WelcomeJill GilliesPortfolio Lead Primary Careihub

Aims of the day

• Share the successes and challenges around

pressure ulcer improvement work in care

homes

• Learn about the tools and resources from the

programme, and

• Network and catch-up with old friends and

make some new ones!

13.00 Welcome Jill Gillies

13.05 Our Approach to Reducing Pressure Ulcers

Ruth Glassborow

13.15 Working in Partnership Joyce O’Hare/Alec Murray

13.30 H&SCP presentations Participating Teams

14.30 Refreshments

14.45 Resources Comms/Data & Measurement/Evaluation Teams

15.15 Improvement Approach to Urgent Care: GP Out of Hours Collaborative

Diane Campion

15.30 Celebrating our Success Jill Gillies

15.45 Close

Our Approach to Reducing Pressure Ulcers

Ruth Glassborow, Director of Improvement Support & ihub

EvidenceScottish

Health CouncilQuality

Assurance

The Organisation

Better quality health and social care for everyone in Scotland

The Improvement

Hub

ihub role

Supporting health and social care services to redesign and continuously improve

ihub framework for supporting improvementStart Here

People at heart of

everything we do

National Improvement ProgrammesCare Delivery

• Living Well in Communities• Primary Care • Mental Health• Acute• Dementia• SPSP Medicines• Place, Home and Housing• Maternity and Children’s

System Enablers• Strategic Planning• Outcomes-based commissioning• Transformational Service Redesign• Third and Independent Sector Engagement• QI Infrastructures • Evidence, Evaluation and Knowledge Exchange • Person Centred Health and Care

Tailored and Responsive Improvement

Support

Grants and Allocations

We use a blend of technical QI methodology, design methods and relational change management techniques

Overview of our current offerings

Outcome 7: People using health and social care services are safe from harm

‘The very first requirement in a hospital is that it should do the sick no harm.’

(Florence Nightingale)

National Health and Wellbeing Outcomes

Acute hospital work

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

5 boards have an improvement or sustained

improvement

The average number of grade 2-4 PU acquired in Scotland’s hospitals has

dropped by 30 each month

Reducing Pressure Ulcers in Care Homes

Learning from Pressure Ulcer Reduction

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

Leadership/governance

Tissue Viability resource

Understanding/ using data

Risk assessment & care planning

Education

Equipment

The role of the MfI

The Improvement Hub (ihub) is a part of Healthcare Improvement Scotland

Working in Partnership

Joyce O’Hare, Care InspectorateAlec Murray, HIS

@spsp_pc #spsppu

The Scottish Patient Safety

Programme – Reducing

Pressure Ulcers in Care

Homes (SPSP-RPUCH)

National Improvement

Programme

@spsp_pc #spsppu

OUR AIM

A 50% reduction in grade 2-4 pressure ulcers acquired in care homes by the end of Dec 2017.

Who is involved?

Working in partnership

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

• Acute Adult

• Mental Health

• Maternity, Paediatrics and

Children

• Primary Care • General Medical Services

• Community Pharmacy

• Dentistry

• Community nursing and

• RPU care homes

Supporting health and social care

services to redesignand continuously

improve

To reduce the number of events which cause harm to people from healthcare delivered in any setting.

The SPSP Journey

2008Launch of SPSP Acute Adult

2010 NHSScotlandQuality Strategy

2013• Launch of SPSP in Primary

Care, • SPSP Mental Health• SPSP Maternity and

Children’s Improvement Collaborative

2014-16• Pharmacy in Primary

Care Collaborative• Warfarin• NSAIDs• Safety Culture

2015•Launch of SPSP Medicines, and•Healthcare Associated Infection Improvement Programme

2016• SPSP Dentistry in Primary Care• SPSP Sepsis in Primary Care• Reducing Pressure Ulcers in Care

Homes Improvement Programme• Introduction of GP Clusters• Integration of Health and Social Care

20:20 Vision

Outcome 7: People using health and social care services are safe from harm

National Health and Wellbeing Outcomes

“...everyone in healthcare really has two jobs when they come to work every day:

to do their work and to improve it.”What is ‘‘quality improvement’’ and how can it transform healthcare? Batalden,P; Davidoff.F Qual Saf Health Care. 2007 February; 16(1): 2–3

‘The very first requirement in a hospital is that it should do the sick no harm.’

(Florence Nightingale)

‘First, do no harm’ Hippocrates c ~420 BC

Projects sometimes seem Titanic

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

11 applications from Health

and Social Care

Partnerships

8 shortlisted for interview

4 successful

applications (5 HSCPs)

The right person for the jobCompetitive Recruitment Process

• Perth and Kinross• East Dunbartonshire• Dumfries and Galloway

• Argyll and Bute and Highland (joint)

Why do pressure ulcers

matter?

Impact on people

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

Pain

Odour / drainage

Infection deathDistress

Embarrassment

Financial Impact

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

The expected cost of healing a pressure ulcer in the UK

ranges from £1,214(grade 1) to £14,108 (grade 4). Dealey C, Posnett J, Walker A. The cost of pressure ulcers in the United Kingdom. Journal of Wound Care. 2012, (6): 261–2, 264, 266.

So what did we do?

- A ‘Break Through Series’

Collaborative Approach

What is a Break Through Series (BTS) Collaborative?

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

• Short term learning system

• Brings together a number of teams to make improvements

• 2 members of practice team attend Learning session (away team)

• Additional team members working locally (home team)

http://www.ihi.org/resources/Pages/IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievingBreakthroughImprovement.aspx

Away team

CH_1

CH_2

CH_3

CH_4

CH_5

Dumfries and GallowayArgyll and Bute and Highland

East Dunbartonshire Perth and Kinross

Away team

CH_1

CH_2

CH_3

CH_4

CH_5

Away team

CH_1

CH_2

CH_3

CH_4

CH_5

Away team

CH_1

CH_2

CH_3

CH_4

CH_5

Steering

Group

Meetings

Da

ta –

Re

po

rts?

Da

ta –

Re

po

rts?

Da

ta –

Re

po

rts?

Da

ta –

Re

po

rts?

The Collaborative Model

LSAlignment

with national

work

LSKickoff

LS

Organisational

Self

Assessment

Continued Supports

Institute for Healthcare

Improvement

Support to implement key changes, improvements and

measurement:

• Board Support

• Site visits

• WebEx

• Flash Reports

Two Way Learning

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

• SBAR

• Driver diagrams

• Care Bundles

• PDSA

• Run charts

• Trigger tools

• Safety Culture and climate

Annual returns to Care Inspectorate from care homes for adults, Jan 1st 2015 to Dec 31st 2016 (1128 respondents)

• 3647 reported pressure ulcers in total

• 3.2 pressure ulcers per care home per year

• 66% of pressure ulcers develop in our care

• Assuming all pressure ulcers are reported

Data from the Collaborative

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

• 63% are newly acquired

• 41% being picked up as grade 1

• Average of 4.85 PU per care home

• So 1 PU every 2 months per care home

What else did the data show?

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

• Low incidence of Pressure Ulcers • Most common sites of PUs

(heels, tailbone and sitting bones)• More developed than Inherited

Continuation of Data Collection.New Collaborative Team focus onEducation, Prevention, Recording, Escalation

East Dun.

Argyll and Bute

Perth & Kinross

Dumfries and

Galloway

Highland

Education and training X (all) X X (1x) XInduction for new starts X (2x)Risk assessment tool X (all) X X (1x)Equipment pathway / Dressing pathway

X (1x) X (1x)

SSKIN bundle X (1x)Pain assessment / Person-centred care

X (1x)

Integrated care plan for health and social care

X

Areas of focus selected by participating H&SCPs

Resources Developed - Recognise, Record/Report, RespondScottish Adaptation of the European Pressure Ulcer Advisory

Panel Pressure Ulcer Classification Tool

Scottish Excoriation and Moisture-related Skin Damage Tool

Safety Cross

SSKIN care bundle

Data collection tool

Guidance to accompany data collection tool

Driver diagram

Case studies x 3

Catmoor (PK)

Abbey Gardens (DG)

Canniesburn

(E Dun)

Summary of themes

Resident Information leaflet

HCSW induction book Pressure ulcer collaborative

Pressure Area Prevention 2017

PU training evaluation

Session plan PU prevention 2017

Skin Test

PDSA

A&B Model

Education bundle

ED Red Day Review Tool (version 4)

ED Pressure Ulcer Identification Flowchart

NHS GGC Grading competition

&

All Grading Education Card

NHS GGC Pressure Ulcer Daily Risk Assessment (PUDRA) Risk Assessment

tool

PUDRA Guidance notes

PK Adapted Pressure Ulcer Safety Cross

PK Adapted Pressure Ulcer Safety Cross Guidance

PK Protocol for provision of equipment to Care Homes 2012

PK Care Home Pressure Ulcer Support Pathway

NHS Tayside Preliminary Pressure Ulcer Risk Assessment (PPURA)

PK Staff Questionnaire (Before)

PK Staff Questionnaire (After)

PK Tissue Viability Evidence Gathering Tool

PK Action Plan

NHS Education for Scotland resources

• Applicable for acute or community setting and social care

• Online module accessed via LearnPro

• Nine modules

• Hard copy educational workbook

• Anticipated online learning time = 5 hours to complete the modules, comprising 9

• Activity-based learning

• On completion of the course you can print a "Statement of Completion".

The Prevention and Management of Pressure Ulcers

Evaluation

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

Microsite

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

• Care Inspectorate is hosting a microsite with information from the

programme: www.pressureulcer.scot

• The co-produced motion graphic ‘What the HIS Standards mean for Care Homes’ is available on this site.

• Care inspectorate evidence gathering tool information

More Than Just Safety

As part of Healthcare Improvement Scotland’s Improvement Hub (ihub), SPSP activities support the provision of safe, high quality care, whatever the setting.

• Leadership and Governance• Tissue Viability resource• Data – reporting and use for

improvement• Risk assessment and care planning• Education• Equipment • The role of Quality Improvement

(QI) and the Model for Improvement

• Working across care sectors

Reducing Pressure Ulcers in East Dunbartonshire Care Homes

Kathleen Halpin & Janice Cameron

Our Team Our Partners

Aims & Methodology

Introduction

An initial scoping exercise

demonstrated that there was no

robust data of previous PU Incidence

in our 5 Care Homes in East

Dunbartonshire .

It was also unclear if PUs were being

graded correctly and uniformly in all

the Care Homes.

Improvement

Methodology Used

Process Mapping

Driver Diagrams

Fishbone Diagram

Self Assessment

PDSA

Data Collection

Local Steering Group

Clinical Effectiveness

Local Aims

Training

Risk Assessment

Reporting & Monitoring

An informal approach to improving pressure ulcer grading knowledge

As part of the SPSP Reducing Pressure Ulcers in Care Homes Project it was agreed that a tissue viability nurse specialist would provide support and education to the participating care homes in the East Dunbartonshire Health and Social Care Partnership.

The focus of the education was accurate diagnosis and grading of pressure damage. Groups of care home staff comprising of registered nurses and care support workers were asked to diagnose and grade pressure damage from a series of photographs. These photographs were images contained in the pressure ulcer grading and moisture lesion tools currently used by all staff.

The education was delivered in an informal discussion style making reference to the aforementioned tools.To determine the impact of an informal training session focusing on diagnosis and grading of pressure damage pre and post education scores were compared.

Cohort 1Pass rate Pre education was 33% of participantsPass rate post education was 94% of participantsPre education scores ranged from 22% - 61%, median 44%Post education scores ranged from 39% - 100% median 83%

Cohort 2*Pass rate Pre education was 9% of participantsPass rate post education was 45% of participantsPre education scores ranged from 20% - 70%, median 25%Post education scores ranged from 30% - 80% median 50%

Cohort 3*Pass rate Pre education was 37.5 % of participantsPass rate post education was 100%Pre education scores ranged from 10% - 90%, median 35%Post education scores ranged from 50% -100% median 85%

Cohort 4*Pass rate Pre education was 30 % of participantsPass rate post education was 70%Pre education scores ranged from 15% - 85%, median 35%Post education scores ranged from 35% -100% median 75%

* Care home liaison nurse participant

Pressure Ulcer Daily Risk Assessment (PUDRA) Surname: Forename: Hospital:

Ward:

Points to consider:

Use within 8 hrs of admission to care area

Re-assess daily and more frequently if

a person’s condition changes

Sex:

DoB:

CHI

1

Pressure Damage

Does the person have redness and/or existing pressure damage?

IF YES, prescribe a minimum of 2 HOURLY care to avoid further damage occurring and complete the pressure ulcer interventional plan overleaf.

Date Location of redness / ulcers Grade of ulcer Date Location of redness / ulcers Grade of ulcer / / / /

/ / / /

/ / / /

2 Mobility Does the person require assistance to mobilise?

3 Continence Does the person have continence issues with urine and/or faeces?

4 Nutrition Does the person appear malnourished and/or unable to eat or drink?

5 Skin Is skin compromised by any other source, e.g. neurological deficit; surgery; medication; diabetes; co-morbidities?

6 Judgement In your clinical judgement, is this person at risk of developing pressure damage? If Yes, please give details:

Record YES/NO answers in the grid below. If YES to any of the questions 2-6, the person is at risk of developing pressure damage. Prescribe a minimum of 4 HOURLY pressure relieving care interventions and complete the pressure ulcer interventional plan overleaf.

If NO to all statements, continue intervention, prescribing as assessed for individual need and re-assess daily.

Date Time Pressure Damage

Mobility Continence Nutrition Skin

Compromised Clinical

Judgement Active Care Prescribed

Signature

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

/ / : hrly

Complete prevention of pressure ulcer interventional plan overleaf for all patients with redness/pressure damage and for those at risk.

NHSGGC PUDRA October 2017

Attach Addressograph

Prevention of Pressure Ulcer Interventional Plan

Aim: To incorporate effective pressure ulcer prevention strategies to reduce/eliminate potential for pressure ulcer development.

Outcome: To prevent pressure ulcer development through establishment

of effecting work practices in line with SSKINS bundle.

S

SKIN INSPECTION

S

SURFACE

K

KEEP MOVING

I

INCONTINENCE /

MOISTURE

N

NUTRITION

S

SELF MANAGEMENT / SHARED CARE

Sign / Comments

Date of initial plan:

Check:

Pressure areas hourly.

Skin under medical devices hourly.

Specify medical devices used:

Specify:

Mattress:

Cushion:

Detail additional pressure redistributing equipment:

Reposition

hourly in bed and chair.

Overnight patient / carer has agreed to repositioning_____ hourly.

Specify any manual handling equipment used:

Skin care to be carried

out hourly.

Specify products required for increased moisture / continence management:

Optimise nutrition and hydration.

Refer to MUST

Discuss and agree plan with patient / family / carer

YES NO

“Prevent Pressure Ulcers” leaflet given to patient / family / carer?

YES NO

Date discontinued: ___________________

Date of initial plan:

Check:

Pressure areas hourly.

Skin under medical devices hourly.

Specify medical devices used:

Specify:

Mattress:

Cushion:

Detail additional pressure redistributing equipment:

Reposition

hourly in bed and chair.

Overnight patient / carer has agreed to repositioning_____ hourly.

Specify any manual handling equipment used:

Skin care to be carried

out hourly.

Specify products required for increased moisture / continence management:

Optimise nutrition and hydration.

Refer to MUST

Discuss and agree plan with patient / family / carer

YES NO

“Prevent Pressure Ulcers” leaflet given to patient / family / carer?

YES NO

Date discontinued: ___________________

Date of initial plan:

Check:

Pressure areas hourly.

Skin under medical devices hourly.

Specify medical devices used:

Specify:

Mattress:

Cushion:

Detail additional pressure redistributing equipment:

Reposition

hourly in bed and chair.

Overnight patient / carer has agreed to repositioning_____ hourly.

Specify any manual handling equipment used:

Skin care to be carried

out hourly.

Specify products required for increased moisture / continence management:

Optimise nutrition and hydration.

Refer to MUST

Discuss and agree plan with patient / family / carer

YES NO

“Prevent Pressure Ulcers” leaflet given to patient / family / carer?

YES NO

Date discontinued: ___________________

PUDRA

Red Day Review Tool

PRESSURE DAMAGE MONITORING & REPORTING

Inherited (ORANGE)

Was the resident admitted to care home with damage from elsewhere i.e. hospital?

Acquired (RED)

Did the damage occur while residing in care home?

Record on paper Safety Cross

Care Home staff assess and grade pressure damage (using EPUAP).

Complete organisation documentation eg: SSKINS, PUDRA and Wound Chart if appropriate.

Red Day Review

Care Home staff and CHLN will complete Red Day Review Tool together within 3 working days and submit to CH Manager. Tool will inform staff if all measures have been implemented to avoid risk of PU and/or provide feedback on areas of

improvement.

Is the damage due to pressure or friction, moisture or both? Refer to Scottish Adaptation of EPUAP Classification Tool and Scottish Excoriation & Moisture Related Skin Damage Tool. If unsure refer to CHLN or senior staff members.

Reassess Regularly Reassess PU regularly and document in wound assessment tool. Implement any changes required to pressure area care, skin care or dressing choice.

Has the Pressure Ulcer deteriorated?

YES NO

Refer to CHLN Complete referral form for CHLN including all relevant information. CHLN will peer grade PU and assist in care planning and advice on

dressing regime.

Update documentation Record confirmed grade of PU (if acquired PU, document if avoidable or

unavoidable). Update risk assessment tools and Care plans.

Results

1 1 1

3

2

5 5

4

3 3

6

5

0

1

2

3

4

5

6

7

Oct 16

No

v 1

6

De

c 1

6

Jan 1

7

Feb

17

Ma

r 17

Apr

17

Ma

y 1

7

Jun 1

7

Jul 17

Aug 1

7

Sep 1

7

Co

un

t

Count of Newly Acquired Pressure UlcersNov 16 - Sep 17

1

2

1

2

3

1 1

2 2

3

5

4

3

1

4

2

1

00

2

4

6

01

/1…

01

/1…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

Nu

mb

er

of

pre

ssu

re

Ulc

ers

Avoidable/Unavoidable Newly Acquired

Pressure Ulcers Nov 16 - Sep 17 Avoid

able

1 1

2 2 2 2

4

3

4

7

5

4

1

3

1

2

1

4

1

2 2

1 1 1

0

1

2

3

4

5

6

7

8

01

/1…

01

/1…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

01

/0…

Nu

mb

er

of

Pre

ssu

re

Ulc

ers

Pressure Ulcers Peer Grading Accurate or Changed

Nov 16 - Sep 17(Including Newly Acquired AND

Inherited) Accurate

RECOGNISE

Pressure Damage

REPORT

Report to trained staff

RESPOND

Ensure all appropriate

pressure relieving

interventions are

implemented

www.pressureulcer.scot

Getting Started –

Our Model for

Implementation

Hilary Brown, Argyll & Bute

H&SCP

Sara Sears, Highland H&SCP

Getting Started

• Organisational support from Assistant Director of Nursing and Lead Nurse

• Initial meeting with outline expectations of involvement in the project

• Interview with HIS

• Induction days and steering group

• Self selection of Care Homes via A&B Care Home Network and Highland Carehomemanagers meeting and Integration Leads - contrasting- LA/Private; small/large; island/mainland; residential/nursing.

• Met with Care Home staff- base line data and DATIX; learning needs analysis; roles and responsibilities agreed.

Key Stakeholders

• Project Leads (Associate Lead Nurse and Integration Lead) invited Care Home managers, Key staff they identified (Champions), District Nurses, Tissue Viability link nurses, Local Area Managers to an initial meeting

Additional Stakeholders could have been included:

• Tissue Viability specialist

• Continence Link/Specialists staff

• Integrated Equipment Store staff

• CHEF/Education staff

Key Learning Points

• Gather your team/s-check who else should be included

• Describe the work plan- use ihub resources

• Gather data- baseline self report and ongoing, DATIX, RCA, staff learning needs analysis

• Analyse data in open and supportive way- care home staff know their residents-identify quick fixes; assessment tools and processes

• Staff support- induction processes, training plan, training support

• Information board on display- generate interest and discussion in the homes

• Report progress through appropriate channels

What worked in Argyll and ButeKey Stakeholders:Care Home ManagerCare Home StaffCommunity Nursing Team

Key Resources:SPSP RPUCH NES Pack/website, especially;• Data Collection Spreadsheet• Pressure Identification Tool (NATVNS)• SSKIN Bundle, Root Cause AnalysisTraining for all staff

Key Roles:Care Home ChampionLink District Nurse – with access to a Tissue Viability Nurse when neededManagement support in Care HomeLead Nurse support in HSCP

1

•Build on what you have. Care Home and Community Nursing team work extremely closely and as a team, meeting at least weekly. We use a link nurse system for easy communication. This affords the opportunity to jointly scrutinise & review data, management plans and recognise knowledge gaps for planning future joint development sessions. Involve specialists when necessary.

•Having a pressure ulcer champion in the home really reaps rewards in keeping focus and updating the data.

2

•Review current baseline knowledge of staff regarding pressure ulcer identification and management. This should be with Care Home and Community Nursing staff. Could use the P&K tool - we did.

•Arrange joint training at the earliest opportunity. It is useful for all home and community nursing staff to have this same baseline and understanding of current evidence and resources. People think they know but maybe not.

3

•We were a very small scale trial and there was low incidence of pressure ulcers, but this focus meant we all learned together

•We used resources that had been agreed together, we successfully tested guidance for residents & relatives

•We identified issues and looked for solutions together, eg. Moisture and pressure problems from continence product change

•We shared our progress and learning at the Care Home Network with other care home teams, this will continue

TEAM APPROACH MAKES IT WORK

Key Learning Points:

What is your model for other H&SCPs ?Key Stakeholders: Key Resources: Key Roles:

•Lead and Associate Lead Nurse•Carehome Quality Improvement Lead•Community Nurses•Carehome Managers •Tissue viability nurse specialist

Gap analysis questionnaireRisk Assessment ToolSSKIN bundleData collection spreadsheetRoot Cause AnalysisTV and moisture Grading ToolAudit Tool

Tissue Viability Nurse SpecialistCommunity Nursing TeamsLead Nurse/Associate Lead NurseCarehome Staff (key interest)Carehome Managers

Carehome managers and representatives with an interest in tissue viability attended educational events with Associate Lead nurse and tissue viability nurse specialist. Gap analysis completed and areas for learning identified. Presentations and practical sessions given and discussed and programme developed. Feed back given. Model for these managers and key person to take the learning back to the home and roll out training..

Partnership working with Health and Social Care. Use meetings which are already in place. Engage with the key stakeholders and ensure that managers and key staff are involved . Motivated individuals engaged in the process are key. Ensure support of specialist nurses and start small and ensure use of PDSA cycle.

Audit and review showed not best model . Model changed to provide educational session for community nursing team same information then being delivered to staff for large event and community teams then to support delivery of training. Package of information developed to provide to all homes and community teams for education and audit

Reducing Pressure Ulcers in Care

Homes Improvement Programme

Dumfries and Galloway’s Journey

Nicola Sloan, Patient Safety Project OfficerPaula Riley, Improvement Advisor

Getting started

Our checklist•Leadership Commitment•Right people in the room•Understand our landscape•Infrastructure to support•Communication

"As Chief Officer of Dumfries

and Galloway Health and

Social Care Partnership, I fully

support our proposed

engagement in the Reducing

Pressure Ulcers in Care Homes

Programme. As a Partnership,

we are proud of our genuine

engagement across the

statutory, Third and

Independent sector and are

confident that the strong

relationships that exist would

prove vital to the success of

this Programme."

Psychology

SystemsVariatio

nTheory

Local learning

•Ownership•Learning events•Knowledge and skills•Theory into practice•Leadership•Networking

What does culture look and feel like?

Does it make a difference?

0

1

2

3

4

5

6

7

8

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-16

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

Nu

mb

er

of

Pre

ssu

re U

lce

rs

Months

Number of Newly Acquired & Inherited Pressure Ulcers recorded monthly- Care Home 4

Newly Acquired

Inherited

Median

Extended Median

Start ofTested QI

Tested

• Leadership at all levels

• Relationships and culture

• “Give a little”

• Frequent engagement

• Equal partners

Last thoughts....

Resources –Data Collection Toolkit

Keir Robertson, HIS

Guidance Page

Care Home Lookup

Data Collection Tool

Data Collection Tool

Month with no identified Pressure Ulcers

Data Collection Tool

Month with no identified Pressure Ulcers

Notifications after data entry

Data Analysis

Data Analysis

Data Analysis

Available Measures in Analysis

Newly Acquired Pressure Ulcers

Newly Acquired Grade 1 vs. Gradable 2+ Pressure Ulcers

Inherited Pressure Ulcers

Location Pressure Ulcer Inherited from

Inherited Grade 1 vs. Gradable 2+ Pressure Ulcers

Newly Acquired and Inherited Grade 1 Pressure Ulcers

Newly Acquired and Inherited Grade 2+ Pressure Ulcers

Pressure Ulcer Location on Body

Primary Cause of Pressure Ulcer

Prevention Care Plan in Place Y/N

Risk assessment completed on admission

Risk Level

How often was risk assessment updated

Care Plan Review Frequency

Treatment Care Plan in Place Y/N

Prevalence of Pressure Ulcers

Grade 1 vs. Gradable Grade 2+ Pressure Ulcer Prevalence

Evaluation Case studies

Sarah Harley (Evidence and Evaluation for Improvement Team)

Aims and approach

• Purpose was to illustrate and explain the range of changes being implemented and the difference these are making to practice and residents’ care

• Conducted by specialist associates

• Case study approach feasible within the constraints of evaluating a programme operating in multiple locations in a short timescale

Case selection

Abbey Gardens – Dumfries and Galloway

Canniesburn – East Dunbartonshire

Catmoor House – Perth and Kinross

Three care homes were selected to illustrate a range of successful changes

Data collection

• Enquiry structured to understand and capture the tests of change and what difference this is making for staff and residents

• Face-to-face and telephone interviews with care home staff, nurses and local leads

• Strengths – allows in-depth illustration of complex change and the role of important contextual factors

• Limitations – doesn’t allow generalisation

Key learning

• Multiple tools being used successfully; enabling assessment to be linked directly to responsive care planning and the more timely and effective use of equipment.

• Education and training has been crucial for building knowledge and confidence.

• Improved assessment practices have been empowering for staff; helping them to understand why pressure ulcers develop and how to be responsive to change.

Key learning

• Assessment being linked with appropriate action on what works well for different people given their care needs, preferences and capacities.

• Leadership crucial enabler

• Better communication and relationships amongst staff and with relatives is helping to develop a culture of safety and person-centred care.

Next steps

• The work has momentum to sustain, with changes being embedded such

as through the use of induction for new staff.

• Plans for spread through sharing success within their own organisations

and other providers locally.

• Case studies and key learning to be made available on microsite.

Urgent Care PortfolioImprovement Approach to Urgent Care

Diane Campion

Healthcare Improvement Scotland

What does Out of Hours Mean?

• 2004 – General Medical Services Regulations enabled GPs (independent contractors) to opt out of providing General Medical Services:– Between 1830 and 0800, at weekends, on public holidays and during

Protected Learning Time

• NHS Scotland Health Boards are now responsible for providing GP services Out of Hours

• No contractual obligation or mandate on GPs to work during out of hours period

• 1.3 million calls per annum to NHS 24

• c25% of callers provided with information only

• 74,000 referrals to GP OOH from NHS24 on a monthly basis:

• Half are directed to attend one of the 64 Out of Hours Centres throughout Scotland

– Highest attendance group are Under 5s

• One in Five are visited at home by a GP or other healthcare professional

– Most Home Visits are for Older Age Groups

• c10% receive GP telephone advice; c7% are advised to attend an Emergency Department; c6% are transferred to Scottish Ambulance Service

Urgent Demand

GP Workforce• 4,465 GP posts in Scotland, (c8 GPs per 10,000)• 2,228 GPs contribute to GP OoH, equating to an estimated WTE of

353• 6% contribute around 1,000 hours or more over the year to out of

hours• 25% contribute less than one hour per weekNursing Workforce• 2,175 Registered Nurses employed by General Practice• 6% of these Nurses work in Out of Hours

Current Workforce Estimates

National Review of Primary Care Out Hours 2015

• Health Secretary – Ms Robison announced this Review in response to the high volume of unfilled Out of Hours medical coverage throughout Scotland

• Pulling together: transforming urgent care for the people of Scotland - November 2015

• Healthcare Improvement Scotland commissioned to produce National Guidance for Urgent Care

Menta

l

Health

Children

Frail and

Elderly

Pallia

tive

Care

Urgent Care

Ritchie Review Themes

Urgent Care Portfolio

Base

linin

g &

Prof

iling

Right Time Right Care

Improvem

ent Approach

For Urgent Care

Outcomes Focused Person Centred Care

Meet the team

Improvement Approach to Urgent Care

• Theme: Frail and Elderly

• Partnership Working: Scottish Care and Care Inspectorate

• Method:

– Explore: Structured Interviews with 2 Care Homes and 2 Care at Home Services in North and South

– Identify: Findings and Possible Improvements

– Confirm: Always Event Methodology

Improvement Programme

• Care Inspectorate and Healthcare Improvement Scotland joint funded Improvement Adviser

• Partnership working with NHS 24 and Erskine

• Intended Outcomes:– Getting right care at the right time for people in receipt of care in a

care home and care at home setting

– Improving confidence in decision making by care home and care at home staff

– Raise the profile of the importance of the care at home worker

Three Lenses of Guidance

Commissioners

UrgentCare

Guidance

Providers

Users

Phase Description From Ends

Design and Inception Develop Project Initiation

Documentation

September 2016 December 2016

Establish Programme Governance

Agree Terms of Reference

Evidence Gathering Develop Approach and Methodology January 2017 March 2017

Establish Working Groups February 2017 June 2018

Execute Project Plans April 2017 August 2018

Deliver Local Engagement

Programme

August 2017 December 2017

Drafting and Publication Establish Technical Advisory Board

(TAB)

August 2017 December 2017

Submit Recommendations from

Working Groups to TAB

December 2017 February 2017

Submit Discussion Papers/Terms of

Engagement to Steering Group

September 2017 November 2017

National Guidance Draft 1.0 November 2017 December 2017

Regional Consultation Events January 2018 March 2018

National Guidance Final January 2018 March 2018

Ministerial Acknowledgement February 2018 March 2018

Publication of National Guidance for

Urgent Care

March 2018 April 2018

Consultation Public Consultation April 2018 February 2019

Schedule of work

Celebrating our SuccessJill GilliesPortfolio Lead Primary Careihub

In Summary• Education and training is an important element of

this work

• New relationships over different disciplines and organisations formed

• Gathering data about pressure ulcers has been challenging

but…• From 5 HSCPs you have tried, tested, developed

and approved 29 tools that WILL help colleagues and peers

Looking forward to hearing about your

local celebratory events