What we are doing for you - Health in Wales

“What we are doing for you”

Annual Quality Statement 2013-14 This document has been designed to be read on line as well as in hard copy. By reading on line, you will be able to access additional information using the easy hyperlinks contained within the document.

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Annual Quality Statement

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Hywel Dda provides healthcare services to a total population of around 375,000 throughout Carmarthenshire, Ceredigion, Pembrokeshire and bordering counties. It provides Primary, Community, Emergency, Mental Health and Learning Disabilities services through GP's, Dentists, Pharmacists and Optometrists and General and Community Hospitals and Health Centres. This Annual Quality Statement (AQS) provides an opportunity for the Health Board to let our communities know what progress we have made in improving the quality and standards of the services we provide.

Hywel Dda has worked with the public in designing this year’s Annual Quality Statement and has used this information, along with Welsh Government guidance, How To Guide and the feedback report from last year’s peer review process to form this year’s Annual Quality Statement. We hope you will find this information interesting.


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Contents 1

Welcome

2

Introductions

3

Looking Back over the Past Year • • • • • • •

4

Staying Healthy Safe Care Effective Care Dignified Care Timely Care Individual Care Our Staff

Looking Forward


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Welcome During the past year Hywel Dda University Health Board has worked hard to push forward with the priorities identified in last year’s Annual Quality Statement. Some have been achieved, but need to be sustained, and in others where we have achieved some improvement, still require more work. We welcome this opportunity to take an honest look at how well we have performed during the reporting year and to outline future improvements we aim to make. Chris Martin Chair for 2013/14

Providing safe, person centred, high quality care is our priority at Hywel Dda University Health Board. The vision for Hywel Dda is creating a sustainable healthcare system for our people which has a greater focus on care closer to home, prevention, well-being and improved quality of life. There will be an increasing focus on creating a wellness service rather than a sickness service. Our commitment to quality and wellness is reflected in this year’s Annual Quality Statement.

As Chair of Hywel Dda’s Quality and Safety Committee, I want our population to know that Quality and Safety is what drives us to improve the way our services are delivered. We always start with what we consider to be a safe service – one that I want my own family to have when they access our services. And where we hear about any concerns, the Committee seeks assurance about what is happening. I want this Annual Quality Statement to show you what we are doing for you.

Trevor Purt Chief Executive for 2013/14

Sian-Marie James Chair of Quality & Safety Annual Quality Statement

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Introductions Last year, Hywel Dda shared with our population what we wanted to do to improve services for the forthcoming year. We identified a number of priorities, which are outlined below to improve the quality of patient care and outcomes.

We said ...

We Did ... •

Improve patient experience

•

• • • •

Increase patient and public engagement

•

•

Case study: The butterfly scheme to identify and provide tailored care for dementia patients within hospital has been rolled out, we have trained more than 1,000 staff and we are now appointing Butterfly Champions on each ward Case study: Volunteering for Health now has over 250 volunteers in 70 different roles across 59 different healthcare sites, these include patient be-frienders and meet and greeters at hospital. 100% of patients and staff said they had a positive impact on patient experience 91% of patients surveyed said they were satisfied with the level of care provided (internal audit) We’re helping nursing homes to also measure themselves against standards We developed a database of patient stories and guidance on their use We launched The Assuring a Positive Patient Experience Strategy to help ensure patients receive a positive experience of care and learn from situations where things have gone wrong: http://www.wales.nhs.uk/sitesplus/862/opendoc/231291) We now have almost 1,000 members in our membership scheme Siarad Iechyd / Talking Health, which provides opportunities for people to shape services and improve health Patient representatives have been used to plan new services and buildings, from the Renal Unit at Withybush Hospital to new maternity services

Approximately 97% of in-hospital deaths have been reviewed, with learning points identified and shared to make improvements • RRAILS now been implemented across all Community Hospitals and remaining Mental Health and Learning Disability areas. Initial compliance audits have shown a improvement in compliance with most areas achieving 95%. •

Reduce mortality


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• • • •

Reduce harm

• • • •

•

Improve quality assurance

•

•

•

Foster a culture of quality and safety

•

•


There has been a year on year reduction on the number of C difficle in patients aged 66+ - 13.5% reduction in 2013/14 since previous year Hand hygiene compliance is better than All Wales average - Varies between 86-91% better than All Wales We’ve increased the number of risk assessments for clots – between 20 and 30 per cent in surgery and orthopaedics and 10-20 per cent in medicine – to assist in prevention) Incidents of pressure ulcers have increased (26%) but this follows work to improve recognition and reporting. We’re continuing to work at reducing them by reviewing and taking action following each case We’ve put new systems in place to share learning – from visual displays to presentations We’ve introduced a Medicines Event Review group to look at incidents and share learning Case study: A smaller range of Warfarin tablet (used to thin blood) strengths are being used to make it safer and reduce the likelihood of human error Case study: Work progressed to introduce the Seeing Red campaign (due for September 2014) to ensure protected quiet time for ward staff when administering medicines We produced an annual plan for quality and safety and formed a working group to drive forward improvements We invited the Good Governance Institute to review what we were doing; they found no serious issues of concern and we are now addressing areas raised for improvements through an action plan A dashboard was developed and is now being aligned with the website My Local Health Service to better share and receive information with the public http://mylocalhealthservice.wales.gov.uk/ We’ve started the training programme and since its launch: 430 staff have completed the bronze level; 51 have completed silver; and 22 are on the gold network The Improvement Academy is piloting many leadership schemes. Case study: the Consultant Leadership Programme launched and is being discussed with a local university to see if it can be accredited at Masters level Case study: we are using different elements of data to find areas where falls occur on wards and prevent them Page 6

Looking Back Achievements The Health Board has made some good progress in the quality initiatives identified last year.

The Fundamentals of Care audit found 91% patient satisfaction with level of care provided (explained within the document). Introduction of a the Fundamentals of Care Audit tool for Nursing Homes 8568 in hospital deaths reviewed since April 2010 Shared learning taking place via Learning Flier, Audit Meetings Quality Dashboard developed in line with My Local Health Service Review and continued progress on implementation of medicine related National Patient Safety Alerts. Medicines Event Review Group re-established to review medication incidents and share learning across the HB Change of warfarin strengths available on prescription to prevent errors-recommendations as a result of some incidents. Increase of completion of risk assessments to assist in the prevent clots (Venous thromboembolism) between 2030% in the specialties of Surgery and Orthopaedics and an increase of 10-20% in specialty of Medicine Annual Quality Statement

Challenges Whilst we have a lot to celebrate we recognise that there have been some challenges and emerging risks during the past year, which have been discussed at the Board wide Quality & Safety Committee.

The need to improve management of patients who may be likely to fall. This is linked to a Health & Safety Executive Improvement Notice. Recruitment of clinical staff in specialist areas, such as Accident & Emergency, Paediatrics, Radiology etc. Sustainable service models across the Health Board for services such as Cardiology and understanding how this can be achieved while still providing safe and accessible services. Understanding the cause of patient deaths in hospitals and what steps we would have to take to reduce these, this links to the mortality reviews and the Risk Adjusted Mortality Index (explained within the document). Ensure that we participate in all National Clinical Audits and that we robustly collect information to support improvement and compare clinical outcomes. These challenges have informed the priorities for the forthcoming year outlined in the Looking Forward section. Page 7

Staying Healthy Further information on progress against the 10 pledges can be found at http://www.wales.nhs.uk/sitesplus/862/page/53848 Brief Advice

Alcohol Misuse

Brief advice is a simple framework for discussing health and well-being. • Ask a person about their health and well-being when the opportunity arises • Advise them to consider the benefits of making a change, if they are interested • Act by offering encouragement and information about sources of support

Alcohol misuse has a significant impact upon not only the population of the Hywel Dda area but also the workload undertaken by the University Health Board. Data shows increasing levels of health related harm both in terms of binge drinking and short term problems from alcohol use but also chronic alcohol misuse.

We will support local people lead a healthier life, enjoying a better quality of life in line with the 10 pledges.

•

A brief advice training package ‘Talking with Patients about Healthy Lifestyles’ was developed for staff. Development of Hywel’s Handbook and Hywel’s House – a “how to” guide and online resource for staff to assist staff to offer brief advice. In 2013-14, 11 “Brief Advice” training sessions were delivered to staff. Hywel’s Handbook and Hywel’s House were highly commended at the Hywel Dda ‘Best of Health’ awards in January 2014.


The University Health Board have made progress in the following areas:

• • •

Implementation of Hywel Dda Substance Misuse Prevention Action Plan Continued roll out of alcohol screening and brief advice Developing clinical pathways to improve secondary care responses to alcohol related hospital admissions Improving data collection on Emergency department attendance related to alcohol misuse

Further planned improvements include: •

• •

Working with key partners to implement a community development alcohol project in the Fishguard and Goodwick area in Pembrokeshire Population wide alcohol awareness raising campaigns in the Hywel Dda area Developing Alcohol Liaison Services within secondary care settings Page 8

Staying Healthy Healthy Weight

Tobacco Control

Across Hywel Dda, 22% of adults and 12.5% of children aged 45 years are obese.

Twenty one percent of the adult population of Hywel Dda report smoking (23% of men and 21% of women). That is approximately 66,100 people who are smokers. Pembrokeshire exhibits a higher smoking prevalence rate of 23% compared with rates of 20% in Ceredigion and Carmarthenshire.

County Carmarthenshire Ceredigion Pembrokeshire

Adults 26% 19% 23%

Children (4-5yrs) 13% 10.6% 13.1%

We will help 12,000 people lose weight in line with the 10 pledges, by 2016 The UHB have successfully implemented the Obesity Pathway describes actions taken at community, primary care and specialist levels to help people reach, obtain and maintain healthy weight. In Hywel Dda, the Pathway has been implemented by: 1. Community based prevention and early intervention 2. Community and primary care weight management services 3. Specialist multi-disciplinary team weight management services The UHB will continue to meet the minimum standards of the pathway across all levels. We will focus on strengthening the Level 3 specialist multi-disciplinary weight management service and developing a referral pathway for overweight and obese children. Further information is available at: www.hywelddahb.wales.nhs.uk/healthy-wednesday Annual Quality Statement

We will help 5,000 people to stop smoking or prevent them from starting in line with the 10 pledges, by 2016 While smoking prevalence continues to fall it remains a significant cause of illness in Hywel Dda, the effects of which result in demand on HDUHB’s Health and Social Care services across community, primary care and secondary care; and on the services provided by its partner organisations across statutory and voluntary sectors. Achievements: • A comprehensive Tobacco Control Strategy and Smoking Cessation development plans have been completed and agreed. • Working with partners to reduce the number of people who smoke to achieve All Wales targets. • Implementation Hywel Dda UHB Smoke Free Sites Policy and ongoing support to local to introduce smoke-free policies in playgrounds • Development and Implementation of Mind cessation service for mental health service users. Further planned improvements include: • Driving forward a Pharmacy smoking cessation service • Training midwives in smoking brief intervention Page 9

Staying Healthy Access to Influenza Vaccinations

Teenager Booster Vaccination

The uptake of influenza vaccinations by persons aged 65 and over, and under 65’s in a clinical risk group in Wales is far short of the World Health Organisations recommendation of 75%.

The teenage booster, also known as the 3-in-1 or the Td/IPV vaccine, boosts a child's protection against three separate diseases: tetanus, diphtheria and polio.

During the 2012/13 Influenza Programme, 17 out of the 99 community pharmacies in Hywel Dda were accredited to provide vaccinations and they undertook 301 vaccinations.

In 2010/11 local and national evidence highlighted the need for the Teenage Booster vaccination programme to be reviewed to ensure that delivery provides efficient services, improves uptake and reduces inequalities. Hywel Dda University Health Board agreed that a change to a School Nursing based service from a predominantly GP based service would be of benefit to increase the uptake of vaccination and protection of our young people against these infectious diseases.

To emphasise the efforts needed to improve the uptake of influenza, in 2013/14 the influenza programme became part of the updated measures for the NHS. The University Health Board aimed to expand availability of the NHS Influenza Vaccination Service in community pharmacies during 2013/14 to meet the Chief Medical Officers target of involving at least 25% of the Health Boards pharmacies. The 25% target was exceeded, with Hywel Dda achieving 43% involvement and the University health board was placed third in Wales for the number of vaccinations provided. However based on the number of vaccinations per head of population, Hywel Dda achieved the highest ranking for Wales. Indications for the 2014/15 influenza programme are that community pharmacies have established themselves as an integral part of the delivery of vaccinations. The focus for 2014/15 is to increase further the number of pharmacies that can provide vaccinations to complement and work with GP surgeries to improve the uptake amongst the target groups. Annual Quality Statement

The new school based vaccination service was implemented from the Spring term April 2012. There was a significant increase in uptake of teenage booster vaccination HDUHB All Wales

2012 28.3% 42.1%

2013 80.9% 64.2%

Following the development of further vaccination programmes for school aged children including seasonal influenza. It has been established that the current School Health Nurse model is not suitable or resourced to deliver a high volume of vaccinations in the school setting. The UHB has agreed that the way forward would be to develop a Nurse led immunisation team, which would be efficient due to focus and ownership of process on immunisation from start to finish. Page 10

Staying Healthy Self Management Programmes Self Management Courses aim to support individuals with a chronic condition, which means supporting individuals who have a health condition or disease that is persistent or otherwise long-lasting in its effects to develop skills to help them to manage their health and well being. Additionally, courses aim to give participants the confidence to take responsibility for their own care and make better use of health services, whilst also encouraging them to work in partnership with health and social care professionals. Courses are led by individuals who have personal experience of either living with or caring for someone with a chronic health condition. Two Volunteer Tutors or EPP Cymru Coordinators deliver each course. We provide • Chronic Disease Self Management Programme (CDSMP) ; a six week course • Looking After Me (LAM) a course for carers;a 6 week course • Introduction to Self Management (ISM); a three hour taster session. • COPD Self Management for Life (SM4L); a seven week course Hywel Dda University Health Board currently is the only Health Board providing the COPD SM4L programme

You can self refer to these programmes or be referred by a health or social care professional. The contact number for EPP is 01554 899035 or via [email protected]

Completers Hywel Dda Total Carmarthenshire Ceredigion Pembrokeshire

12/13 222 133 37 52

13/14 339 (20% increase) 161 57 121

Further planned improvements include: • •

•

Single contact point for referral to self management programmes identified and in place from August 2014. Research to start in September 2014 to assess and evaluate the implementation of a lay tutor led self management programme for people with Type 2 Diabetes Implement and evaluate the Introduction to Self Management (ISM) course for carers of people with chronic/long term conditions.

We will improve access for people with chronic/long term conditions to self management programmes.


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Safe Care Never Events Hywel Dda University Health Board (HDUHB) is committed to protecting patients from avoidable harm. Avoidable harm is categorised under the umbrella of Never Events for which there is a universal agreement of the types of incidents which can occur for which the National Health Service should have robust systems in place to prevent occurrence. Never events are defined as serious, largely preventable patient safety incidents that should never occur if the available preventable measures have been embedded into daily practice by the Health Board.

Hospital Acquired Thrombosis

A hospital acquired thrombosis (HAT) (blood clot) can happen when you are a patient in hospital as well as up to 90 days after you go home. About one in every 1000 people get a blood clot from being in hospital each year. You may be familiar with people getting DVT after flying, but you are much more likely to get a blood clot after going into hospital. About two-thirds of clots happen during, or 90 days after a hospital stay. We will reduce the number of avoidable hospital acquired thrombosis.

Incidents are considered to be Never Events if: • The incident either resulted in sever harm or death or had the potential to cause severe harm or death. • There is evidence that the never event has occurred in the past and is a known source of risk. • There is existing national guidance or safety recommendations, which if followed would have prevented the incident from occurring.

The UHB has: • Established a HAT Implementation Group • Increased completion of clot (venous thrombolembolism) risk assessments between 20-30% in the specialties of Surgery and Orthopaedics and 10-20% in the specialty of Medicine • Complete Root Cause Analysis (RCA) for identified HAT • Developed a patient information leaflet for HAT

During 2013/14 HDUHB reported one Never Event, identified under the category of Misidentification of Patients relating to histopathology specimens. A detailed investigation took place with an action plan being developed and led by the Medical Director. Learning is shared from any serious event throughout the organisation via: • Case studies at meetings/Junior Doctors Induction • Learning fliers/posters

Further planned improvements include: 1. Reinforce the view of a zero tolerance towards avoidable HAT 2. Increase the reporting of HAT on DATIX (internal incident reporting system). 3. Investigate all identified HATs using RCA tool specifically for HAT and develop action points 4. Include HAT and VTE risk assessing in junior doctors’ induction 5. Continue to use recognised Quality Improvement Methodologies – incorporate HAT into Silver IQT (internal training for staff).


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Safe Care Reducing Harm from Falls

Falls in the Community

The Ceredigion Strategic Falls group, established in 2010, is a multi-agency group with members from Health (Nursing, Therapies and Public Health Wales), Aberystwyth University (Sports and Exercise Science and Psychology Departments), Ceredigion County Council (Social Services, Environment etc) and Third Sector organizations (Age Cyrmu, Care & Repair).

Falls prevention strategies continue to be a key priority for community services. In relation to service provision for older people and adults with physical disability and sensory impairment, these are focused on the key areas which reduce the risk of falls according to the evidence base:

All ambulance (WAST) callouts for an incident of a fall, where the patient is not transferred to hospital due to injury, are referred to the community nursing service for an initial assessment. The patients are then referred into other services as appropriate, such as Primary Care. GPs have signed up to a Quality Performance framework for falls and frailty which will be further embedded in practice during 2014/15. Work is underway to embed telecare (offering remote care of elderly and physically less able people, providing the care and reassurance needed to allow them to remain living in their own homes) into the assessment process as both an opportunity to signpost into the service when a fall has occurred as well as the responders undertaking the assessment with appropriate clients.

Strength and Balance Exercise Provision – Community programmes which improve the strength and balance of frail older people are now available across Carmarthenshire in community venues. These include ‘Postural Stability’ and ‘Exercise following Stroke’. For those adults who are more independent, working in partnership with other organisations has allowed the development of a ‘Simple Guide to Strength and Balance for you to……Keep on Walking’ Multi Disciplinary Team Assessment – Working with the Welsh Ambulance Services NHS Trust has allowed us to develop a care pathway. This pathway allows an individual who has suffered a fall at home to remain at home providing they are medically fit to do so. The community Multi Disciplinary Team will visit the individual at home to undertake a falls assessment. Individuals who are frail and are at risk of a fall or indeed have fallen are referred by the GP to the multi disciplinary team. Rapid Access Frailty Service – For those individuals who continue to fall despite intervention from the GP and the Community Multi Disciplinary Team, they may benefit from a comprehensive assessment by a Geriatrician as well as the Multi Disciplinary Team.


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Safe Care Compliance with Patient Safety Alerts

Reduction in Mortality & Harm

The University Health Board is required to inform the Welsh Government how it has met a number of national Patient Safety Alerts, published by the National Patient Safety Agency.

Risk Adjusted Mortality Index (RAMI) was developed in the 1990s to measure the risk of death during a hospital stay for specific diagnoses and procedures. Predictive variables used include the patient’s age, gender, race, diagnosis related groups, presence or absence of comorbidity, presence of any secondary diagnosis. RAMI is one of a range of quality improvement measures which allows hospitals to investigate deaths and make improvements over time.

Through analysis of reported patient safety incidents, and safety information from other sources, the NPSA (National Patient Safety Association) developed advice for the NHS in order to help ensure the safety of patients. Alerts cover a wide range of topics, from vaccines to patient identification. As a part of the Health Boards approach to improving Quality & Safety we are ensuring all existing alerts are checked for compliance. Given a number of alerts were issued prior to the creation of the Health Board is important we check compliance still exists. The NPSA Medicines group is currently undertaking work on addressing compliance levels with the various alerts that have a education element. Hywel Dda reported the following compliance and since the end of the financial year compliance has increased further. Compliance Alerts Hywel Dda

63%

Rapid Response Reports

Notices

72%

100%

We will continue to monitor all in hospital deaths and feedback the learning within the organisation. 8568 in hospital deaths reviewed since April 2010 across the UHB. We have: • Participated in the development of an All Wales Mortality Review. • Used the All Wales Mortality review process to review all inpatient deaths to ascertain whether clinical processes could be improved and enable peer review. Approximately 97% of in hospital deaths have been reviewed since the process began • As a result of this process the Medical Director has issued feedback letters to all medical staff which identifies learning points to ensure learning is shared across the health board. • Reported weekly on current progress, concerns raised and All Wales Mortality review questions

The Medicines Management team has undertaken work to assess compliance levels with alerts that have a medication element. Additionally Internal Audit have been asked to undertake a review of processes associated with alerts. Annual Quality Statement

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Safe Care Rapid Response to the Acutely Ill (RRAILS) RRAILS is a term used for the early recognition and intervention with rapid treatment of patients who become acutely ill whilst on wards. The aim is to avoid further deterioration and possibly death. Four Care Bundles were introduced. A care bundle is a set of interventions that when used together, significantly improve patient outcomes. The bundles covered the following: Admissions bundle - what proportion of the patients admitted to your clinical area have a full set of observations on admission and have a plan for the frequency of observations which has been communicated to all clinical staff? Recognition bundle - what proportion of your patients are regularly risk assessed using a track and trigger system and are routinely screened for severe sepsis (a life threatening condition caused by infection) if found to be at risk? Response bundle - What proportion of your patients are treated appropriately and in a timely manner if their condition deteriorates? Sepsis Six – What proportion of your patients are given Oxygen, fluids and antibiotics within 1 hour of being diagnosed with severe sepsis?

Achievements • RRAILS now been implemented across all Community Hospitals and remaining Mental Health and Learning Disability areas. Initial compliance audits have shown a dramatic improvement in compliance with most areas achieving 95%. • The National Early Warning Score system (a scoring system combining the scores from a selection of routine observations for adults) was launched across the Health Board in August 2013. The Resuscitation team were able to train 70% of clinical staff and have completed 3 compliance audits since the introduction. Results continue to be disseminated through the County RRAILS structures and have shown overall improvement in documentation. • The Paediatric Early Warning Score system (a scoring system combining the scores from a selection of routine observations for children) has now been implemented across all paediatric general ward areas Future Improvements 2014-15 • • •


Complete role out plan for Capturing RRAILS indicators onto the nursing metrics and support teams in capturing indicators. Work towards the reporting standards required to meet the Sepsis target. Launch new sepsis bundle

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Safe Care Healthcare Associated Infections Healthcare associated infections (HCAI) are infections resulting from medical care or treatment in hospital (in or out patient), nursing homes and even the patient’s own home. Healthcare associated infections can affect any part of the body, including the urinary system (urinary tract infection), the lungs (pneumonia, respiratory tract infection), the skin, surgical wounds (surgical site infections), the digestive (gastrointestinal) system and even the blood stream (bacteraemia).

Achievements

Although anyone can get a HCAI some people are more susceptible to acquiring an infection. There are many factors that contribute to this: • Illnesses, such as cancer, diabetes and heart disease, can make patients more vulnerable to infection and their immune system less able to fight it • Medical treatments for example, chemotherapy which suppress the immune system. • Medical interventions and devices for example surgery, artificial ventilators, and intravenous lines provide opportunities for micro-organisms to enter the body directly • Antibiotics harm the body's normal gut flora ("friendly" microorganisms that live in the digestive tract and perform a number of useful functions). This can enable other microorganisms, such as Clostridium difficile, to take hold and cause problems. This is especially a problem in older people.

The Health Board have maintained a fairly consistent rate for MRSA cases, although there has been a slight increase in 2013/14 since the previous year.

We will continue to reduce health care acquired infections over the next 12 months. Annual Quality Statement

There has been a year on year reduction on the number of C difficle in patients aged 66+ • 13.5% reduction in 2013/14 since previous year Hand hygiene compliance is better than All Wales average • Varies between 86-91% better than All Wales

The Board have agreed that the approach in Hywel Dda will be to: 1. Reinforce the view that all avoidable infections will not be tolerated. 2. Recognise the positive impact of managing & preventing the most frequently occurring infections i.e. Respiratory Infection, Urinary Infection, Skin and Surgical Site Infection 3. Engage, energise and empower all our staff across the acute and community sector with special efforts to get upstream into the community. 4. Continue to use recognised Quality Improvement Methodologies. 5. Accept that Welsh Government will continue to challenge around MRSA and C. Diff 6. Monitor E. coli bacteraemia as a better surrogate for infections across our services and will set a local target of 20% reduction over 3 years. Page 16

Effective Care Links with Stroke Association During 2013-14, we commissioned the Stroke Association to provide a service with a value of about £75,000 per annum. A co-ordinator will be responsible for the day-to-day running of the service: accepting referrals, assessment, developing individual work programmes, recruiting, training, deploying and supporting volunteers and running weekly groups where applicable. The Stroke Association will also work with existing communication groups to support their transition to becoming self-supporting. We will continue to improve the health and well being of people following a stroke. This work builds upon previous Stroke Association services. This 3 year partnership will play a central role in the progression of a holistic service for people with stroke and offer the opportunity, through patient stories, to further improve the way that the Health Board delivers care Opportunities to progress a joint commissioning agenda with colleagues in local authorities will be a natural next step for this work. This could be a positive example of health and social care integration working within the context of a broader ‘coproduction’ framework


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Effective Care Local Primary Mental Health Services The GP is often the first point of contact for people with mental health concerns and the mental health care which they provide in local settings helps to normalise mental health issues.

2013-14 2013

Local Primary Mental Health Support Services support General Medical Services to improve access to mental health care within primary care settings, and to improve the outcomes for individuals accessing these services. Our aims are: 1) 80% of assessments to be undertaken within 56 days from the date of receipt of referral. 2) 90% of therapeutic interventions to be started within 56 days of an assessment They do this through the provision of: 1) Primary mental health assessments for individuals. 2) Interventions where e required, following assessment. 3) Referrals and signposting to other services which might improve or prevent a deterioration in the individual’s mental health. 4) Information and advice for individuals and their carers about other services that are available to them. 5) Information, advice and other assistance for primary care providers (GPs and practice staff).

Annual Quality Statement 2013-14

We have exceeded the 80% target and are consistently achieving over 95% of assessment being undertaken within 56 days. Further improvements identified as from 1st April 2014: 1. To ensure that 80% of assessments are undertaken within 28 days from the date of receipt of referral. 2. To ensure 90% of therapeutic interventions are started within 28 days of an assessment. 3. To continue with current data collection processes around the revised targets

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Effective Care Advanced Practice in Mental Health

Cancer

We have developed an Advanced Nursing Practice post working in Adult Acute Care Services within Carmarthenshire. This role has been operational since February 2013 with an Advanced Nurse Practitioner acting autonomously in managing care and treatment for both mental health and physical health conditions, independent prescribing, and acting as a Responsible Clinician for patients subject to the Mental Health Act.

There are three key components to tackling cancer: Prevention, Early Identification and Rapid Treatment. Whilst it is not possible to commit to reducing the incidence of cancer, due to the nature of the disease, it is possible to encourage healthier lifestyles to minimise avoidable cancers, to promote symptom awareness so that patients present earlier in the progression of disease and to provide access to rapid diagnosis and treatment. These in turn give the best chance of maximising the period of survival after diagnosis.

The role has been viewed positively and has contributed to substantial improvements to the Acute Care Service and has also contributed to the development of original research within mental health services. A pilot project on nurse-led medicines monitoring has demonstrated the health benefits of closely monitoring the physical health of individuals and the prevention of unwanted side effects from medicines. This work will be published later this year and further developed within the University Health Board. A further study in collaboration with Swansea University has received £207,000 in funding from the National Institute of Social Care and Health research that will provide early intervention with people suffering from ideas of self harm and suicide with the aim of providing more positive outcomes and hopefully avoiding the need for hospital care. The Advanced Nurse Practitioner role has been so successful that we are developing further Advanced Practice posts over the coming years.


Stage of Cancer Treatment- There was an improvement between 2011/12 and 2012/13 and there is a general greater awareness of the importance of recording the staging of cancers on the national information system. Cancer Waiting Times- 95% of Urgent Suspected Cancer (USC) referred Cancer Patients treated within 62 days and 98% of Cancer Patients identified through other routes to be treated within 31 days Non Urgent Suspected Cancer (NUSC). The Health Board will achieve the has committed to achieving the 95% target by September 2014. The Cancer Action Plan (available at http://www.wales.nhs.uk/sitesplus/862/page/67114 sets out the actions required to improve survival, including the measure to improve staging of cancer as reducing waiting times as reported above.

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Effective Care Clinical Audit

Research & Effectiveness

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.

Research and Innovation at Hywel Dda University Health Board (UHB) are supported by Research and Development (R&D) funding from the National Institute of Social Care and Health Research (NISCHR), Welsh Government. R&D funding is allocated to Health Boards and NHS Trusts in Wales according to their level of research activity. The R&D Department supports clinicians carrying out commercial and noncommercial clinical trials, and works strategically to increase the numbers of Chief Investigators, Clinical Research Portfolio studies, and subjects recruited.

The Welsh Government’s National Clinical Audit and Outcome Review plan (http://www.wales.nhs.uk/sitesplus/documents/986/NCAOR%20 ANNUAL%20PLAN%202013.14%20%28FINAL%29.pdf) is one of the core mechanisms for assessing the quality of healthcare in Wales and is a means for Hywel Dda University Health Board to compare its current practice with the best provided elsewhere in Wales and drive forward improvements in quality and safety. The plan compiles a list of mandatory national clinical audit projects that the Health Board must participate in (where services are provided). The Health Board participated in all 29 of these national audits (out of 29 applicable) during 2013/14. The plan is also comprised of Outcome Reviews (formerly confidential enquires). The purpose of these is to assist in maintaining and improving standards of care for the benefit of the public. The Health Board participated in 3 such studies during 2013/14. Clinical audit outcomes and learning are shared via departmental meetings, Mortality and Morbidity meetings and the Whole Hospital Audit meetings which are held bi-monthly. Annual Quality Statement 2013-14

The R&D Department is based at the Clinical Research Centre, Prince Philip Hospital and at Withybush General Hospital. The Clinical Research Centre at PPH provides dedicated space for research projects to be undertaken. It has a patient waiting area, a Clinical Room, and 2 research laboratories for sample analysis. Funding from Welsh Government has enabled the research infrastructure across the UHB to be increased. In the 2013-24 period Hywel Dda R&D received funding of £518,000 and is hosting or leading on over 300 research studies ranging from international drug trials to local educational studies, with a good deal of the work focused on new Cancer treatments, Respiratory disease and Diabetes. The R&D Department liaises with Finance and Clinical Support Services (e.g. Pathology, Pharmacy, Radiology) to ensure that the requirements of the Research Governance Framework for Health and Social Care in Wales and other regulatory requirements are complied with.

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Dignified Care Fundamentals of Care Royal College of Nursing’s ‘Nutrition Now’ campaign. One of the All Wales Nutrition Standards is a standard to ensure that patients have access to fresh water and beverages. This includes water jugs being changed on a regular basis jugs and patients being offered seven or more hot beverages a day. Although many of our wards are demonstrating that this happened, there is still work to do to ensure that this is the case for all our wards.

Hywel Dda continues to take part in the annual All Wales Fundamentals of Care Audit which looks at the standards in the Fundamentals of Care (Welsh Assembly 2003) document and provides us with the opportunity to see where we are providing excellent care and where we need to focus our improvement work. The Fundamentals of Care audit has been undertaken within the hospital setting since 2009. The 12 standards are: • • • • • • • • • • • •

Standard 1 – communication and information Standard 2 – respecting people Standard 3 – ensuring safety Standard 4 – promoting independence Standard 5 – relationships Standard 6 – rest and sleep Standard 7 – ensuring comfort, alleviating pain Standard 8 – personal Hygiene, appearance and foot care Standard 9 – eating and drinking Standard 10 – oral health and hygiene Standard 11 – toileting needs Standard 12 – preventing pressure sores.

Some of the work to date includes: • Eating and Drinking: the results reflect the considerable improvement work that has been undertaken within Hywel Dda to influence and improve nutritional and hydration care to our patients. This work includes monitoring compliance with the All Wales Nutrition Standards and staff involved in the Annual Quality Statement 2013-14

•

Ensuring comfort and alleviating pain: We continue to work towards ensuring that every patient is assessed for any pain using a tool that is appropriate for them and their needs; and that pain relief is administered in a timely manner with no delay. Progress has been made to standardise the assessment process for pain, with a section for pain assessment included in the new patient observation chart Also, work has been undertaken to develop and implemented care plans to support the management of pain. Hywel Dda has also introduce the ‘Abbey Pain Tool, which is a pain assessment tool for patients who are unable to verbalise their pain e.g., patients with dementia, and the assessment is based on non-verbal signs of a patient being in pain.

•

Continence care: progress has been made around this aspect of care, but it is recognised that there is still work to do. The continence specialist nursing team have led the work to raise awareness and understanding of the All Wales Continence Bundle documents which supports the assessment and care planning around this aspect of care. Page 21

Further work is required to ensure that every patient receives support in meeting their continence needs that is individualised to them. This includes: Making sure that the HB continence promotion care plan is used appropriately Ensuring that there is a clear assessment process for the use of continence pads. •

Preventing Pressure Sores: The number of patients who developed pressure sores whilst in hospital is continually monitored and has shown reduction in year and the audit findings reflects the work that we have done to date. Robust processes are now firmly in place for the assessment of patients to identify their risk of developing pressure sores and over the last 12 months we have worked to ensure that patients received the aspects of care that must be provided to patients at risk of developing pressure sores. This includes strengthening the use of the SKIN Bundle, which is the document used to record the aspects of care that must be provided to all patients at risk of developing pressure sores. Where a patient develops a pressure sore, a through investigation is undertaken to understand whether there were things that could have been done to avoid it from happening and then these lessons are shared across all services. We need to continue to build on the improvements achieved to date and the Tissue Viability Team is working on raising the awareness of the recently issued All Wales best practice statement on prevention and management of moisture lesions to ensure the right management strategies are put into place for tissue damage caused via this process. (NB a moisture lesion is defined as being caused by urine/faeces/perspiration which is in continuous contact with intact skin and there are occasions when moisture lesions are incorrectly identified and managed as pressure sores).


Area for Improvement: • Oral health and Hygiene: this is an aspect of care that required urgent improvement work and since January 2014, work has been undertaken to ensure that the All Wales documentation to support the assessment and care planning around this aspect of care is introduced within all inpatient areas across the Hywel Dda. Progress is being monitored via the HB Oral Health Steering Group.

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Fundamentals of Care in Nursing Homes

Dignity & Essential Care Inspections

Measuring the quality of care provided by Nursing Homes is a key priority for Hywel Dda and we undertook some work to adapt the inpatient Fundamentals of Care audit tool so that we could evaluate the performance of Nursing Homes and ensure that the health needs of patients funded by the NHS are being met.

Dignity & Essential Care Inspections (DECI) provide a core part of Health Inspectorate Wales’s (HIW’s) inspection programme within NHS Wales. This programme addresses the following domains; Patient Experience, Fundamentals of Care, Management and Leadership, Quality and safety.

In addition, the audit was an opportunity to identify where and how the Health Boards and NHS can support Nursing Homes, who often work alone with limited staff and resources.

The Inspection identifies areas of good practice in relation to dignity and essential care and also areas for development within the areas observed.

The results to data have identified key themes of good practice with staff familiar with procedures around safeguarding the vulnerable and procedures to isolate patients.

Examples of good practice identified from the DECI undertaken in Glangwili General Hospital by HIW in May 2013 included: • The departments were observed were clean and tidy with clear signage in place. • Staff were polite and sensitive with good communication and discreet when providing personal care. • Staff ensured that patients’ language preference to communicate in either Welsh or English was met. • Assessment of patients care needs such as, pain assessment, nutrition and risk of pressure damage were in place. • Regular encouragement was made to patients to drink fluids and mealtimes were protected from unnecessary interruptions. • Improvements identified from the inspection included aspects of communication and the Fundamentals of care

Further planned work includes: • Each nursing home will have an action plan, developed in partnership with NHS staff, with key actions to improve services for patients. • Work is required to further adapt and develop the tool to ensure that the questions are relevant for long term care patients in Nursing Homes. Work is also required to develop a set of questions that are uniquely related to this care sector.

There were some key pieces of work that the Health Board agreed, as a result of the DECI review. The action plan can be access as follows: LINK


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Dementia Care We are committed to provide dementia patients high quality care. There have been a number of initiatives that have been introduced during 2013/14 which are aimed at improving the patient experience: •

The University Health Board is committed to improving the patient safety and well-being of patient’s with dementia whilst they are in hospital and have introduced the ‘Butterfly scheme’ to support this. The scheme helps to identify patients with dementia confusion or forgetfulness through the use of a discreet Butterfly symbol, and encourages staff to offer a positive and appropriate response to this group of patients. Awareness training has been undertaken across the Health Board and most wards have a ‘Butterfly’ champion.

•

The Stirling University Dementia Resource Pack has been provided to each ward team. This pack contains guidance information for those staff working with patients with dementia.

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The University Health Board and Marie Curie have jointly appointed three registered nurses, whose focus includes palliative care for patients with dementia. These roles are unique in Wales and will support work around care planning as well as provide specialist training programmes.

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Staff in the acute hospitals and Older Adult Mental Health Liaison services are working together on a ‘Transfer of Care Initiative’,


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Dementia Champion: Volunteers are being piloted in several ward areas as part of a structured research project.

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Environmental assessments in ward areas have been carried out across our acute hospitals using an audit tool designed by the Kings Fund and the results have resulted in changes e.g. in Withybush Hospital toilet doors having been painted yellow, block colours introduced and specialist clocks put in place.

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An ‘Acute Hospital Action Plan for Dementia Care’ has been developed, which attempts to ensure that a systematic approach to improvements in care processes and systems for patients with dementia and is being taken forward across all our hospitals.

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Work has been undertaken, in conjunction with Mental Health teams, to improve hospital and discharge procedures for those patients with dementia. This is called the ‘General Hospital Dementia Pathway’

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A ‘Standardised General Hospital Mental Health Liaison’ referral form has been put into use to support staff in making timely and appropriate referrals to Mental Health Teams within each locality.

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A pilot project, to develop a 7 day a week service provided by the Older Adult Mental Health Community Teams, ran from October 2013 to April 2014 In Carmarthenshire. The evaluation identified that the service has provided significant benefit to patients and carers and this is being built into future service planning

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Timely Care Access to GP Services

1000 Lives Improvement Service

GPs “must provide” essential services at such times, within core hours (the period beginning at 8am and ending at 6.30pm on any day from Monday to Friday except Good Friday, Christmas Day or bank holidays),, as are appropriate to meet the reasonable needs of its patients, and to have in place arrangements for its patients to access such services throughout the core hours in case of emergency”. The complexities of modern life means patients cannot always attend ttend at their GP surgery in the middle of the day. Patients are frequently expected to be at work up until 5pm and cannot afford to take time off to attend appointments.

The aim of the new 1,000 Lives Improvement Unit is to support health boards in achieving the NHS national and local priorities by:

We will improve access to GP services and meet the Tier 1 target at 100% compliance.

Projects that had made significant gains under the legacy 1000 Lives Plus programme have continued to be operational operat in our university health board,, reporting to their most relevant groups or committees, including rapid response to acute illness (RRAILS), falls in the community, enhanced recovery after surgery (ERAS), health care associated infections (HCAI) , transforming tran theatres, transforming maternity care, transforming care and hospital acquired thrombosis (HAT). However, it is recognised that we need to do things differently to lead to whole system change and continuous improvement. In response, we have broughtt all improvement programme areas together under one umbrella - Creating a safe environment and a protecting patients from harm.

In 2014-15 the UHB is offering an Improving Access grant to any GP practice in Hywel Dda who wishes to bid for supplementary resources in order to find more innovative ways for their patients to access services. The UHB has commissioned an Extended Hours Enhanced Service from practices who can show that there is a patient need for appointments at specific times. Annual Quality Statement 2013-14

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• •

Supporting health boards and trusts to continuously find new and better ways of doing things to improve health and healthcare, and enable a better patient experience and outcomes Building capability within thin the workforce to develop de an improvement driven NHS. Setting the direction and challenge for organisations to t constantly adapt and improve.

These will be priorities in 2014/15 driven forward by the Improvement Academy, which will provide bespoke support across facilitation, facilit project management, measurement, data and business analysis and health economics. Page 25

Individual Care Putting Things Right Hywel Dda continues to implement the NHS Concerns, Complaints and Redress Arrangements (Wales) Regulations. The Parliamentary and Health Service Ombudsman "Principles for Remedy”, set out six principles that represent best practice and are directly applicable to NHS procedures: • • • • • •

Getting it right Being customer focused Being open and accountable Acting fairly and Putting Things Right Seeking continuous improvement

Further information can be found in the Annual Governance Statement. Under the NHS Concerns, Complaints and Redress Arrangements (Wales) Regulations 2011, the University Health Board has a duty to produce a ‘Putting Things Right’ annual report to be published as part of this statement. This can be found on the university health board’s website at www.hywelddahb.wales.nhs.uk and provides further detail about the types of concerns received and the lessons learned.

Learning from Patient Experience & Feedback Understanding the experiences of patients, their relatives and carers is a priority for the Health Board. We know that sometimes people have good experiences and sometimes they are not so good, but we firmly believe that understanding these experiences will support provision of high quality care. There is no single or simple route to understanding experience. The Health Board approach draws on a wide range of sources and information including formal, informal, real time, periodic, quantitative, qualitative, ad hoc and systematic. The key is to look at all this information so that they provide meaning and an understanding of what it is like to be a patient in the Health Board. It is look at various aspects of patient experience. The ‘what’ such as cleanliness, physical comfort including pain control, getting the right information at the right time to help understand what is happening, and consistent, timely and co-ordinated care and the ‘how’ and include being treated with respect by staff, not least to preserve dignity, being treated with compassion and responsiveness as an individual, and being treated with honesty, listened to and involved in your own care. The final question in the National Patient Experience Survey asks respondents to rate their overall experience using a scale of 0 – 10 85 % respondents rated their experience as between 10/10 – 8/10


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Individual Care Sensory Loss Standards

Investors in Carers Scheme

One significant commitment during 2013-14 has been to deliver the Welsh Government standards for improving the ways people with sensory loss access healthcare information. This has been progressed on a partnership basis with a range of local, regional and national groups.

The Investors in Carers (IiC) scheme is a framework of good practice, which health settings can utilise to develop their Carer Awareness and ways of working to support Carers in their county.

The Sensory Loss Standards Implementation Group (SLSIG) has met regularly and among its success measures have been the level of engagement and the wide cross section of patients, third sector organisations and statutory agencies attending and contributing at these meetings. The Health Board will improve the way people with sensory loss access healthcare information Progress to date has been good but it is recognised that more work is needed, for example on how any sensory loss issues are identified and flagged so as to help the individual during the course of their care. From April 1st 2014, a new service will be available in order to provide a flexible interpretation and translation service to help support people with sensory loss receiving healthcare. Other successes include a ‘walk and talk’ session at the renal unit in Withybush Hospital, which has led to improvements by including patients with a sensory loss at the developmental stage. We have also established a specific working group to improve services for people who are deaf or hard of hearing and this is being led by the Audiology Department in partnership with other groups. Annual Quality Statement 2013-14

The scheme has been rolled out to all GP Practices in the Health Board area and is being piloted with ten hospital settings and pharmacies. The scheme consists of the Practice or any other health care setting having a Carer Protocol which sets out what they do for Carers. When they have gathered their evidence the folders are then assessed and if successful they are awarded with a Bronze level certificate which is valid for two years. A Silver level for GP surgeries has also been developed and some surgeries. The UHB aims that all 56 GP surgeries to attain the bronze level either for the first time or having their Bronze level revalidated. Also for as many surgeries to progress to the Silver level where already three practices have achieved this level. Achievements: • GP Surgeries current bronze level as at 31st March 2014: o Ceredigion 10 out of 16 (63%) o Pembrokeshire 7 out of 15 (46%) o Carmarthenshire 16 out of 25 (64%) • 10 Pharmacies participating in the Bronze level • 8 out of the 10 Hospital sites have started the Bronze level • Started developing a Young Carer version for secondary schools. • Increase in numbers of Carer referrals for further help and support. • GP Toolkit with examples of Best Practice documents etc. Page 27

Individual Care Non Emergency Patient Transport

Support for Life Grant Scheme

Inefficient patient flow and legacy processes can be problematic for patients and raise healthcare costs by failing to make the best use of skilled staff time. The Griffiths Review of Non Emergency patient Transport in Wales was clear in its recommendation for stronger management of non-emergency patient transport- both budgets and performance.

Hywel Dda Charitable Funds made £100,000 of grant funding available to establish the Support for Life grant scheme for the purposes of enabling collaborative community healthcare improvement projects with key partners, the third sector and voluntary and community groups.

The University Health Board aims to address these issues Hywel Dda Invest to Save funds have been applied to the design of a pilot project role and temporary employment of a Non Emergency Patient Transport (NEPT) Manager.. This work is generating cost savings, improving the patient experience and opening the organisation to purposeful, task related and cost-effective collaboration. An evaluation of the impact of the role on key hospital staff across the 4 principal sites, Withybush, Bronglais, Prince Philip and Glangwili has drawn attention to both time and money savings associated with; relieving staff of the administrative burden of the ECR repatriation process, engaging the voluntary and commercial sectors and adopting new protocols. Financially, the role has included the development of a communication strategy building on feedback from Hywel Dda Citizens Panel Surveys and has provided the capacity to address issues unimagined at the start of the pilot. A dedicated system has been created to facilitate timely, efficient and effective patient flow. The pilot project has begun to develop protocols and importantly generate staff and patient confidence in a system that can work. Annual Quality Statement 2013-14

The scheme aimed to support initiatives which prevent illness, tackle risk factors, support people to live in their own homes and make more effective use of community and third sector health services – part of the wider strategy to develop community services and reduce overreliance on hospitals. Applicants were asked to address one or more of the following key themes: • Care closer to home- including basic foot care • Investment is prevention- exercise referral schemes • Reducing lifestyle related illnesses- smoking, alcohol consumption. Examples of a supported project is: Age Concern Pembrokeshire -Age Concern Pembrokeshire is a local charity established to promote the wellbeing of older people resident in Pembrokeshire. Its aim is to promote the well being of all older people and to help make later life a fulfilling and enjoyable experience. The charity was awarded £4,602 from the Support for Life grant scheme in April 2013 to support their ‘Best Foot Forward’ project. The project has provided access to basic toenail cutting within local community venues whilst also engaging with older residents through activities and socialisation opportunities. Page 28

Individual Care Siarad Iechyd/Talking Health Involvement

Citizen’s Panels

The University Health Board was the first NHS organisation in Wales to establish an involvement and engagement scheme. Siarad Iechyd / Talking Health provides members with up to date information about the health board and offers opportunities for members to influence and shape health services. Anyone with an interest in health can sign up to become a member. Members interested in surveys had opportunities to provide their views in 2013/14 on issues including:

There are three Citizens’ Panels within the Hywel Dda University Health Board area, one in each of the three counties of Carmarthenshire, Ceredigion and Pembrokeshire.

• •

Carers needs assessment survey in Ceredigion Welsh Government’s - Proposed Welsh Declaration of the Rights of Older People.

Members willing to comment on draft publications were joined the Readers’ Panel and gave suggestions on improving leaflets: • • • •

Smoke free site signage “Taking your own Medicines as a Hospital Inpatient” leaflet “Investors in Carers – why should I register as a carer with my GP surgery” leaflet “‘Florence’ the Simple Tele-Health Service” leaflet

Siarad Iechyd / Talking Health members supported developments within the University Health Board by participating in focus groups including: • •

Welsh Government’s “TalkCare” patient events Annual Quality Statement Focus Group

We will increase the membership of Siarad Iechyd/Talking Health to involve more people in their local NHS.


Every panel is a local partnership and has included Dyfed Powys Police and the local authority as key partners, with some additional local partners which vary in each area. The Citizens’ Panels are administered by Dyfed Powys Police on behalf of the partners. During 2013/14 Citizens’ Panels were asked questions by the University Health Board on themes including infections in hospitals. Infections in hospitals The Infection Control team asked the Citizens’ Panels general questions, seeking views on what information is desired by the public in relation to infection risks/prevention to elicit high level themes in relation to Healthcare Associated Infections (HCAI) information that the public might find useful. Choose Well Hywel Dda University Health Board initiated the exercise to seek reassurances that the public were aware of “Choose Well” and that individuals knew how to access the right treatment in the right place. The PPE team analysed the results from the questionnaire and fed back to the Choose Well Steering Group for consideration. Public and Patient Engagement is promoted and enabled through various partnership working arrangements. MORE INFO LINK HERE Page 29

Our Staff Workforce Profile

Staff Engagement

The workforce is the University Health Board’s most valuable resource and our vision is to enhance the range and scope of roles and retain the current high level of commitment our staff to deliver the very best service for the local community. The UHB workforce strategy will focus upon modernising and refining how we use our current staff across the Health Board looking at opportunities for new and extended roles linked to professional career pathways and working closely with our colleagues in social care and the Welsh Ambulance Service the development of new roles. We will continue to develop our workforce to provide high quality care.

A Staff Survey Group was established to identify priorities and work with the service in developing specific area action plans, based on the survey results. This group reports to the staff engagement sub-group of the Workforce and Organisational Development Sub-Committee, which will monitor progress and take strategic elements of the action plan.

Hywel Dda Health Board currently employs 9915 staff in 7,459.64 in full time posts the remainder in part time positions. Associated risks with the profile of the current workforce: • The age profile of the workforce in Primary Care • The age and gender profiles within acute nursing, medical, midwifery, estates, therapy services, healthcare scientists • Potential reduction of medical training posts • Proposed future changes to medical education The processes in place to ensure delivery of the strategy: • deployment and redeployment management • imaginative recruitment • engagement and partnership working • clinical leadership and management development • use of workforce intelligence • modernisation of roles and working practice Annual Quality Statement 2013-14

While the survey identified that there is a high level of dedication from our staff, key issues for improvement are: • The need to improve management competency, communication and trust in senior management all of which are key indicators for engagement, and improvement. • The need to demonstrate that the survey results will be acted upon Members of the Staff Survey Group have progressed a detailed assessment through a series of PDSAs This was aimed at supporting managers to develop specific improvement plans, and measures to test /demonstrate the improvement in their areas. The results of this exercise combined with other formal team assessment information, consistently revealed that the issues raised within the staff survey would be significantly improved through prioritisation of the following in all areas; Improvement in PADR/Appraisal; Improved communication between managers and their teams and Improved management competency.

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Our Staff Improving Quality Together

Volunteers

Improving quality together is the national learning programme for all NHS Wales staff and contractors. It provides a common and consistent approach to improving the quality of services in NHS organisations across Wales. Improving Quality Together will help improve the way in which we work to help us offer even better care for patients and service users.

Going into hospital can be a stressful and lonely time but having someone to talk to or help you with simple tasks can make all the difference.

Bronze - an online introduction to quality improvement 430 staff have now completed the Bronze E-learning package which all staff are encouraged to do. This level provides general information on Quality Improvement Silver - a short course that helps you put bronze-level learning into practice The Silver level takes the knowledge of Quality Improvement into action. This is aimed at staff who lead teams and is delivered in-house, as part of, or as a bespoke programme. So far over 51 staff have received the training with many working on Improvement projects. Gold - a network of improvement coaches supporting staff doing Silver-level projects Hywel Dda has an Internal Gold network group consisting of 22 individuals who have detailed understanding and experience of quality improvement. This group hold meeting on a regular basis and provide support to Silver delegates in the delivery of their Quality Improvements.

This is where Volunteering for Health comes in and Hywel Dda Health Board has numerous opportunities for volunteers in Carmarthen, Pembrokeshire and Ceredigion. Volunteering for Health is Hywel Dda Health Board’s volunteer service. The project was developed to improve patient’s experience of healthcare for the benefit of local people by action by local people. Volunteering for Health now has over 250 volunteers in 70 different roles across 59 different healthcare sites. As well as benefiting patients many of our volunteers have gained vital work experience which has increased their chances of securing future employment and gaining entrance into university or college. There are numerous opportunities for volunteers to make a difference to a patient’s stay in hospital, for example becoming a befriending volunteer to help people feel less lonely while in hospital, volunteer as a gardener, or in the pharmacy. Chairman Chris Martin said: “Our volunteers are valuable members of the team within the Health Board. Their contribution can make all the difference to a patients experience and I would like to thank them all for giving up their time to enhance other people’s lives.”

We have actively embraced the Improving Quality Together framework and have made good progress in embedding core skills, which will help improve the care we provide. Annual Quality Statement 2013-14

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Achievements 2013 / 2014 Hywel Dda University Health Board (HDUHB) has become the first health board in Wales to be awarded platinum accreditation for the Corporate Health Standard. The Corporate Health Standard is the national mark of quality for health and wellbeing in the workplace, recognising good practice and work places which target key preventable ill health issues. Heulwen Harden and Stephanie Williams won the National Maternity Support Foundation Award for Bereavement Care and their ‘Loved and Lost Babies or Yellow Balloons’ projects at the Royal College of Midwives Annual Awards. Also, Pembrokeshire Community Midwife Elspeth Lancaster has been awarded Welsh regional winner of Johnson’s Baby Mums’ Midwife of the Year. Hywel Dda University Health Board has been given recognition for promoting breastfeeding and the mother and baby relationship by achieving stage two of the UNICEF UK baby friendly initiative. It is envisaged that phase 3 will be completed within the year. The assessment team were very impressed with the level of commitment and knowledge demonstrated by the staff. The Health Board was shortlisted in four categories in the Welsh Language in Healthcare Awards 2013 and won all four. These are for the Bilingual Skills Strategy, Welsh Language e-Learning package, the ERAS Project in Orthopaedics in Prince Philip Hospital and the Bilingual Memory Task. Congratulations to Dr Anne Barnes of Ward 10 Withybush Hospital for being awarded an MBE in the 2014 New Year's Honours List.

LE&D were awarded a prestigious Inspire Wales Award in June 2013 for partnership working with the Princes Trust Cymru. The Domestic Abuse Team was successful in winning the category for Joint Working with the Third Sector and Partnership Organisations. A “Team Wales” approach to improving quality in secure mental health services has been shortlisted for a prestigious Health Service Journal award. It must be recognised that these are a small selection of the achievements from Hywel Dda University Health Board Annual Quality Statement 2013-14

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Looking Forward Hywel Dda University Health Board has a Quality and Safety Committee in place, which provides assurance to the Board in relation to the arrangements for maintaining and improving the quality and safety of patient centred healthcare in accordance with its stated objectives and the requirements and standards determined for the NHS in Wales. It does this through providing evidence based and timely advice to the Board to assist it in discharging its functions and meeting its responsibilities with regard to the quality and safety of healthcare. The Quality and Safety committee structure for the health board has been extant since April 2010. This structure consists of an overarching Quality and Safety Committee and a number of sub-committees and groups that have delegated responsibility for key areas of work in relation to quality and safety. The Quality & Safety Committee is directly accountable to the Board for its performance and provides advice and assurance by producing a formal report after each meeting. The Health Board have developed a Quality Framework which provides a definitive source of information which describes the Health Boards approach to quality assurance and safety. The Quality Framework has been designed to facilitate the implementation of legislative requirements, standards and its own priorities. A robust governance framework for quality and patient safety is essential in the Health Board. It provides assurance to the Chief Executive, the Chairman, the Board, senior managers and clinicians that the essential standards of quality and safety are being delivered and are embedded throughout the organisation. Some key themes emerging from last year, which have been reported and discussed through the Quality & Safety have been incorporated into the following year’s priorities are as follows: o Independent Reviews which look at events in other hospitals such as Francis Review in Mid Staffordshire o Reviews which look at services within our own hospitals, such as how we provide Cardiology Services, Dignity, Management of Outpatient follow ups, Radiology Reporting, Medical Devices Review o Winter pressures – how the hospitals coped last year and how lessons learnt can be incorporated into future planning. o Inpatient falls, which looked at seriousness and types of falls within our organisation and compared it to other hospitals across the UK. o How well we are participating in a wide range of National Clinical Audits and actions required to ensure full participation. o Safer use of medications o Compliance with a range of Standards such as Standards for Health Services in Wales, Welsh Risk Pool etc. o Compliance with safety alerts. Annual Quality Statement 2013-14

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Looking ooking Forward

Staying Healthy Safe Care * Develop of programmes to tackle to problems of poor health, such as smoking and alcohol * Continue to strive to improve access to vaccinations/immu nisations within the community

* Continue to review and learn from all inhospital deaths * Zero tolerance towards hospital acquired infections * Increase compliance with patient safety alerts * Continue to review and learn from inpatient falls * Safer use of medicatons

Effective Care * Identify areas where we need to make impro vements in service, performance, such as stroke * Ensure full participation in National Clinical Audits

Dignified Care

Timely Care

Our Staff

* Ensure lessons are learnt from DECI inspections * Increase compliance with Fundamentalsof care Audit * Roll out Fundamentals of Care Audit in Nursing Homes

Individual Care

* Ensuring the patients who need urgent and emergency care are fast tracked to specialist clinical opinion * Extending hours of some GP surgeries to allow better access for patients

* Improving the patient experience by responding more effectively to patient queries and concerns. * Supporting carers by continuing the progress of investors in carers scheme, across Hywel Dda

* Explore all opions for the recruitment of skilled staff for a modern NHS. * Ensure staff retention and develop by undertaking regular personal develop review and ongoing training programmes such as Improving Quality Together

Quality Improvement Priorities


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Seeking Views & Comments The views of our patients and carers are at the heart of improving the way in which we deliver our services. Monitoring how well we're doing through the eyes of those people who use our services is the most effective way of knowing what we do well and what we can do better. If you wish to provide feedback on the Annual Quality Statement or require any further information please contact the Media Office on [email protected]


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