Patient experience improving across Wales - 1000 Lives Improvement

e r ’ e W

TRANSFORMING CARE! SPRING 2012

www.1000livesplus.wales.nhs.uk

Aneurin Bevan Health Board, Department of Medical Illustration

Patient experience improving across Wales

Nurses spending more time at the bedside, improved ward environments and a significant reduction in pressure ulcers are just some of the benefits patients have received thanks to the Transforming Care programme. In the two years since its launch, the innovative programme has empowered frontline NHS staff across Wales to make changes that have improved the patient’s experience of care and the safety and quality of services in both hospitals and the community. From small pilot pieces of work on a few hospital wards, Transforming Care has spread to all health boards and trusts becoming an integral part of day to day work. Professor Jean White, Chief Nursing Officer for Wales, said: “Transforming Care has had such a positive impact on both patients and staff alike. The focus has been on improving the quality of care delivered and ensuring a better experience for patients. “It has enabled frontline staff to often make small, but significant changes for the benefit of their patients, leading them to spend more time at the bedside. This in turn has provided the opportunity for patients to communicate their needs, resulting in a better hospital experience and faster recovery.” One of the most significant improvements of Transforming Care has been the redesign of systems and processes to enable nurses to spend more time directly caring for patients. Staff are now spending around one third more of their time with patients, which not only improves their care, but

communication, with patients able to express their needs and be listened to, ensuring they feel less isolated and have a clearer understanding of their care.

Better designed wards with appropriate and easily accessible equipment are ensuring less waste and more efficiency. A zero tolerance approach to pressure ulcers and the implementation of the SKIN bundle has also delivered success results with many hospital wards across Wales going more than a year without a single incident. Patients have also benefitted from improvements in care in a number of areas including: n Fewer falls in hospitals and the community thanks to better organised wards, improved risk assessment and measures put in place to prevent falls re-occurring. n Improved ward environments for older patients to ensure they feel less anxious. n Improved monitoring of patients, including hourly checks to ensure they receive care appropriate to their needs and any deterioration in their condition is discovered sooner enabling treatment to begin at an early stage.

“Transforming Care is helping healthcare staff to build the kind of NHS that we all want to work in – and more importantly, that we would all want to experience if we were patients,” says Jan Davies, Director, 1000 Lives Plus. “Patients and families are seeing the real benefits of the work – person-centred care, better communication, more pleasant ward environments and increased dignity for patients.”

What’s inside! News across Wales n Intentional rounding n Improving dementia care n Reducing pressure ulcers n Improved maternity care n Transforming Care in the community Plus n 10 success stories n Meet the Transforming Care team n Transforming Care spreads across Wales n Transforming Care online

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For further information, visit www.1000livesplus.wales.nhs.uk/transforming-care

Betsi Cadwaladr University Health Board

Intentional rounding improving relationships with patients The introduction of intentional rounding has proved so successful it has quickly spread from just a few wards to more than 50 wards across the health board and into a number of residential care homes. Both patient care and the patient’s experience has improved thanks to the process which involves nurses checking patients at set intervals to assess and manage individual care needs. Patients are given the opportunity to tell staff what they need and receive a drink with each intentional round, improving their nutrition. Patients will also be offered a snack between meals where this is appropriate. Many wards have also linked intentional rounding with the care bundle which is used to stop pressure ulcers developing, ensuring all checks can be carried out at the same time. It has also helped to reduce the possibility of falls on the ward and reduced call bell usage. Jill Galvani, Executive Director of Nursing, Midwifery and Patient Services said, “Intentional rounding has improved staff relationships with patients and provides a consistent structure for delivering care. “Patients are telling us that they feel cared for and reassured, knowing that within a short space of time they will be visited by a nurse and given an opportunity to raise any personal needs. “The round places the patient at the centre of care and reduces anxiety and social isolation.”

Aneurin Bevan Health Board

Getting the Job DONE on mental health wards Combining the concept of intentional rounding with general observations is helping to improve communication and care in mental health wards. Staff have used the ethos of intentional rounding, which advocates hourly checks on patients, to enhance its observational work and developed a ‘prompt card’ for staff to use. The card encourages staff to ask the patient questions that will help them to assess their mental health at that time. It uses the acronym DONE which stands for Distress, Observations, Needs and Environment. It includes questions about how the patient is feeling, if they are responsive, if they need anything to eat and if they feel safe.

It is carried out during each observational round with each patient and will take place according to individual need. The work has been piloted on an older adult ward in Ystrad Mynach Hospital and is about to be rolled out to adult mental health wards in St Cadoc’s Hospital, Caerleon. Karen Smith, Equality and Diversity Training Manager, who is leading the work, said: “We knew that we needed to adapt intentional rounding to ensure it would fully meet the needs of mental health patients. This work has helped us to develop a more therapeutic relationship with them. “It has helped to enhance our general observational process and the questionnaire ensures staff think more clinically about what the patient may need.

Powys Teaching Health Board

Transforming care in the community Re-organising environments in community hospital wards and district nursing areas has improved efficiency and enabled staff to spend more time on direct patient care. The district nursing team in Welshpool have been working closely with two residential homes to ensure visits take place on a set day each week, with an allocated carer available to meet the nurses and ensure residents’ medical notes are ready along with all the necessary equipment. This has ensured more efficient use of time, enabling nurses to provide more direct care, and improved communication with both carers and residents. In Llanidloes Community Hospital, work has also been taking place to improve care for dementia patients. Staff have introduced memory boxes that contain personal information on a card about the patient’s history, including family, hobbies, home and photographs. The box, which is kept at the patient’s bedside, has enabled staff to build links with the patient and the patient in turn feels less anxious and more comfortable in their surroundings. Linda Gethin, North West Powys Senior Nurse, said, “Transforming Care in the community has enabled nurses to spend more time with patients and helped to ensure patients feel more comfortable in their environment. “It has made our services more efficient and has been embraced by staff who are proud of the difference it is making.”

Nurses check patients’ needs regularly

Meet the Transforming Care team Sian Bolton is the Acting Director of Service Improvement in NLIAH, part of the executive team leading the organisation. Transforming Care falls under her remit. Lisa, Des and Emma are all Service Improvement Managers at NLIAH. Lisa Henry is a Registered Biomedical Scientist in medical microbiology. She has worked on the Transforming Care and Skills for Change programmes for the past two years, working closely with Aneurin Bevan and Cwm Taf Health Boards to engage staff and spread Transforming Care. Des Brown has worked on the Transforming Care programme since it started in Wales, mainly with Abertawe Bro Morgannwg University and Powys Teaching Health Boards. He has drawn on his experience in the National Patient Safety Agency and similar organisations to advise teams implementing Transforming Care and other 1000 Lives Plus programmes including RRAILS, Reducing Harm from Falls, and Transforming Maternity Services. Emma Thomas has worked on the Transforming Care and Skills for Change programmes since 2009, on a wide variety of programmes and with organisations across Wales. She has worked particularly closely with ward teams in Hywel Dda and Cardiff & Vale University Health Boards and Velindre NHS Trust.

The Transforming Care central team (from left to right) Lisa Henry, Sian Bolton, Des Brown, Emma Thomas

Transforming Care TV News reports have been filmed around Wales celebrating the many successes of Transforming Care. Ward staff have been asked about the improvements they have put in place and the huge difference it has made to the patients they look after. Watch the videos online at www.1000livesplus.wales.nhs.uk/transforming-care


Cwm Taf Health Board

ABM University Health Board

Person-centred care for dementia patients

Better care and faster discharge times in maternity

Dementia patients and those who care for them are receiving better care and support thanks ‘This is me’ to the introduction of a new initiative called ‘This is Me’. This leaflet will help you support me in an unfamiliar place Staff have adapted a leaflet from the Alzheimer’s Society which My Name asks the patient or the person who knows the patient best to My Carers Name answer a number of questions My Doctors about their life and what’s Name important to them. Questions are included about hobbies, life so far, home and family, sleep patterns, things which may cause anxiety and things which are useful for relaxation. The answers help build up a picture of the person’s identity and enables staff to meet their needs more fully and build up a stronger relationship with them. The leaflet has been piloted on a ward in Aberdare Community Hospital and has already received positive feedback from patients, carers and staff. Becky Thomas, Transforming Care Lead Facilitator, said: “The ‘This is Me’ work has been very positively received by everyone involved. For our patients it has meant they have felt more at ease in their environment and because we know more about their needs. “It has enabled our staff to see the person in the patient and by knowing their history they have more confidence in knowing what they can do to help and forge a stronger relationship with them.”

More time is being spent on direct care and discharge is now 50 per cent quicker on a maternity ward in Singleton Hospital – thanks to changes introduced by midwives. Ward 18 has been re-organised to enable the discharge process to be carried out in a dedicated room rather than at the main desk, ensuring the paperwork is in one place and there are less interruptions. Staff have also improved the ward environment by ensuring equipment and medication is readily available on one trolley and patient notes are taken at the bedside. Chris Jones, Ward Sister, said: “Transforming Care has inspired staff to introduce small changes that are making a big difference to the women on our maternity ward. “Patient satisfaction has increased because staff are able to spend time ensuring the women have everything they need and the faster discharge process enables women to return home more quickly. “One simple thing such as moving the discharge process away from the main desk has led to many more ward improvements which have improved both the quality and efficiency of care.”

Developed by the Alzheimer’s

Society, supported by the

RCN

The changes have increased the time spent directly caring for patients by 20 per cent and have received recognition from the Royal College of Midwives who highly commended the work in the PostNatal Improvements category of their recent awards. Becky Thomas, Transforming Care Lead, Cwm Taf Health Board

1000 Lives Plus faculty member Annette Bartley is an internationally recognised expert in helping nursing teams make and sustain improvements. She helped pioneer Transforming Care in Wales.

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success stories from Transforming Care in Wales 1. Better quality of care and improved patient experience. 2. Significant reduction in development of pressure ulcers. 3. Nurses spending more time at the bedside. 4. R e-organised wards improving efficiency and creating more comfortable environment. 5. Improved communication between staff and patients. 6. Frontline staff empowered to make changes to improve patient care. 7. Increased staff morale leading to patients feeling more confident about the care they are receiving. 8. Consistent, regular and structured checks on patients improving management of their care needs. 9. Fewer falls in hospitals and the community – thanks to better organised wards, improved risk assessment and measures to prevent falls re-occurring. 10. Rapid spread of the work across Wales and the incorporation of the ethos into other areas of healthcare including maternity, dementia, theatres and mental health services. Cardiff & Vale University Health Board

Increasing the time nurses spend with patients Improving the efficiency of a ward in Llandough Hospital, near Cardiff, has doubled the amount of time nurses spend with their patients from 40 to 80 per cent. The increased time on ward West 3 has come from identifying and addressing activities that were particularly time consuming. A nominated key holder is now responsible for the medications cupboard reducing the amount of time spent looking for the key. De-cluttering the ward has made a big difference and more efficient stock control and labelling of supplies and equipment has created real time savings. Deputy Ward Manager Helen Luton said: “Transforming Care has really changed the way we work. “We’ve reduced interruptions for nurses from 23 times per hour to nine times an hour and we’ve also seen a reduction in the number of falls on wards and gone several months without a pressure ulcer.” The achievements generated through the Transforming Care work are displayed on notice boards on the ward, providing a boost to morale and maintaining the momentum for improvements.

‘Well-organised ward’ (WOW) principles have transformed the way wards look and function across Wales, freeing up valuable time for nurses to increase direct patient care.


Hywel Dda Health Board

Velindre NHS Trust

Consisted structured care prevents pressure ulcers

Sustaining Transforming Care improves patient and staff experience

Many wards have also chosen frontline members of staff to be Pressure Ulcer Champions, who encourage the whole team to be responsible for delivering care based on the SKIN bundle, discuss and learn from each other, and celebrate their success. Judith Bowen, Clinical Practice Development Nurse and Transforming Care Lead Facilitator, said, “The zero tolerance approach and the new care bundle has given us a consistent and structured way of delivering care which is really benefitting patients. “Staff have embraced the work so much that if, on the rare occasion a pressure ulcer does develop, they are devastated and passionate about reviewing and reflecting on practice to avoid it happening again. “Our Pressure Ulcer Champions are fantastic in helping to drive the work forward and inspiring everyone to want to make improvements that will ensure the care we deliver is as good as possible.”

Transforming Care spreads across Wales

Transforming Care has rapidly spread from work on specific areas in just a few wards to becoming part of the way NHS Wales does business.

Most recent figures from January 2012 show that Transforming Care is now an integral part of the day-today work on 300 wards in health boards across Wales. From initially focusing on empowering nursing staff to improve patients’ experience of care, a multi-disciplinary approach has been taken to spread the initiative with everyone involved in the process from dietitians to physiotherapists, porters to doctors. Sian Bolton, Acting Director, Service Improvement, NLIAH said, “Transforming Care has acted as a vehicle to help improve nursing practices across NHS Wales and is a platform to share good practice. “It is becoming an automatic way of thinking and is powerful because it taps into the core reasons why individuals enter the NHS; because they want to spend as much time as possible caring for patients and making their experience as comfortable as possible. “All members of staff are now involved and this approach has given staff more ownership, more motivation and broadened their outlook about the changes they can make to improve patient care.” From an acute setting, many areas of Transforming Care are now moving into primary care where they are beginning to make a difference to patients in the community.

Staff are embracing Transforming Care and using the methodology in many different healthcare settings.

Work to reduce pressure ulcers, for example is taking place in care homes across Wales along with initiatives to improve dementia care and reduce the number of falls. Transforming Care is also now linked to a number of new areas including Transforming Theatres and Transforming Maternity Services and is seen as an integral part of 1000 Lives Plus, incorporating a shared language and improvement methodology that is being embraced by staff. The work is also being introduced to students with many organisations including Transforming Care as part of their curriculum and students are regular participants in study days. “It’s really important that students are involved in Transforming Care as we have an important role in caring for patients when on our placements and it helps us prepare for our role as qualified nurses,” says Jess Makos, third year Nursing student at Cardiff University. “The work should definitely be included in our curriculum as it is part of the future of the NHS and so are we.”

Transforming Care online You’ll find all the latest Transforming Care news, tools and resources online at www.1000livesplus.wales.nhs.uk/transforming-care The site also features several video reports covering the different aspects of Transforming Care, with staff from around Wales discussing their experience of successfully implementing the work, as well as

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Strong leadership and staff positivity has ensured Transforming Care has delivered sustained improvements for patients in Velindre Cancer Centre. Re-organisation of the ward and ensuring all appropriate equipment is in one place has enabled nurses to spend around 20 per cent more of their time directly caring for patients. By sustaining a tidy ward thanks to the introduction of cleaning rotas, nurses are freeing up time and have reduced their footsteps from 12,000 to 5,000 during a normal shift. Staff on the First Floor Ward have taken complete ownership of the work. Improvements have been sustained in many areas for over 18 months, ensuring higher quality care for patients. Protected meal times and regular checks on patients are also helping to ensure both staff and patients have a consistent structure to their day. Caroline Morgan, Ward Manager, said: “Transforming Care is now an integral part of our day-to-day thinking and staff are proud of the work they are continually delivering. “Everyone in the team is involved in the work and we have constant staff training and reflection of our practices to ensure we are maintaining high standards. “The improvements we have made have greatly improved morale for both staff and patients. Delivering structured care and having a better organised ward means it is a much calmer environment which in turn inspires confidence in our patients and helps to improve their experience.”

Transforming Care has been developed and delivered by the National Leadership and Innovation Agency for Healthcare and is a key part of 1000 Lives Plus. 1000 Lives Plus is the national improvement programme supporting organisations and individuals to deliver the highest quality and safest healthcare for the people of Wales. Every health board and trust in Wales, together with universities, voluntary organisations and charities, other public sector services, and commercial organisations are involved in 1000 Lives Plus. The programme is focussed on building capacity and sustaining and spreading improvements. It supports frontline staff across Wales through evidencebased ‘programme areas’ and provides clinical leadership through its Faculty. It is committed to engaging patients and students in improvement work and promotes an internationally-recognised quality improvement methodology. For further details, visit www.1000livesplus.wales.nhs.uk Email [email protected] Tel (029) 2082 7653

n Introducing Transforming Care n The Well Organised Ward n Tools to help prevent pressure ulcers n Time-saving strategies n Success stories n How Transforming Care links to other 1000 Lives Plus work

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Designed at Design Stage www.designstage.co.uk. Some photographs courtesy of Aneurin Bevan Health Board, Department of Medical Illustration, and Betsi Cadwaladr University Health Board.

A zero tolerance approach to pressure ulcers and the implementation of a new care bundle has made a big difference to patient care in wards across the health board. Staff have introduced the SKIN bundle in most acute wards and it helps nurses to keep focussed on four key areas to improve patient care: the Surface of the skin, Keeping the patient moving, avoiding Incontinence and ensuring Nutrition. Patients are regularly assessed for risk using the bundle as an aide memoir and their results clearly recorded on a chart at the bottom of their bed. The number of days a ward goes without a pressure ulcer incident is also clearly recorded on a notice board using a Safety Cross calendar. Some wards have gone several months without any pressure ulcers. In Prince Phillip Hospital one ward has gone more than 295 days without incident, a ward in Withybush Hospital has gone more than 145 days without incident, and a ward in Bronglais Hospital has now had no pressure ulcers for more than 190 days.