenciesPoint 1 AIM 9you can always tell who has done an AIM course) AIM course is NHS North West Due to our input AIM course is now held 2-4 times per month and is now a formal part of our approach to management of a patient triggering EWS Point 2 - HCA All HCA staff in the Trust must now also evidence they have attended specific Trust training on observations Point 3 Bank/Agency We identified and responded to the risk here. All bank staff must have received training on observations. Key members of our local staff agency were trained in what we expected and all of agency staff have now received formal training on our charts and how they are used Point 4 - Audit We audit wards post SUI daily whilst we are there to determine immediate improvements as well as routine audits Lets look at some of the practice development we did as additional frame-working for our competencies

    16. 3. Competence & Practice Development Introduction Competencies must be based on practical, realistic and supportive policies and guidelines influenced from the ground floor up. The degree of work needed to ensure this was wholly unanticipated at the outset of the project. We would have limited success if we did not deal with practice development issues that were barriers to the success of the competencies. Point 1 - Policies guidelines Example - fluid balance policy & observations policies now exist which contains realistic and achievable guidance on how to improve practice (e.g. estimating). When to start/stop FB, links to obs guidelines, hydration policy, policy for acute illness Point 2 - Staff involvement & ownership Much of our CG100 observations policy has emerged from the ground floor up. People must see the practical worth. This is part of the process of planning for any and all barriers to success Point 3 - Barriers to success accessing the correct Trust mechanisms for making change and getting the right senior champions & exec team Point 4 - Personal responsibility versus Trust responsibility Roles and responsibilities are made very clear in the relevant policies (e.g. observations and fluid balance) and competencies, (signing for training, FB entries, competencies etc). We work through our existing ward processes (e.g. NPSG and NPPG) to ensure high level staff as well as ground level staff are engaged in practice development. Stronger link between competency guideline - clinical practice Point 5 Audits & feeding back Feeding back our successes and positive witnessing of good practice is itself empowering. We have taken great measures to ensure that particularly good practice areas are highlighted by the Trust Introduction Competencies must be based on practical, realistic and supportive policies and guidelines influenced from the ground floor up. The degree of work needed to ensure this was wholly unanticipated at the outset of the project. We would have limited success if we did not deal with practice development issues that were barriers to the success of the competencies. Point 1 - Policies guidelines Example - fluid balance policy & observations policies now exist which contains realistic and achievable guidance on how to improve practice (e.g. estimating). When to start/stop FB, links to obs guidelines, hydration policy, policy for acute illness Point 2 - Staff involvement & ownership Much of our CG100 observations policy has emerged from the ground floor up. People must see the practical worth. This is part of the process of planning for any and all barriers to success Point 3 - Barriers to success accessing the correct Trust mechanisms for making change and getting the right senior champions & exec team Point 4 - Personal responsibility versus Trust responsibility Roles and responsibilities are made very clear in the relevant policies (e.g. observations and fluid balance) and competencies, (signing for training, FB entries, competencies etc). We work through our existing ward processes (e.g. NPSG and NPPG) to ensure high level staff as well as ground level staff are engaged in practice development. Stronger link between competency guideline - clinical practice Point 5 Audits & feeding back Feeding back our successes and positive witnessing of good practice is itself empowering. We have taken great measures to ensure that particularly good practice areas are highlighted by the Trust

    17. 3. Competence & Practice Development Point 1 - There was no clear Trust Wide Policy on Oxygen therapy Point 2 Prioritisation tool & stop the clock Staff had no clear practical guidance on why and how to prioritise the clinical observation of patients. This is where stop the clock and the prioritisation tool came in. Stop the clock- this was developed initially by nursing staff on orthopaedic wards following incidents of clearly documented deterioration with no action documented.. and was subsequently picked up by medical wards. There are set times with clear prioritisation Point 4 EWS & ABCDE aim assessment EWS raised 0-5 and patient not in extremis? Perform ABCDE assessment then repeat EWS, if EWS> perform as graded response dictates Point 5 Handover communication Handovers for acutely ill now include: EWS, fluid balance, details of referral and management plan Point 1 - There was no clear Trust Wide Policy on Oxygen therapy Point 2 Prioritisation tool & stop the clock Staff had no clear practical guidance on why and how to prioritise the clinical observation of patients. This is where stop the clock and the prioritisation tool came in. Stop the clock- this was developed initially by nursing staff on orthopaedic wards following incidents of clearly documented deterioration with no action documented.. and was subsequently picked up by medical wards. There are set times with clear prioritisation Point 4 EWS & ABCDE aim assessment EWS raised 0-5 and patient not in extremis? Perform ABCDE assessment then repeat EWS, if EWS> perform as graded response dictates Point 5 Handover communication Handovers for acutely ill now include: EWS, fluid balance, details of referral and management plan

    18. 3. Competence & Practice Development Point 1 Reducing EWS Until recently only F2 or Band 6 (Sister) could reduce observations frequency). Now there are flow charts for areas of exception using EWS so that they can delay referral or if appropriate de-escalate EWS frequency as long as EWS is < trigger point and patient is of no concern Point 2 New areas (assist in development of new areas such as surgical close obs/stroke) Point 3 Uncommon clinical competencies Competency crib sheets and bullet point sheets, (e.g one or two sided bullet point sheets that can be accessed if staff come across a chest drain, tracheostomy or CVP etc). Just enough information to allow for the patient to be safe until further expertise can be accessed. What makes me safe? Point 4 EWS application universal A&E didnt initially use EWS which we identified as an opportunity for a patient to deteriorate (wards and A&E were speaking in different languages). Now EWS is used in A&E and always checked prior to transfer further reducing opportunity for a missed opportunity to spot a potential problem. Obstetrics now have MEWS and EWS is even used in recovery and daycase (with exception/flow charts etc) Point 5 Ward Feedback & change Our feedback has changed practice In one ward our feedback has triggered a staffing review, in another area one area was split into two wards to help it run more efficiently. We also influenced a temporary reduction in capacity in one area until processes could be reviewed Point 6 Skills Drills (starting to run in our acute respiratory ward) Point 1 Reducing EWS Until recently only F2 or Band 6 (Sister) could reduce observations frequency). Now there are flow charts for areas of exception using EWS so that they can delay referral or if appropriate de-escalate EWS frequency as long as EWS is < trigger point and patient is of no concern Point 2 New areas (assist in development of new areas such as surgical close obs/stroke) Point 3 Uncommon clinical competencies Competency crib sheets and bullet point sheets, (e.g one or two sided bullet point sheets that can be accessed if staff come across a chest drain, tracheostomy or CVP etc). Just enough information to allow for the patient to be safe until further expertise can be accessed. What makes me safe? Point 4 EWS application universal A&E didnt initially use EWS which we identified as an opportunity for a patient to deteriorate (wards and A&E were speaking in different languages). Now EWS is used in A&E and always checked prior to transfer further reducing opportunity for a missed opportunity to spot a potential problem. Obstetrics now have MEWS and EWS is even used in recovery and daycase (with exception/flow charts etc) Point 5 Ward Feedback & change Our feedback has changed practice In one ward our feedback has triggered a staffing review, in another area one area was split into two wards to help it run more efficiently. We also influenced a temporary reduction in capacity in one area until processes could be reviewed Point 6 Skills Drills (starting to run in our acute respiratory ward)

    19. 4. Results We have received notable recognition for our work Point 1 In addition: Subjective responses positive feedback from ward staff and managers Good feedback from exec teams, Trust education & training group, steering group for acute illness and resuscitation team Point 2: Results feedback: Our Trust results are communicated to staff through: Clinical Governance ACE committee Directly via Senior Clinical Nurses to ward staff Waiting for our research teams findings but in the meantime.We have received notable recognition for our work Point 1 In addition: Subjective responses positive feedback from ward staff and managers Good feedback from exec teams, Trust education & training group, steering group for acute illness and resuscitation team Point 2: Results feedback: Our Trust results are communicated to staff through: Clinical Governance ACE committee Directly via Senior Clinical Nurses to ward staff Waiting for our research teams findings but in the meantime.

    20. EWS Audit Trust Wide 2009

    21. This and the next slide presents data that was part of our NICE 50 audit note the radical improvement Dates: March 2008, October 2008, May 2009, November 2009 The percentage doesnt mean EWS has never been done. It simply means that if EWS has been missed more than once in 24 hours the audit criteria have not been met. This and the next slide presents data that was part of our NICE 50 audit note the radical improvement Dates: March 2008, October 2008, May 2009, November 2009 The percentage doesnt mean EWS has never been done. It simply means that if EWS has been missed more than once in 24 hours the audit criteria have not been met.

    22. Here is another one from the NICE 50... Again, this doesnt means observations have not been recorded or increased appropriately. It just means that the prescription for observations and their frequency has not been documentedHere is another one from the NICE 50... Again, this doesnt means observations have not been recorded or increased appropriately. It just means that the prescription for observations and their frequency has not been documented

    23. Points to explain: - We will achieve around 60% as opposed to the original 90%. - This reflects the sheer amount of practice development and support necessary which was totally unanticipated - If we had JUST focused on the competencies alone we may have achieved higher. - However, we would have been paying lip service to the competencies. - We feel patients are safer with 52% completion Figures relevant up until mid March 2010 Primary Responders Outreach and Specialist Nurses competencies have been drawn up but not launched for these groups yet Secondary responders this will also shortly include ST and middle grades Difficulties keeping the data live as staff leave and start all the time, every quarter these figures are re-verified to take account of this There are only three clinical areas left for us to complete recovery, short stay and haematology 74% of the relevant workforce engaged in training! 59% or more will be throughPoints to explain: - We will achieve around 60% as opposed to the original 90%. - This reflects the sheer amount of practice development and support necessary which was totally unanticipated - If we had JUST focused on the competencies alone we may have achieved higher. - However, we would have been paying lip service to the competencies. - We feel patients are safer with 52% completion Figures relevant up until mid March 2010 Primary Responders Outreach and Specialist Nurses competencies have been drawn up but not launched for these groups yet Secondary responders this will also shortly include ST and middle grades Difficulties keeping the data live as staff leave and start all the time, every quarter these figures are re-verified to take account of this There are only three clinical areas left for us to complete recovery, short stay and haematology 74% of the relevant workforce engaged in training! 59% or more will be through

    24. 100 represents average mortality across the country Does anyone remember mortality? Do you know what your mortality rate is in your Trust? Ours back in August 2008 was 136 (before re coding of the data set it was 108) Each slide (confidence interval) of relative risk has complex rare procedures of high risk and poor outcome at the top end and very routine low risk at the bottom this is why the middle bit is the mean Median range of the sample groups has improved and we are now well below the target range for relative risk reduction (82%) which puts us in the top 25% of Trusts THIS REFLECTS combination of all of our Trust mechanisms of which we formed a major role100 represents average mortality across the country Does anyone remember mortality? Do you know what your mortality rate is in your Trust? Ours back in August 2008 was 136 (before re coding of the data set it was 108) Each slide (confidence interval) of relative risk has complex rare procedures of high risk and poor outcome at the top end and very routine low risk at the bottom this is why the middle bit is the mean Median range of the sample groups has improved and we are now well below the target range for relative risk reduction (82%) which puts us in the top 25% of Trusts THIS REFLECTS combination of all of our Trust mechanisms of which we formed a major role

    25. Mortality Although as stated earlier we changed the data set, regardless of the data set we still showed a drop in 15% We set an ambitious goal to reduce mortality by 15% in one year we achieved this and have continued to reduce mortality for the last 2-months we have been within the 25% Trusts nationally for mortality (Dr Foster) In the last few months this translates as 73 people less dying. 73 people who would not have gone home The bottom line shows the older data set and the top shows the new data set Although as stated earlier we changed the data set, regardless of the data set we still showed a drop in 15% We set an ambitious goal to reduce mortality by 15% in one year we achieved this and have continued to reduce mortality for the last 2-months we have been within the 25% Trusts nationally for mortality (Dr Foster) In the last few months this translates as 73 people less dying. 73 people who would not have gone home The bottom line shows the older data set and the top shows the new data set

    26. Questions You need to work FAST and communicate WIDELY and inclusively. Let your champions do the work for you Reliance on competency acquisition in absence of supportive practice development and a Trust Wide Strategy is bound to have limitations Staff loss requires regular consolidation. Ultimately, ward staff will get better at replacing their key ward champions but was difficult to start with Either a feedback action plan has major concerns or SUI occurs in either case this usually merits revisit Extra care must be taken to ensure that key content is delivered in the right place at the right time for foundation doctors and this is something we are still working on Practice development can be both good and bad as it can create short term confusion (the pace of change is rapid as in chart changes etc). However, in the long term it garners better staff compliance and respect as staff feel better engaged (after all the changes have come from them) Changes advised by peripatetic educators can be seen to reflect the realism of practice and the needs of staff whilst also serving to increase patient quality and safety. In this way, peripatetic educators empower front line staffYou need to work FAST and communicate WIDELY and inclusively. Let your champions do the work for you Reliance on competency acquisition in absence of supportive practice development and a Trust Wide Strategy is bound to have limitations Staff loss requires regular consolidation. Ultimately, ward staff will get better at replacing their key ward champions but was difficult to start with Either a feedback action plan has major concerns or SUI occurs in either case this usually merits revisit Extra care must be taken to ensure that key content is delivered in the right place at the right time for foundation doctors and this is something we are still working on Practice development can be both good and bad as it can create short term confusion (the pace of change is rapid as in chart changes etc). However, in the long term it garners better staff compliance and respect as staff feel better engaged (after all the changes have come from them) Changes advised by peripatetic educators can be seen to reflect the realism of practice and the needs of staff whilst also serving to increase patient quality and safety. In this way, peripatetic educators empower front line staff

More Related