Stopping the Pressure through Education & Training

Dr Lisa Bayliss-Pratt

Assistant Director of Nursing NHS Midlands and East

Pauline Milne

Deputy Head of Education and DevelopmentEast of England Multi-Professional Deanery

Tracy BurrellActing Assistant Director of NursingBlackpool Teaching Hospitals NHS Foundation Trust

Lorraine ThursbyService Lead Manual Handling & Tissue ViabilityGeorge Eliot Hospital

Frances Igbonwoke Associate- Safer CareNHS Institute for Innovation and Improvement

Dr Lisa Bayliss-Pratt

Assistant Director of Nursing

NHS Midlands and East

Objectives of Session are to:

• provide an overview of the Pressure Ulcer education and training workstream

• explain the concept of the Pressure Ulcer education and training framework

• discuss Pressure Ulcer education and training in the context of a continuous learning environment

• share examples of how Pressure Ulcer training can be systematically implemented

Cluster Ambition:

To eliminate avoidable grade 2, 3 & 4 pressure ulcers by December 2012

Linked to:

• Stop the Pressure Campaign• SSKIN • Pressure Ulcer Pathway• Safety Thermometer / CQUIN• Intensive Support Visits• Communication and Engagement

Campaign

IST Learning: Key Findings• Availability and timeliness of pressure relieving equipment • Variable levels assessing competence• Training focused heavily on management rather than

prevention • Root Cause Analysis often showed failure to assess correctly,

not having appropriate care plans in place• Nursing documentation varied in quality and completion• Non–concordance was regularly cited as a reason for

patients acquiring an unavoidable pressure ulcer – this requires further exploration

• Many organisations recognised the benefits of using the safety thermometer

• Assessing avoidability was variable across the SHA Cluster as a whole

Pauline Milne

Deputy Head of Education and Development

East of England Multi-Professional Deanery

Aims of the Pressure Ulcer Education & Training Framework

• Clarify roles and responsibilities in relation to pressure ulcer prevention from ‘board to ward’

• Develop learning outcomes relevant to staff groups• Provide easy access to existing learning materials &

good practices • Develop a web based platform to host and

maximise access to the framework• Explore accreditation of the framework for the

future

Why a framework…

• To share existing good practices• To enable individuals and organisations to determine

pressure ulcer education and training needs for their entire workforce

• To raise the profile and priority of pressure ulcer education and training across the workforce

• To bring together existing pressure ulcer education and training materials into one central accessible repository

Structure of the Framework The PU Education and Training Framework includes roles and responsibilities, learning outcomes and education materials for the following:

• Patients, Lay Carers and Relatives • Non Clinical Staff • Non Registered Clinical Staff• Registered Practitioner• TV Link Nurse / Clinician• Sister / Charge Nurse / Team Leader / Matron• TV Specialist Nurse• TV Service Clinical Lead• Board Member

Content of the Framework

• Web based learning package but materials can be saved / printed off / adapted for local use

• Examples include:Patient information leafletsMandatory training presentationsCompetency workbooksToolkits Research articles

Application of Framework Job type Roles and Responsibilities Learning Outcomes Pressure Ulcer Education and Training Materials

Sister / Charge Nurse /Departmental Manager / Team Leader / Matron

To ensure all patients in your clinical area receive high quality careTo be responsible, accountable and role model the delivery of high quality care which will prevent the development of pressure ulcersEnsure a skilled and competent workforce through staff appraisal, clinical supervision and personal development planning Promote an open and honest cultureInstigate the Root Cause Analysis (RCA) process and take corrective action in response to findings Ensure lessons are learned from root cause analysis and resultant changes in practice implemented

Early recognition of where safety lapses have occurred and take corrective action through established governance processesPromote a culture of zero tolerance to avoidable pressure ulcersMonitor, analyse and challenge the impact of Improvement Programmes including the data that is reported i.e. NHS Safety Thermometer, serious incidents, and harm free careIdentify and disseminate good practice and learning in relation to pressure ulcer prevention, treatment and harm free careAssure Director of Nursing / Trust Board that lessons have been learned and actions taken to ensure the prevention of pressure ulcers in area of responsibility Role model and deliver intentional rounding ensuring this does not become a ‘tick box’ exerciseEffectively implement clinical improvement programmes and monitor their impact (for example Productive Ward, HIA, Safe Care)Ensure that all relevant risk assessments/ impact ( i.e. Waterlow/Braden/MUST/Walsall) and pressure ulcer interventions (i.e. SSKIN, STOP the Pressure) are fully understood by staff, implemented appropriately and their impact monitored

The learning outcomes of a Registered Practitioner and Tissue Viability Link Nurse / Clinician are assumed as a baseline. Additional learning outcomes for the Sister / Charge Nurse / Departmental Manager / Team Leader / Matron role are:Demonstrate an in-depth understanding of the actions required to eliminate avoidable pressure ulcers in your area of responsibility Articulate the actions required to promote an open, fair culture and a high quality clinical learning environmentArticulate how to lead the investigation of a Clinical Incident / Pressure Ulcer, including implementation of the recommendations through robust action planning Demonstrate how ‘Harm Free Care’ is championed in your area of responsibility

Demonstrate the ability to triangulate the NHS Safety Thermometer data with other relevant data sets e.g. Serious Incidents reports, complaints/concerns etc.

Assumes access to the learning materials available to Registered Practitioners and Tissue Viability Links Nurses / Clinicians. The pressure ulcer education and training materials listed below are in addition to those available to Registered Practitioners and Tissue Viability Link Nurses / Clinicians. ‘Habits for Improvers’ Undertake and be competent at the NHS Safety Thermometer training accessed from the ‘Harm Free’ Care website and Safety Thermometer guidance Basic Patient Safety Theory; Root Cause Analysis Training. Audit/Review Visit skills e.g.. ‘walk abouts’ Understanding and challenging Safety Thermometer data prevalence/incidence/gradesNHS Seven Steps to Patient Safetyhttp://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=59787

Guidance on Quality Dashboards RCA guidance RCA Toolkithttp://www.nrls.npsa.nhs.uk/resources/rca-conditions/ NHSI Improvement Tools – cross reference to FI materials NHS Midlands and East Policy for the Reporting and Management of Serious Incident in the East Midlands NHS Being Open Guidance: Communicating patient safety incidents with patients, their families and carers http://www.nrls.npsa.nhs.uk/alerts/?entryid45=65077 Appraisal/Clinical Supervision GuidanceCheck with HR / website

Frances Igbonwoke

Associate-Safer CareNHS Institute for Innovation and

Improvement

Equipping to eliminate avoidable pressure ulcers grades 2-4

Primary Outcome Primary DriversSecondary Drivers

Building capability to prevent and eliminate

avoidable pressure ulcers grades 2-4 by

Dec 2012

Access to Knowledge

Competent care delivery

Patient and carers equipped with

knowledge

Continuous Learning

1.Competency frameworks and workbooks

2. Buddying/shadowing and mentoring

3. Webinars, e-learning, DVDs

4. Learning networks and best practice forums

1. Knowledge of roles and responsibilities

2. Assessed competencies

1. Verbal & documented communication by care giver

2. Education materials and resources

3. Learning, sharing and support groups

1. Measurement

2. Agreed improvement methodology

3. Knowledge and design of consistent

‘reliable’ care processes

4. Continuous learning from incidents, tests of

change

NHS Change Model

Leadership instilled culture of learning

Real-time access to knowledge

A framework for studying and improving care processes to achieve consistently good outcomes

Working and learning collaboratively with all partners, patients and carers

www.changemodel.nhs.uk

Systematically monitoring safety, quality, processes for their impact on patient outcomes and efficiency

Robust delivery of ongoing team training and skill building, analysis for and creation of feedback loops for continuous learning and system improvement

Quality incentives and standards lined up to prioritise staff training

Supporting Resources

– ‘Your skin matters’ (Energising for excellence, High Impact actions for nursing and midwifery) http://www.institute.nhs.uk/building_capability/hia_supporting_info/your_skin_matters.html

– The Productive Operating Theatre- Consumables and equipment http://www.institute.nhs.uk/quality_and_value/productive_operating_theatre/consumables_and_equipment.html

– Harmfree care website http://harmfreecare.org/harm-free-care/

– NHS Change Model: www.changemodel.nhs.uk

Tracy Burrell

Acting Assistant Director of Nursing Blackpool Teaching Hospitals NHS

Foundation Trust

The Story from Blackpool: Achieved in the last 3 years:• 64% reduction in the number of Hospital Acquired

Pressure Ulcers > Grade 2 over the last 3 years• 33% reduction in the number of patients acquiring a

pressure ulcer whilst in their care.

Between April 2011-March 2012:• 30% reduction in the number of hospital acquired

pressure ulcers• Over 50% of nursing staff undertaken training in pressure

ulcer prevention (e-learning and/or pressure ulcer prevention work book).

How Blackpool achieved Results (1)

A Shared purpose• A stronger focus on prevention of pressure ulcers• Re-energised Pressure Ulcer Prevention Group focussing on improving

patient safety and experience through prevention of pressure ulcers• Corporate and local driver diagrams

Engaging to mobilise• Increased ownership and engagement from the clinical divisions

Leadership for change• Enhancing the Ward manager role• Enhancing the Matron role• Re-focussing of Link nurses

How Blackpool achieved Results (2)

Rigorous delivery• Introduction of a pressure ulcer workbook that all staff must

complete – linked to appraisal/OLM• Introduction of e-learning package for all nursing and Midwifery staff• Matrons’ training as part of accredited development programme• Launch of the Skin and Safety walk round tool (intentional rounding)• Local action plans to improve prevention of pressure ulcersTransparent measurement• New more meaningful reporting format• Revised RCA reporting to standardise with current Trust practice• Tissue viability as a Nursing Care Indicator MetricSpread of Innovation• Share point intranet information site• Revision of TBM

How Blackpool achieved Results (3)

Improvement methodology• Improvement of clinical systems• Improvement of staff education / skills / competencies• Staff engagement / ownership• Statistical Analysis / Evaluation

System drivers• Reduction in preventable harm: • Local Trust target 30% reduction in year 11/12• CQUIN target - nurse training / education• Improved quality of patient care / experience

Blackpool Next Steps:

• Engagement with Community staff• Sharing best practice• Improved reporting for community• Standardising practice / documentation

post amalgamation• Revise wound care formulary• Improving referral / continuing care

systems

Lorraine Thursby

Service Lead Manual Handling & Tissue Viability

George Eliot Hospital

An example from George Eliot Hospitals (1)

Engaging medical staff right from the start:• Pressure ulcer awareness received by junior doctors on arrival on day

one as part of manual handling induction• Further manual handling sessions to further increase awareness• Pressure ulcer prevention training linked in Post Graduate training

within first three weeks of induction

Result• Doctors actively assessing the patients’ skin on arrival• one inspired consultant gastroenterologist now engaged in the

Pressure ulcer change programme taking forward work to reduce pressure ulcers through improving nutrition and hydration

An example from George Eliot Hospitals (2)

Pressure ulcer prevention, everyone learning, everyone’s business:• Routinely part of manual handling highlighting correct

handling techniques to minimise impact of shear and friction on skin; effective use of pressure relieving beds, mattresses and the MUST for all assisted-handling to have slide sheets

• Clinical Mandatory Updates: All disciplines including medical staff receive key messages in pressure ulcer prevention from both Manual Handling and Tissue Viability

Result:

What have we achieved so far?Nurse Sensitive Indicators data for Tissue Viability and Nutrition prior to medical education and launch of Trust PUP campaign (February 2011)

Nurse Sensitive Indicators data Q1 2012/13 for Tissue Viability and Nutrition following active medical education in both Tissue Viability and Manual Handling

• Last grade 4 hospital acquired avoidable pressure ulcer - August 2011

• Last grade 3 hospital acquired avoidable pressure ulcer - November 2011

• Last year’s final total of grade 2 post 72 hours avoidable/unavoidable pressure ulcers: 154

What have we achieved so far?

To Excel at Patient Care

Dr Lisa Bayliss-Pratt

Assistant Director of Nursing

NHS Midlands and East

Summary

• Building capability to prevent and eliminate avoidable pressure ulcers is a priority• Continuous learning system is key to

maintaining a skilled workforce and achieving change at scale and pace• Continuous feedback from YOU!

QUESTIONS & DISCUSSION