Download quality matters - County Durham and Darlington NHS Foundation Trust

Appendix 1 – Behaviours Framework
Clinical Quality & Safety Improvement Strategy
‘Quality Matters’ is the clinical quality and safety improvement strategy for
County Durham and Darlington NHS Foundation Trust. The purpose of this
strategy is to support the delivery of the organisation’s vision, which is as
follows:
‘Right First Time, Every Time’
The Trust’s ambition
Since 2011, the Trust has been an integrated healthcare provider, providing
services in both acute and community settings, supplemented by health
improvement services. Through consultation with our staff, we developed our
mission statement ‘with you all the way’. This reflects our commitment to
provide the best possible care to our patients at all stages along their care
pathway and the best possible experience to our patients and staff, using
resources wisely. Reflecting these different elements, we also articulated four
‘best’ touchstones to supplement our mission statement.
Recently the Trust has reviewed its future direction, with its staff and external
stakeholders and has affirmed both: a


A vision for the future of ‘Right First Time, Every Time’: we want to
ensure that our patients are treated in the right place, by the right
clinician, first time and every time, 24/7; and
A set of strategic principles setting out standards that our services
should meet in order to realise our vision.
‘Quality Matters’ is one of the Trust’s two core strategies for realising our
vision, together with our Organisation Development Strategy, ‘Staff Matter’.
They will be supported with strategic developments in enabling areas such IT,
Estates and Workforce.
This strategy therefore complements the Trust’s Organisation Development
Strategy, ‘Staff Matter’. Together these two strategies set out the
organisation’s principles and objectives in order to:


Improve the quality of patient care (Safety, Effectiveness and Experience)
Improve the experiences of staff in terms of career development and
behaviours.
The whole framework is encapsulated in the diagram overleaf:
2
3
Values and behaviours
Alongside the development of the above framework, we have decided to
adopt the NHS Constitution values as our Trust values. We used the values
to engage with staff to develop our behavior framework. These will underpin
the delivery and success of this strategy. We will recruit and nurture our staff
so that we see these values and behaviours at all times from all staff. The
values are as follows:
The behaviour framework can be found at Appendix 1.
4
How we developed the Strategy
We have used a discussion document for over 12 months to enable
stakeholder engagement to influence our evolving clinical and quality strategy.
These were originally two separate documents ‘Right, first time, 24/7’ and
the Quality Strategy 2013-2015. However, these have now been merged into
one overarching strategy; this document. The decision to have one document
for both the provision of clinical services and the ongoing improvement of
quality and safety was suggested by our lead clinicians and one that
stakeholders agreed with. As such, this document encompasses and
replaces the Quality Strategy approved by the Board in October 2013. The
Clinical Strategy Steering Group will continue to drive the ‘Effectiveness’
priorities of this strategy, building on all the work which has taken place to
date in evaluating options for service configuration and service improvement
areas under the three ‘Breakthrough’ headings of:



Transforming Unscheduled Care
Centres of Excellence; and
Integration and Care Closer to Home
In addition, this strategy incorporates the Trust’s obligations and priorities in
its Quality Accounts and other safety initiatives including the ‘Sign up to
Safety’ pledges (Appendix 2). The priorities were agreed via stakeholder
events, Quality Account engagement and more recently focus groups with a
variety of staffing groups. The aim of this is to bring all of our priorities into
one overarching strategy and plan.
Areas that are still important but that the Trust has already made significant
improvements on, such as health care acquired infections, will still be
monitored internally and outcomes shared with our stakeholders. However,
this strategy focuses on the organisation’s most significant quality
improvement priorities.
Priorities for 2015-2017
The NHS, since the publication of High Quality Care for All1 in 2008, has used
a three-part definition of quality. NHS England describes this on its website
as:
‘The single common definition of quality which encompasses three equally
important parts:
• Care that is clinically effective- not just in the eyes of clinicians
but in the eyes of patients themselves;
• Care that is safe; and,
• Care that provides as positive an experience for patients as
possible
High quality care is only being achieved when all three dimensions are
present- not just one or two of them. And when we strive for high quality care,
we must do so for everyone, including those who are vulnerable, who live in
poverty and who are isolated. By seeking to deliver high quality care for all,
1High
Quality Healthcare for All, Darzi, 2008
5
we are striving to reduce inequalities in access to health services and in the
outcomes from care.’
As such, the priority areas for clinical quality improvement and safety for
CDDFT are aligned to these three essential dimensions.
Safety
Patient Falls
Sepsis
Learning from incidents
Effectiveness
Right patient, right place, right time
Care bundles
Health Improvement
Unscheduled Care
Experience
Dementia Care
End of Life
Nutrition & Hydration
Monitoring & Reporting
The Quality & Healthcare Governance Committee is responsible for providing
assurance to the Board of Directors that the Trust is managing the quality of
patient care, the effectiveness of clinical interventions, patient experience and
patient safety. The Committee will review the quality goals at its meetings to
ensure that progress is being made in relation to the key areas for
improvement.
Operational Committees within the Trust will also provide specialist advice
and monitoring for their dimension (see table below).
6
In order to track progress there will be one singe quality improvement plan
that is cross referenced to other relevant quality initiatives, e.g. CQUIN,
Quality Accounts, Sign up to Safety etc. Progress will also be reported in the
Trust’s annual Quality Accounts, which will be made available on the Trust’s
website, NHS Choices and included in the Trust’s annual report.
Measurement tools and outcome measures will be identified, developed and
agreed by Quarter 1 2015 to enable quantitative monitoring in addition to
work-stream updates.
Priority
Patient Falls
Operational
Lead (s)
Joanne Todd
Sepsis
Lisa Ward
Learning from
Incidents
Right Patient,
Right Place,
Right Time
Care Bundles
Joanne Todd
Health
Improvement
Unscheduled
Care
Dementia Care
End of Life
Nutrition &
Hydration
Accountable
Director
Director of
Nursing
Medical Director
Diane Murphy
Director of
Nursing
Medical Director
Jeremy Cundall
Medical Director
Lee Mack
Medical Director
Stuart Dabner
Medical Director
Jayne
Director of
McClelland/David Nursing
Bruce
Julie Clennell
Director of
Nursing
Jennie Winnard
Director of
Nursing
Operational
Committee
Safety
Committee
Safety
Committee
Safety
Committee
Clinical Strategy
Steering Group
Clinical Strategy
Steering Group
Clinical Strategy
Steering Group
Clinical Strategy
Steering Group
Patient
Experience
Forum
Patient
Experience
Forum
Patient
Experience
Forum
7
Patient Falls
What do we want to achieve?
We will ensure that all appropriate measures are taken to reduce the chance
of patients falling & suffering harm.
Why is this important?
Patient falls continue to be one of the highest adverse events reported. This
often results in harm to patients and occasionally death. Successful
prevention strategies include identifying patients who have the highest risk for
sustaining a serious injury from a fall and taking preventive action to modify
and compensate for these risk factors. Reporting all falls or near misses as
incidents helps us identify additional risk factors, take action where
appropriate and share learning.
How will we achieve this?





Falls Group to investigate the causes of preventable falls, using incident
and near miss information
Work-stream plan to be developed and monitored by the Falls Group
Falls Care Bundle to be monitored as a process measure
Root cause analysis (RCA) investigations to be undertaken rapidly
following any serious harm caused following a fall
Aggregated RCA to be undertaken of falls resulting in serious harm over
the last 12 months.
How will we know we have been successful?
No preventable deaths from falls

Year on year reduction in incidents reported for preventable falls
causing harm to patients
Increase in compliance with the Falls Care Bundle
8
Sepsis
What do we want to achieve?
We will identify & treat sepsis at the earliest opportunity.
Why is this important?
Sepsis is a life threatening condition that arises when the body’s response to
an infection injures its own tissues and organs. Sepsis leads to shock,
multiple organ failure and death, especially if not recognised early and treated
promptly.
Sepsis claims 37,000 lives annually in the UK. Early intervention can save
lives, reduce length of hospital stay and the need for critical care admission.
How will we achieve this?





Implement the sepsis care bundle in all areas of the Trust
Develop a post-1hour pathway to start when the bundle elements have
been completed
Develop an audit tool and identify outcome measures
Raise professional awareness internal and external to the Trust through
partnership working, study days and ward based education
Raise public awareness of sepsis through the World Sepsis Day &
Medicine for Members events
How will we know we have been successful?
Zero ‘failures to rescue’ (people whose clinical condition deteriorates
but where this could have been better managed or prevented) as a
result of sepsis
No deaths from sepsis where the sepsis has not been identified &
treated appropriately.
Compliance with the care bundle
9
Learning from Incidents
What do we want to achieve?
We will inform patients, families and staff when we make mistakes, investigate
and share any lessons we learn, and implement change to prevent
recurrence, where possible.
Why is this important?
It is important that patient safety incidents that could have or did harm a
patient receiving care are reported so they can be learnt from and any
necessary action can be taken to prevent similar incidents from occurring in
the future, where possible.
How will we achieve this?





Understand which areas/staffing groups are good or poor reporters of
incidents
Develop an education/awareness programme to increase the reporting of
incidents that could have or did cause harm
Train staff to undertake robust Root Cause Analysis investigations to
identify causes & contributory factors of incidents
Monitor actions taken to reduce harm – both in response to RCA
investigations and following thematic analysis of incidents
Aim for a reduction in the proportion of incidents causing harm to patients,
including patient falls, medication issues and avoidable pressure ulcers.
How will we know we have been successful?
No Never Events
No preventable pressure ulcers



Year on year reduction in medications incidents resulting in harm
Year on year reduction in avoidable falls resulting in harm
Year on year increase in patient safety incident reporting (particularly
near misses & no harm incidents). Reported as being in the upper
quartile in the National Reporting & Learning System for patient safety
incident reporting.
10
Right care, right place, right time
What do we want to achieve?
We will ensure that patients and service-users are cared for in the most
appropriate clinical environment by staff with the right skills, and ensure that
all transfers of care to other clinicians and care settings are clinically
necessary.
Why is this important?
The earlier a patient is seen, diagnosed and treatment plans agreed the better
their outcomes of care and experience are. This also improves use of
resources by removing, repeated, unnecessary or duplicated assessments
and tests. It is also known that many patients have been moved from one
ward to another for reasons not related to their specific care or condition.
These issues can resulting in a poor patient experience and increase risks to
patient safety as a result of fragmented care. If a patient does not receive the
right care in the right place at the right time, this can result in delayed
discharge or unplanned readmission to hospital.
How will we achieve this?
By developing and implementing plans and service improvements, including
the work on service configuration and strategies in our three ‘Breakthrough
areas: Transforming Unscheduled Care; Centres of Excellence and
Integration and Care Closer to Home – led by the Clinical Strategy Steering
Group:
 Understanding patient flow to implement change
 Planning patient discharges as early as possible in the patient and
enacting plans in a timely manner
 Monitoring and understanding why patients are transferred between wards
for non-clinical reasons
 Reviewing and implementing new ways of working that focus on removing
duplication and waste in a patient’s pathway of care
 Developing workforce plans that focus on “front of house” services being
consultant delivered
How will we know we have been successful?
 Year on year reduction of patient transfers for non-clinical reasons
 Year on year decrease in patients with delayed transfer or discharge
 Year on year reduction of readmissions to hospital
 Improved clinical outcomes i.e. mortality


Reduction in length of stay

Improved staff experience as measured in the staff survey

Positive patient feedback in the FFT, outpatients’ survey, discharge
surveys & national inpatient surveys.
11
Care Bundles
What do we want to achieve?
We want to achieve the best clinical outcomes in nationally benchmarked
pathways, such as fractured neck of femur. We will identify other clinical
pathways/best practice bundles that could increase the quality & effectiveness
of our care.
Why is this important?
A number of ‘best practice care bundles’ have been developed to support
clinicians in providing care that is evidence based and known to provide the
best results. Research continues to provide innovative solutions and develop
new pathways to treat patients. It is important that the best possible care and
treatment is provided to achieve the best clinical outcomes.
How will we achieve this?




Improve adherence to the fractured neck of femur pathway through
education & support
Develop & implement a clinical pathway/care bundle for Acute Kidney
Injury
Adopt further care bundles within all Care Groups that will contribute to
improving quality, safety & clinical effectiveness
Continue to review clinical outcome data to identify new pathways/bundles
to introduce in response to any new guidance or deficiencies identified
How will we know we have been successful?
 Top 20% in benchmarked data for fractured neck of femur
Zero ‘failures to rescue’ as a result of Acute Kidney Injury
Remain at or below expected levels of deaths in nationally
benchmarked mortality data
Reduce the number of mortality2 alerts received
2
Alerts indicating excess deaths known as Variable Life Adjusted Display charts (VLADs)
12
Health Improvement
What do we want to achieve?
We will extend life expectancy, improve quality of life and tackle health
inequalities – in short: longer, better, fairer lives.
Why is this important?
Alongside social and economic factors (poverty, poor housing) our lifestyles
can adversely affect our health. Smoking is the largest cause of early excess
death via cardio vascular disease, cancer and lung disease. Lack of exercise
and the food we choose contribute to obesity and there are now over 3,000
alcohol related admissions to A&Es in England every day. We need to support
Public Health England’s strategy in ensuring that children get the best start in
life and tackling smoking, obesity and harmful drinking.
How will we achieve this?





Implement workplace health programmes for our employees
Continue to make every contact count via brief interventions on major
lifestyle issues such as tobacco, alcohol, food and exercise.
Support NHS Health Check and Just Beat It! - a diabetes prevention
programme
Develop a new service to support people struggling with obesity
Work with partner organization’s to promote health and wellbeing and
ensure parity of esteem in relation to public mental health, for example
through workplace health programme.
How will we know we have been successful?
Reduction in staff sickness absence rates


Publication of a new organisational covenant on our approach to health
improvement by 31 December 2015
Positive feedback from patients using the ‘getting sooner better’
programme
Year on year increase in local number of local people engaged in
wellbeing for life programme – 2,300 supported to achieve personal
health goals in 2015/16.
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Unscheduled Care
What do we want to achieve?
We will provide accessible, high quality emergency care.
Why is this important?
Although we achieve the 95% target for A&E 4 hour waits on average, there
are days when the target is not achieved. Multiple ambulances can be waiting
outside A&E to hand over patients, and patients are waiting for beds to
become available for them to be admitted. This pressure is experienced on
both acute sites, but is particularly high at University Hospitals North Durham
where last year’s ‘winter beds’ have remained open throughout the year.
We recognise the limitations of the existing A&E departments in terms of
capacity and infrastructure. Both of these factors lead to an unsatisfactory
experience for patients and staff, especially at UHND where the physical
space is inadequate.
How will we achieve this?
We will implement the initiatives within the Clinical Strategy programme
(Transforming Unscheduled Care), including:
 Continue to implement the ‘towards midnight’ programme
 Implement systems to ensure no patient admitted via A&E waits longer
than 14 hours to see a consultant
 Redesigning some services so that we can continue to deliver the majority
of acute specialties on a 24/7 basis across County Durham and
Darlington.
 Work towards providing 7-day access to diagnostic tests, such as X-rays,
ultrasound, MRI scans and pathology
 Work towards weekend access to multi-disciplinary teams, which includes
expert nurses, physiotherapists & other support staff.
 Review and, as appropriate, expand capacity and infrastructure
How will we know we have been successful?

Positive feedback from patients via the FFT, surveys & compliments.
Continuous achievement of all A&E targets

Sustained reduction in the number of ambulance handovers that take
longer than 60 minutes
14
Dementia Care
What do we want to achieve?
We will have a workforce that is dementia aware and has the skills and
knowledge to support patients and their families with dementia. We will
contribute to a dementia friendly community.
Why is this important?
Dementia is a syndrome that affects memory, thinking, behaviour and ability
to perform everyday activities. Dementia is overwhelming not only for the
people who have it, but also for their caregivers and families. There is lack of
awareness and understanding of dementia that can result in stigmatisation,
barriers to diagnosis and care. Dementia was identified as a national priority
in 2009 and there is still a long way to go to achieving a dementia-friendly
community.
How will we achieve this?






Develop a dementia strategy
Increase dementia training
Full implementation of the dementia pathway
Auditing against the pathway for continuous improvement
Awareness raising
Creating dementia-friendly environments
How will we know we have been successful?

Positive feedback from patients, families & carers
Continuous improvement in the audits of the dementia pathway

>90% appropriate staff received dementia training

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End of Life
What do we want to achieve?
We want people approaching the end of their life to have confidence that the
care we provide will be consistent with their preferences. We want patients
and their families to be supported and informed of all options available to
them.
Why is this important?
Supporting people who are nearing the end of life can ensure that they
maintain the best possible quality of life, remain in control and minimise
suffering for them and their families.
How will we achieve this?





By being part of the Deciding Right regional initiative
Training staff in the ‘Deciding Right’ principles & DNACPR
Having clear principles and practices to support staff in providing care and
information to patients
Supporting patients to make advance care plans
Helping patients to be cared for in the location they wish to be cared for
and in meeting their choice of place of death
How will we know we have been successful?

Positive feedback from patients & families

>90% training for appropriate staff

Year on year increase in patients being cared for in their preferred
place of care

Continuous improvements in the National Care of the Dying Audit
& local audits of end of life practice (including DNACPR)
16
Nutrition & Hydration
What do we want to achieve?
We will promote optimal nutrition for all patients in our care, ensuring that this
is tailored to individual patient need.
Why is this important?
Clinical malnutrition can lead to poor patient outcomes, hospital acquired
conditions and longer lengths of stay. The provision of enjoyable and
nutritious food and drink or the prescription of suitable artificial nutritional
support is essential to help patients feel better, maintain their strength and
energy and to promote a return to health following illness or surgery.
How will we achieve this?






Identify patients at risk of under nutrition by screening with the MUST tool
Re-energise protected mealtimes and reduce unnecessary interruptions
whilst patients are eating
Encourage the use of dayrooms for meal times & social interaction
Offer a choice of beverages and served appropriately dependent on
patient need
Increase the use of volunteers for mealtime assistance
Provide nutritious snacks between meals for patients at risk of poor
nutrition
How will we know we have been successful?

Positive feedback from patients & families

>98% of all adult patients being screened for under nutrition within
6 hours of admission using the MUST tool
>98% of patients identified as high risk of under nutrition having
an appropriate nutrition care plan implemented.
>95% compliance with the completion of fluid balance chart
Achieving & maintaining the ‘Food for Life Catering Mark’
17
Additional Service Improvement
The Trust has a number of improvement and transformation projects that will
support the delivery of this strategy but are not aligned to just one priority.
These include increased use of technology, such as e-observations and eprescribing and safe staffing levels. All of these projects are intended to
improve the quality of patient care overall.
There are also areas that staff, patients and stakeholders are familiar with and
that remain important, such as healthcare acquired infections, medication
errors and pressure ulcers. We will continue to monitor and report on these
areas under the priorities identified in this strategy.
Measuring Success
Each priority work-stream will have an implementation plan and outcome
measures aligned to the ‘How will we know we have been successful?’
sections. There will be one Quality Improvement plan and set of measures to
track progress. The overall success of the Strategy will be measured via
mechanisms, which include:





Patient experience feedback – this will be via surveys, compliments,
complaints, focus groups & patient groups
Quality Accounts – achieving the annual priorities described in the Quality
Accounts will contribute to achieving the aims of this strategy
Quality Matters – an audit tool against nursing standards and Trust
policies, which identifies any areas requiring additional support or
development to achieve best practice standards
Mortality ratios, clinical outcomes & national clinical audits – we will
continue to monitor our performance against our peers.
Care Quality Commission – if this strategy is implemented successfully,
we will obtain a minimum of a ‘good’ rating, aiming for ‘outstanding’ where
possible.
Appendix 3 provides an overview of the quality priorities and the vision for
each element of quality.
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Appendix 1 – Behaviours Framework
Our NHS Values
Working
together for
patients
Respect &
Dignity
Commitment
to Quality of
Care
Compassion
Improving
Lives
Everyone
Counts
Patients come first in
everything we do. We
fully involve patients,
staff families, carers,
communities
and
professionals
inside
and outside the NHS.
We speak up when
things go wrong.
We value every person
– whether patient, their
families or carers, or
staff – as an individual,
respect
their
aspirations
and
commitments in life
and
seek
to
understand
their
priorities, needs and
limits.
We earn the trust
placed in us by
insisting on quality and
striving to get the basic
of quality of care –
safety, effectiveness
and patient experience
– right every time.
We
ensure
that
compassion is central
to the care we provide
and
respond
with
humanity and kindness
to each person’s pain,
distress, anxiety or
need.
We strive to improve
health and wellbeing
and
people’s
experiences of the
NHS.
We
maximise
our
resources
for
the
benefit of the whole
community, and make
sure
nobody
is
discriminated against
or left behind.
Our Behaviours
You will see that we
You will see that we do not
 Will think of our patients first
 Work within our own teams only,
forgetting we are part of a wider
 Are proud of where we work & our role
organisation for the benefit of
in delivering the services we provide
patients
 Provide clear, open, honest & timely
 Set unrealistic expectations or
information
make false promises
 Keep people informed – give regular
 Withhold useful information or
updates where possible
forget to pass something on
 Work as an effective team, pull together
 Put up barriers to communication
& include everyone
& team work
 Admit when we get things wrong, tell
patients & their families & learn from
this
 Introduce ourselves, explain our role &
 Put our own priorities before those
listen to you
of patients or colleagues
 Be polite, courteous & friendly
 Be rude, abrupt, shout or insult
people
 Respecting others differences

Undermine people’s dignity
 Value people’s privacy & dignity
through actions or words
 Make eye contact & talk to people
 Talk about people as though they
directly, using their preferred name
are not there or don’t understand
 Respect the environment we work in
 Avoid people who need help
 Tolerate aggressive behaviour or
bullying of any description – from
each other, patients or visitors
 Are competent & professional at all
 Let professional registration lapse
times
or fail to keep up with CPD
 Are open & honest, learning from
 Absolve responsibility, pass the
experience
buck
 Are clear about our roles &
 Wait to be chased
responsibilities
 Dismiss new ideas, refuse to try
 Accept responsibility & hold each other
 Ignore or condone bad behaviour
to account for our actions
or poor practice
 Act on concerns & challenge poor
 Ignore research or evidence based
services or behaviours
practice
 Seek out best practice and share it
 Avoid duplication & waste
 Show care & compassion
 Make excuses for lack of
compassion
 Support & empathise with others

Hold inappropriate or personal
 Stop to help others, take the time to
conversations in public areas
help

Use closed body language, show
 Listen to each other & our patients
irritation, be unapproachable
 Be open & honest with patients about
their condition & support them to make
difficult decisions
 See people as individuals, see the
 Make it difficult for people to
whole person & their individual needs,
access the right services at the
respecting their beliefs & ideas
right time
 Be innovative & creative, look for
 Be judgemental, patronising,
solutions
making inappropriate
generalisations or assumptions
 Support people to reach their potential
 Support each other to have a good
work/life balance & healthy lifestyle
 Understand each other’s skills, roles &
 Undermine colleagues, be spiteful
responsibilities & respect everyone’s
or talk about people behind their
contribution
back
 Encourage people to raise their
 Say one thing and do another
concerns
 Be disinterested in other people’s
 Promote & reward innovation
aims, skills or ideas
 Say thank you when others help us
 Value the experience & knowledge of
other team members
 Include all team members in service
developments – everybody has a valid
opinion
Appendix 2
County Durham & Darlington NHS FT
Sign up to Safety Pledge
October 2014
Put safety first - Commit to reduce avoidable harm in the NHS by half and
make public our goals and plans developed locally.
We will
Reduce sepsis by:
-using the Trust sepsis care bundle to identify and treat sepsis and do this within the
golden hour
-keeping sepsis on the agenda and at the forefront of people's mind
-using appropriate steps in preventing resistance including the targeted and prudent
use of antibiotics. Early culture and involvement of microbiology who will support this
-considering that any patient receiving chemotherapy or any patient with a known
haematology disorder are at risk of sepsis
-referring to critical care at an early stage and involving senior members of the team
Provide safe staffing levels by:
-reviewing all areas (hospital and community) using validated tools where available
-apply pragmatic professional analysis to determine current requirements
-establish a validation panel, chaired by Director of Nursing (with Finance and
Human Resources) to review analysis work
Introduce e-observations:
- Implement an electronic system that allows for patient physiological observations to
be recorded, documented and escalated from the patient's bedside
- Ensure that an Early Warning Score is calculated for every observation recording
on ward based in-patients
- Introduce the validated National Early Warning Score as part of e-observations
- Ensure that all staff have access to patient observation data at any point within the
hospital
Review the serious incident process to:
-consider a new way of delivering messages across the organisation so that we have
full assurance that staff are aware of issues that have occurred and learning is
shared
Continually learn – make our organisation more resilient to risks, by acting on
the feedback from patients and by constantly measuring and monitoring how safe our
services are.
We will
Continuously strive to improve the care delivered to our patients and evidence
compliance using our Quality Matters framework to:
-understand at care delivery level how we are doing from a patient's perspective
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-engage with and listen to ward staff to understand the issues and challenges they
face
-monitor compliance with agreed care standards in real time
-gauge awareness of policies
-observe practice and correlation with related documentation
-review the clinical environment
-inform our improvement journey
-acknowledge and share what is working well
Remain accountable to patients and the public by:
-publishing a set of patient outcomes at ward level so that patients and the public can
see how we are performing against safety and experience indicators
Honesty – Be transparent with people about our progress to tackle patient safety
issues and support staff to be candid with patients and their families if something
goes wrong.
We will
Continue to move forward with Duty of Candour principles and monitor
implementation by:
-producing standardised templates for sending letters of apology to patients if an
adverse incident occurs
-utilising the risk management system to identify that staff been open with patients
and relatives when incidents occur
-monitoring compliance with the principles via Safety Committee
-continuing the delivery of Duty of Candour educational sessions across the
organisation
-ensuring that patients are offered a copy of reviews when serious incidents have
occurred
-offer face to face meetings with patients/families when serious incidents and
complaints occur
Continue to involve stakeholders in the identification of key issues for the
organisation by:
-holding a series of updates on progress against key aims identified within the Trust's
Quality Accounts
-ensuring a feedback mechanism through stakeholder events to inform on aims for
coming periods and to ensure agreement on priorities
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Collaborate – Take a leading role in supporting local collaborative learning, so
that improvements are made across all of the local services that patients use.
We will
Share serious incidents across the wider health economy by:
-collaboration with regional work streams to identify and learn from serious incidents
including Never Events
Utilise the "Investing in Behaviours" consortium to improve staff insight and
increase knowledge around Human factors to prevent harm within the
organisation
Support – Help people understand why things go wrong and how to put them
right. Give staff the time and support to improve and celebrate the progress
We will
Support innovation by:
-introducing a Dragons Den. similar to the television show, where staff can take their
ideas and go face to face with a group of Trust "experts" to seek support in the form
of finance and mentorship for implementation
-introducing innovation scouts. We will be looking for innovation scouts to identify
and then develop new ideas, working with front line staff
-holding business case master classes. This will help clinicians and business
managers to create compelling and persuasive business cases which demonstrate
sustainability and high quality for services
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Appendix 3 – Example – to be completed in full following completion of implementation plans
From….
….To
‘With you all the way’
‘Right for you First Time, Every Time’
2014/15

Lower quartile in peer group
for patient safety incident
reporting.

Patients have been caused
severe harm or have died as
a result of a fall over the last
2 years.

Safety
Strong performance in
infection prevention &
control. Better than peers for
pressure ulcer prevention.
Mortality within expected
ranges overall, with some
variation across services &
sites.



Good clinical outcomes
overall with some areas for
improvement.

Effectiveness
Sepsis care bundle
re-launched for
adults.
Reasons for poor
patient safety incident
reporting identified.
New governance
structure/practices
Weekly Patient Safety
meeting – Exec Lead

Clinical Strategy
Steering Group
identified priorities &
data sets
Care bundles
identified
Implement NICE
workplace health
programme for
employees







No dementia strategy.
NCEPOD report for sepsis
expected August 2015
Sepsis care bundle
implemented or children &
maternity patients
Identify staff groups who
are low incident reporters
& support improvements
2016/17

Post-1 hour sepsis
pathway to be
implemented
Upper quartile in peer group for patient
safety incident reporting.
No patients suffering severe harm or
death from a preventable fall.
Continued learning & good performance
with health care acquired infections,
medication errors & pressure ulcers.
No failure to rescues relating to sepsis.

Variable quality of dementia
friendly environments across
the Trust.
Recently signed up for the
‘Right to Decide’ initiative for
End of Life care. End of Life
care variable across the
Trust.
2015/16
Areas for length of stay
reductions identified &
plan implemented
Implementation of plans
for reduction in delayed
discharges
Baseline process &
outcome measures for all
identified Care Bundles
ED at DMH to have 2
entrances
Develop & implement
Dementia Strategy
Include Dementia and End
of Life Training in Trust
TNA & deliver training

Mortality consistently below expected
range on all sites, for all specialties.
Top 20% for all benchmarked clinical
outcomes.
Demonstrable improvements in chosen
care bundles with no failure to rescues
relating to acute kidney injury.
All identified clinical areas to be
dementia friendly.
Dementia aware, skilled &
knowledgeable staff contributing to a
dementia friendly community.
Patients nearing the end of life to be
consistently confident in our ability to
meet their preferences in relation to care
& support provided.
Experience
Variability in practice for
nutrition & hydration
Consistency in achieving nutrition &
hydration standards.
Working together for patients
Commitment to Quality of Care
Our Values
Respect & Dignity
Improving Lives
Compassion
Everybody Counts
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