Tag: Patient Safety

Stephen’s story

In partnership with Sirona Care & Health and North Bristol NHS Trust, our Human Factors programme offers tailored training to support staff working in community health settings. A toolkit has been developed, supported by face-to-face train-the-trainer sessions and collaborative events for shared learning and problem solving.

Stephen Early is a service user and volunteer with Sirona who has been actively involved in the development of this training programme, from designing scenarios to reflect realistic situations that staff might encounter to giving talks at staff inductions.

This is Stephen’s story, introduced by Karen Gleave, Project Lead for Sirona Care & Health.

Stephen is a service user living in one of our Extra Care Services, and currently is a volunteer with Sirona Care & Health and sits on the service user panel/forum.

I met Stephen just over a year ago when I approached members of the panel about working with me to provide a service user’s perspective for the Sirona support worker induction on what it is like to receive a service.

Once Stephen started it became quickly apparent that he was a “natural” talking with people and able to get his message across about how important communication and human factors are when supporting people. Stephen is able to bring the scenarios alive for the audience, has made people laugh and at times brought people to tears.

Stephen is a very inspirational person and has touched the lives of many. The feedback we receive after each induction is really very positive…

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It really shows the great value that service users can make to organisations and how they can help to shape future services.

Stephen’s story

Unfortunately I’ve caught pneumonia about six or seven times, and on about four or five occasions I’ve been took into hospital…

… because I was living by myself I’ve had problems with eating for about six years.

… one of the things they do here is try and make me eat and drink so they make me a sandwich now and then, or every time they come in, no matter what they’re going to do they always make me a cup of tea and put it in front of me, and I feel if they’ve made me a cup of tea, then I should drink it, even thought I don’t feel thirsty if that makes sense, and when I go up to Karen’s they the same, everyone does the same. “Tea Steve!” and it’s great.

So one day the doorbell went and the lady came in and she was a support worker. I think she was, I’m not sure now. She came in and said [grunting] “Alright.”

Well, straight away you know that you were not going to have a conversation with this lady about anything and the worst thing is that these sort of five, ten minutes ones which you might get spread out between the day, maybe three times, maybe four, not sure, all depends on what your needs are, are very important to everyone because it’s communication. It’s talking to someone.

And loneliness in these sort of places is quite bad actually because you know it has an effect on them and on their health as well. Because if you’re feeling down, you’re more likely I feel to get things wrong with you and depressed and things like that, so it’s quite important when people come in that they’re a bit… and say things. So when she came in I knew straight away I wasn’t going to have a conversation with her.

Now if I was feeling a bit unwell or anything like that, or had troubles or things, I wouldn’t have talked to her about it because I knew she wasn’t in the right mood to receive any sort of information. And then she came and said, “Got to make you a drink.” Now “got to”, so that hit me home that “got to” is not “Oh, I’m going to make you a…”, “Got to make you a drink. Can’t understand why you can’t do it yourself.” That was a little whisper underneath the voice.

And then the sandwiches… “What do you want in your sandwiches?” I said, “Well anything please” and then again I heard her say, “Can’t understand why you can’t do it yourself” and then she left. And as soon as she left I got up and I chucked the tea down the sink, and I put her sandwiches in the bin because I wasn’t going to eat or drink anything from someone who didn’t’ want to do anything for me and it made me feel really bad.

So that went on for about six or seven weeks. I stopped taking food, and when they did make me food I just tipped in the bin, and the drinks, because I felt like no one wanted to do it and they didn’t understand me. They didn’t’ understand my problems. They just thought I was lazy. So it didn’t matter if they came in happy or joyful, I would still do it. That was quite a bad experience.

And then a good experience was one lady come to see me, well lots of them. And they come in and ring the bell [brightly] “Hi Steve!” Straight away you know you’re going to have a positive talk to that person and positive reaction. And you’re going to say to that person if there is something troubling you, you’re going to mention it to them, you know, “Oh I don’t feel too good today… Oh I’ve got this problem” or whatever.

And the other thing is they come in and say, “What have you been up to today? What’s been going on? What are you going to do this afternoon?” All them little things, you know, it helps the conversation to go through and it is brilliant. “Oh,” she said, “Is it two sugars, Steve, innit? It’s two innit?” Them little things, it’s not like “Oh, I gotta make you a cup of tea” or anything like that. It’s “I’m going to put in two sugars.” Some don’t even talk about it they just do it and bring it out and put on the table which is brilliant so it’s them sort of things…

…unfortunately the people, some of the residents we have here, I call them my family because they are they’re all my family, and I tell them that. Anyway, they’ve got problems some of them and some of them suffer with memory loss, Alzheimer’s, so they’re not able and some of them can’t speak properly and they cannot relay to the support workers what it means, what they mean to us and they mean everything.

I call all of my support workers “my ladies” because that’s what they are. They’re my ladies. And they’re here… if it wasn’t for them I wouldn’t be here, they mean so much. Doesn’t matter if they come in and make me a cup of tea or just the simplest of things like help me taking off my shoes. My legs swell up around about half past two in the afternoon. They come in and take my shoes off and they always make me a cup of tea when they do it, and they have a little chat whilst they do it, and it means so much.

And I’m able when I go on my induction days to translate to them what they actually mean to people like me and the rest of the residents what they’re doing. Their job’s just as much important as a doctor or anyone like that because they’re doing something to help and they’re not only helping in the sense of doing something like giving someone tablets at the right time or doing some domestic or whatever or making sure someone eats. They’re actually talking to that person, which is fantastic, which makes them feel good.

… if I can hit that one person at induction day and she stays doing caring for maybe ten years? So she might see thousands and thousands of people on her journey through her career. If she carries that through, with all of them, what a magnificent difference that’s going to make! So that’s how I think of it.

Stephen was the winner of Sirona Volunteer of the Year 2015 for his work on the project:

Reducing harm from falls

Colleagues from 35 organisations across the South West took part in a workshop last month in Taunton exploring how we can do more to reduce harm from falls, including occupational therapists, physiotherapists, nurses, falls leads, rehabilitation nurses, falls specialists and ward managers.

Following previous work on falls in this region, the two AHSNs (West of England and South West) were asked to support local organisations to collaborate to reduce harm from falls locally. The aims of the workshop were to:

  • Further develop the collaborative approach to prevention and better management of falls
  • Create a forum to share best practice and learn from each other
  • Encourage networking of like-minded colleagues across the West of England and South West Academic Health Science Networks
  • Embrace quality improvement methodology to effect changes and drive improvement
  • Encourage organisations to develop their own plans and ideas on how to reduce harm from falls in their region.

91% of attendees rated the event as either “good” or “excellent”, and comments included:

“Great to hear good practice from other organisations”

“Really interesting and diverse collection of ideas and projects

“Informal approach was lovely”

“Good to have opportunity to plan way forward as a team”

Attendees worked on organisations action plans. As part of the evaluation, attendees were asked what they would do as a result of today – with many committing to take actions back within their own organisations:

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The event was organised using the Open Space. Read Ann Remmer’s blog here reflecting on this approach.

For more information, download the full event report here and do take a look at this excellent video telling the story of Mrs Andrews – a resource that was recommended during the event:

Just say sepsis!

We had an excellent turnout for our third sepsis masterclass held in Taunton in early February, bringing together health professionals from across the region and with a particular focus on paediatric and maternity sepsis, as well as antibiotic stewardship.

A total of 66 attendees were at the event, representing 32 different organisations, exploring how we as healthcare professionals can fight the fight against sepsis.

The event opened with an extremely moving talk by Susanna Morrish who shared Sam’s Story, a heartbreaking account of her little boy who died from sepsis.

Other speakers included Dr Ron Daniels who talked about the work of the UK Sepsis Trust in awareness raising, Dr Mark Juniper from the West of England Patient Safety Collaborative on the NCEPOD 2015 sepsis report, and Dr Akash Deep from King’s College Hospital London on the challenges the recognition and management of paediatric sepsis. Marian Knight from the National Perinatal Epidemiology Unit and Dr Imogen Montague from Derriford Hospital Plymouth both explored maternal sepsis, while Dr Kordo Saeed considered Procalcitonin (PCT) and its application in sepsis, SIRS and localised infections.

The slides from the event can be viewed here and you can download the full event report here.

To find out more about our work to tackle sepsis in the West of England, please contact:

Ann Remmers
Patient Safety Programme Director
ann.remmers@weahsn.net

or

Nathalie Delaney
Improvement Lead
nathalie.delaney@weahsn.net

 

Recent highlights of our work together

The West of England AHSN continues to be recognised for successfully bringing together healthcare, industry and academic partners across the region – but what are we are actually achieving together? Here are a few highlights from the last quarter, October to December 2015…

Patient safety

  • 10,000 people have benefitted from the emergency department safety checklist so far this last year, which has been piloted by University Hospitals Bristol NHS Foundation Trust. We are now supporting four other EDs to implement the checklist: Weston Area Health NHS Trust, North Bristol NHS Trust, Gloucestershire Hospitals NHS Foundation Trust, and Great Western Hospitals NHS Foundation Trust.
  • The two Bristol Trusts have successfully converted from the Bristol Early Warning Score to the National Early Warning Score (NEWS).
  • A great example of collaborative working: 80 delegates from across the South of England attended our Mental Health Collaborative learning event in December.
  • The Emergency Laparotomy Collaborative is live including all six acute trusts. This work will benefit 1,000 patients a year in the West of England.
  • To date, 435 staff from community organisations have already received Human Factors training. We are now providing funding to Bath & North East Somerset CCG, Bristol Community Health, Gloucestershire Care Services and North Somerset Community Partnership to enable a further 2,500 staff in community settings to receive training.

Informatics

  • Connecting Care has been used to review patient records on 110,000 occasions. Gloucestershire CCG has a final business case which will deliver interoperability in 2016/17. Wiltshire and BaNES are enhancing local systems to connect data for patient benefit across care settings.
  • Patients in the West of England are set to benefit from a new NHS Genomic Medicine Centre based in Bristol, which gained approval in December.

Quality improvement

  • 80 GP practices in Gloucestershire are working with us on our Atrial Fibrillation programme. The first 11 practices found 533 high risk patients who may need clinical review.
  • We have trained 46 GPs, 15 nurse practitioners and health care assistants, and 12 pharmacists as part of Don’t Wait to Anticoagulate, with a further pharmacist training session planned.

OpenPrescribing

  • The OpenPrescribing platform been used on 25,000 occasions, with 94,000 page views, and shares on Twitter have reached a potential audience of 46 million people. The concept has now spread to Wales and Scotland.

Join Dementia Research

  • At Christmas the West of England had achieved number one slot for the highest number of local registrations to the Join Dementia Research service in the country.

Diabetes Digital Coach

  • The Diabetes Digital Coach programme, developed by a consortium led by the West of England AHSN, has been selected as an ‘internet of things’ Test Bed to help people with diabetes in the region self-manage their condition.

Supporting innovation

  • We have supported Folium Optics who have been awarded £1 million funding from SBRI Healthcare competition to further developed their ‘smart tag’ which reminds people to take their medication.

Everything we do and achieve is in collaboration with an extensive range of individuals and organisations across the West of England and beyond. Thank you to all our members, partners, public contributors and staff!

Be sepsis savvy

Every year in the UK there are 150,000 cases of sepsis, resulting in a staggering 44,000 deaths – more than bowel, breast and colon cancer combined. Sepsis is the biggest direct cause of death in UK pregnancies and affects about 10,000 children every year in the UK.

A recent report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) emphasised the need for early recognition to saves lives.

Attendees from across the South West and West of England are gathering today at the third sepsis masterclass in Taunton with a particular focus on improving care for children and mothers with sepsis. You can follow along discussions throughout the day on Twitter using the hashtag #sepsissavvy.

The BBC programme Trust Me I’m A Doctor recently covered sepsis with some powerful stories from survivors about the impact sepsis had on their life. Here’s a clip…

NHS England has published a cross-system action plan ‘Improving outcomes for patients with sepsis’, outlining a number of actions that will be taken across the health and care landscape. This report recognised the role of Patient Safety Collaborative, part of the Academic Health Science Networks, to support local organisations to identify and spread best practice. Today’s masterclass forms part of this work.

Dr Mark Juniper, a consultant in respiratory and intensive care medicine, and Lead Clinical Co-ordinator of NCEPOD will be a speaker at today’s masterclass. Commenting on NHS England action plan, he said: “This is a really important report. If we all take action, fewer people will die from sepsis. All healthcare professionals need to be prepared to treat these patients. Improved recognition, assessment and treatment of sepsis will save lives. Reading this report and acting on its recommendations will help all of us to do this.”

Human Factors training for 3,000 community health and social care staff across the West of England

The West of England AHSN is awarding £65,000 in funding to four community organisations to support the roll-out of Human Factors training for support staff.

Communication and team working are recognised to have significant impact on the quality of safe services for patients. Following the Cavendish Review, the Care Certificate specified standards for support workers (Bands 1 – 4) working in all NHS and social care settings.

Although an appreciation of the principles of Human Factors has been implemented in acute care services in recent years, it has been found that training packages and resources are less applicable to the community health and social care context.

Health Education South West has therefore funded the West of England AHSN to develop an intervention using the SBAR tool (situation, background, assessment, recommendation) to support Human Factors training in patient safety focussing on support works in community settings.

The curriculum for this training was developed by Sirona Care & Health and North Bristol NHS Trust. It is based on how teams communicate and uses communication tools such as SBAR to develop a baseline awareness, which is built upon and embedded during the training using different scenarios. These scenarios were co-designed by the programme lead and service user representative to reflect realistic scenarios that staff might encounter.

To date, 435 staff from community organisations have already received Human Factors training. The West of England AHSN is now providing £65,000 funding to Bath & North East Somerset CCG, Bristol Community Health, Gloucestershire Care Services and North Somerset Community Partnership, which will enable a further 2,500 staff in community settings to receive training.

Train the Trainer

In conjunction with  North Bristol NHS Trust and Sirona Care & Health, we are also training up to 45 facilitators across the region in order to create a faculty with specialist knowledge and experience in Human Factors training for community services.

Organisations that have been successful in their bid for West of England AHSN support are invited to book training dates for facilitators to build the faculty in their organisation skilled in delivering Human Factors training. In order to book you will need a code for access. If you have not received your code, please email nathalie.delaney@weahsn.net.

Contact

For more information about the Human Factors programme, which is one of our Patient Safety Collaborative’s priority areas, contact Nathalie Delaney at nathalie.delaney@weahsn.net.

How can we help you enhance your skills in Patient Safety and Quality Improvement?

The West of England AHSN is conducting a survey amongst health and social care professionals to identify the skills and expertise in our region around Quality Improvement and Patient Safety. And we’re keen to hear from you.

This will help us to better share learning and expertise, and tailor our approach so it meets the healthcare community’s ongoing needs to deliver long-term, sustainable improvements in patient care.

We’re developing our work alongside ‘Q’, an initiative led by the Health Foundation, supported and co-funded by NHS England, and designed to connect people skilled in improvement across the UK.

If you are interested, experienced or trained in Safety or Quality Improvement work, then we would like to invite you to complete this short survey, which should take between five and ten minutes to complete.

This survey is being managed by the West of England AHSN in partnership with The Health Foundation.

For further information, contact:

Kevin Hunter, Patient Safety Programme Manager
kevin.hunter@weahsn.net
0117 900 2413

Emergency Department Safety Checklist rolled out to Weston, North Bristol and Gloucestershire

This month sees the first wave of early adopters of the Emergency Department (ED) Safety Checklist in the West of England, with Weston, North Bristol and Gloucestershire following University Hospitals Bristol’s lead.

The ED Safety Checklist was piloted at University Hospitals Bristol NHS Foundation Trust (UHB) and supported as a SHINE research project by the Health Foundation. The Checklist systematises the observations, tests and treatments in a time-based sequence for all patients other than those with minor complaints.

In its first year the Checklist has had an extremely positive and demonstrable impact on patient safety in ED.  Since its introduction in the UHB ED, there have been no clinical incidents relating to a failure in recognising deteriorating patients or delays in care delivery. (During the winter of 2013/4 there had been five serious incidents of which three occurred in the ambulance queue.)  Mean proportions in Key Performance Indicators (KPI) taken before and after the introduction of the Checklist improved by 5% – 25% in most cases.

Commenting on the pilot, Dr Emma Redfern, Consultant in Emergency Medicine at UHB and Associate Clinical Director for Patient Safety at the West of England AHSN, said: “All key performance indicators have improved since we implemented the Safety Checklist: things like vital sign measurements, pain scoring and administration of pain relief.

“We feel that a well-designed Safety Checklist can improve the quality of care delivered to our patients during periods of crowding.”

Due to the pressures on local urgent care systems, the West of England AHSN is now supporting three other EDs to implement the Checklist, through the development of an easy-to-use Toolkit and a financial award.

Weston Area Health NHS Trust is our first early adopter, while North Bristol NHS Trust plans to implement the Checklist by the end of December.  Gloucestershire Hospitals NHS Foundation Trust will be our next early adopter in early 2016.

With support from the West of England AHSN, UHB have applied for Scaling Up funding from the Health Foundation to roll out the ED Safety Checklist across the whole of the South West, and we will hear if we are being invited for an interview in January.

For more information on the ED Safety Checklist, contact:

Emma Redfern
Associate Clinical Director for Patient Safety
emma.redfern@UHBristol.nhs.uk

Joanna Garrett
Patient Safety Improvement Lead
Joanna.Garrett@weahsn.net

You can watch a short video here about the ED Safety Checklist pilot at UHB. You’ll need the password ‘shine’.

Medicines Optimisation Collaborative launched

The West of England AHSN launched a local Medicines Optimisation Collaborative as part of the Patient Safety Collaborative programme on 4 November 2015.

The event was attended by 54 people from our member organisations across the region. Feedback on the day was very positive with 100% of attendees rating the event as either excellent or good.

Attendees got to watch the new video from the Health Foundation called Pills and found this a powerful example of service improvement in medicines safety:

Attendees also had the opportunity to take part in a QI taster session as part of the West of England Academy. Find out more about the Academy’s work here.

The next steps are for member organisations to commit to testing and measuring specific change packages in the two priority areas of insulin safety and transfers of care. Feedback from collaborative members on how these tests of change are going will be fed back at the next event in late spring 2016.

If you would like to sign up for more information and to take part in future events in the medicines collaborative, please register here.

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