Moving from Special Measures to Good and beyond. · Moving from Special Measures to Good and...
Transcript of Moving from Special Measures to Good and beyond. · Moving from Special Measures to Good and...
Moving from Special Measures to Good
and beyond.London Ambulance Service
11th June 2018
1London Ambulance Service NHS Trust
Aim of session
Share the LAS ‘journey’
Share approaches to improvement
Talk about how we make quality BAU
Share our approach to sustainability
Share Lessons learned
London Ambulance Service NHS Trust 2
How we care for the capital
2 Emergency
Operations Centres
Operating out of over 70 sites
111 Services(recently rated as Good by CQC)
Non-Emergency
Transport Service
2 HART teams
Cycle response unit
Motorcycle response unit
Some facts about London
MulticulturalCapital city
300languages
Seat of Government & Monarchy
3Airports
5Police forces
On severe alert
Tourism Population swells everyday
32Clinical
Commissioning
Groups
5STPs in London
c8.9mPopulation
620square miles
CQC Context :Years 1 and 2• LAS put into special measures and rated inadequate 2015-16,
• 2016-17-Requires improvement, SM retained
London Ambulance Service NHS Trust 5
Since June 2015 Leadership … • 2 Chairs & 3 CEOs
• 2 Directors of Operations
• 3 Directors of Finance
• 6 Directors of HR (& 2 title changes!)
• 2 Director of Comms
• 3 Directors of Performance
• 1 Medical Director
• 2 Directors of Corporate Affairs
• 3 Chief Quality Officers (formally Director of Nursing)
• 6 Chief Information Officers (formally Director of IM&T)
• 1 Director of Strategic Assets and Estates
• 2 NHSI Improvement Directors
London Ambulance Service NHS Trust 6
CQC Approach over first 18 months…• Substantive posts to leadership team
• Funding from commissioners/NHSI (medicines management and Make
Ready roll out)
• Task focused approach re CQC actions
• Monitoring via QIP Programme Board: corporate and operational focus-
> 100+ actions
• Chair and Chief Executive and Board monitoring
• Communications strategy
• Focus on safety and medicines management due to Section 29a
Warning Notice
London Ambulance Service NHS Trust 7
Focus on Medicines Management • Set up system of checks and audit
to ensure drugs removed form
packs have been given to patients
• Appoint Medication Safety Officer
• Review system of code access
arrangements for medicine packs
• Set up control systems for medical
gases
• Address under-reporting of
incidents
London Ambulance Service NHS Trust 8
MedMan• Internal drug tracking and audit system
• Developed in-house
• Utilises existing data streams
• Able to track and trace drugs removed from packs
and given to patients by
• Pack number
• Drug
• Batch number
• Member of staff
London Ambulance Service NHS Trust 9
Perfect Ward
• Mobile
auditing of
medicines
• Compliance
reports
London Ambulance Service NHS Trust 10
KitPrep• Bespoke system designed
for LAS drugs system
• Real-time booking in/out of
drugs packs
• Provides data on drug pack
movements and usage
• Management of station-
based individual drugs
London Ambulance Service NHS Trust 11
London Ambulance Service NHS Trust 12
February 2017 – Moved to Requires Improvement, Special Measures retained
Our approach 2017-18 to date…
London Ambulance Service NHS Trust 13
Not a normal nine months…!!!
Lessons learned from 2016-17• Governance and risk systems/processes still under-developed
• Silo working in operational and corporate teams – ‘ownership’ ??
• Inconsistency and variation across operational teams/sectors still evident
• Monitoring not built into quality assurance processes – no front line to Board
quality monitoring
• Duplicate plans across corporate teams
• Inability to easily access data and information- when did it start going wrong?
• No QI methodology, limited QI capacity and capability
• Variation in capacity and capability across directorates – new executive team
focus on re-structures
• Systems and processes not ‘business as usual’ – focused delivery for
inspection
London Ambulance Service NHS Trust 14
Our Approach 2017-18 contd….
London Ambulance Service NHS Trust
• Reviewed all of the current Trust action plans and completed a gap analysis against the newly defined KLOE’s
• Compiled a single plan for the Trust, combining all quality deliverables aligned within the 2017/18 Business
Plan, Well Led analysis and CQC Action Plan into one Quality Improvement Plan
• This new Improvement Plan incorporated both impact and progression KPIs, all within a clear reporting
framework via the newly created Programme Board
• Introduced Agile and Burn Down improvement techniques- increased focus and pace of change to enable to
‘get to good’
• Also developed a framework to ensure the Trust was prepared and ready for the next CQC
inspection – PMO funding 250k from NHSI
• In addition to the re-structuring and systems and process changes, we ensured that the Trust
had sustainable quality improvement, assurance mechanisms and corporate and clinical
governance
• Leadership development high priority
Ethos of ‘business as usual’ and sustainability
Quality Assurance Visits• Purpose is to enable stations to test if they meet the Key Lines of Enquiry (KLOE) set out by the
CQC
• Carried out every quarter and included:
• An observational review of premises and facilities
• A review of key evidence
• A discussion with staff
• The visits were planned to be a regular ‘business as usual’ activity
• All evidence uploaded to Health Assure
• All monitoring of progress ( alongside other performance indicators0 as part of newly developed
quality assurance framework
– Clinical governance framework review
- Frontline to Board reporting and Performance Management
- Implement Health Assure – monitor variation and compliance
ALL STAFF INVOLVED IN PEER REVIEW PROCESS
London Ambulance Service NHS Trust 16
Risk Management Programme 2017 / 2018 - HealthAssure
140 colleagues trained to date – additional training
dates to be released
Floor walking, champion training and support for staff
Online CQC reporting, self-assessment and evidence gathering software to
provide assurance against the fundamental standards, Key Lines of Enquiry and
clinical review tools.
Launch date 26 January 2018 following a 4 week window for linking of evidence
and actions to the CQC Domains and Key Lines Of Enquiry
New X drive location for policy links
Additional documentation and pointers for KLOEs and
is applicable to LAS will be configured
New CAS module to support with the management and
dissemination of the Department of Health’s
Central Alerts to key stakeholders across the Trust
London Ambulance Service NHS Trust 17
Integrated Assurance Dashboard
1
8
Reporting views – supported by Audit Apps and automatic downloads to system
Risk Management Programme 2017 / 2018 – Incidents
You said - we did, user
feedback and engagement
sessions on system design,
configuration process and
workflow
Feedback email functionality
is now built into the incident workflow
Revamped incident classification and
mapped to the NRLS - continue to reflect
LAS incidents
Developing an e-learning
induction training package
for all staff on incident reporting
and manager investigations
London Ambulance Service NHS Trust 19
Weekly overdue incidents and
unapproved risks report Integrating Datix
shared with senior managers - with Tranman to
resulting in a continued overall streamline the processing
reduction of overdue incidents of vehicle accidents /
damage
Duty of Candour
stage 1 now appears
on the reporting form
Removed all existing paper incident forms
Introduction of a Quality Checking process for all
incidents to review the data quality and NRLS
requirements
Risk Management Programme 2017 / 2018 - Risks
London Ambulance Service NHS Trust 20
Redesign and Reconfiguration of Risk Register
in line with risk management ‘best practice’
Introduction of a ‘back to basics’ Risk Awareness
course for all risk owners, risk leads
and risk coordinators New Datix Risk system
training on the revised escalation
process
Developing a ‘tool kit’ - easy to use for risk staff
Developing risk e-learning packages for training
Training materials ready for relaunch
‘station to board’ and vice versa
New Datix Risk system training on the revised
escalation process ‘station to board’ and vice versa
London Ambulance Service NHS Trust 21
Overview of Agile Process:
Ensuring we ‘Get to Good’
Overview of Agile Process and roles
•Sprint
retrospective• Sprint
Review
AGILE BURN
DOWN
PROCESSScrum
master
Team
members
StakeholdersUsers
Product
ownerROLES
• Increment
• Sprint
Planning
Meeting
• Update
Product
Backlog
• Daily Cycle
PREPARATION
• Agreement of what
• Vision and
expectations
• InitialProduct
Backlog
• Initial ReleasePlan
• Stakeholder buy-in
• Define & assemble
Team
Our focus on what we
are going to do before
mid-December
London Ambulance Service NHS Trust
Agile Burn Down Chart illustration only
• Task/time tracked daily/weekly
Burndown against
agreed targets
• Managed via daily stand ups
• Retrospective reviews ensure quality
• Over 130 actions completed
within 3 month time period
• Evidence of completion and
on-going monitoring within
governance processes
Variations
0
Pro
du
ct
Bac
klo
g
(nu
mb
ers
)123 Secure storage of COSHH products 185
No FGM or Prevent Policy 119
Overfilled drug cupboards 88
Overfilled drug fridges 107
Out of date drugs 212
Doctors unware of how to access
Pharmacy OOHs 83
No controlled drug destruction kit on
POCU 216
No ward controlled drug stock list 29
Pharmacy Risk Register 2
7
Week
Name badges for all staff 209 Update Team of the
Month board 202
Derm OPD Concordia staff uniform
compliance 37
Excess Zopliclone 79
Dress Code compliance including nail
varnish 211
Out of date ward stock lists 214
1 2 6
Missing ceiling tiles Surgical OPD 217
Minors Area ED broken cupboard 43
Limited use of up to
date student induction
pack 112
Limitedfeedback to staff
about incidents 6
Out of date BNFs 11
Emergency Drug Cupboard medication
not removed 118
No summary of #NOF pathway 93
Unlocked cleaners cupboards 213
No up to date local IV injectables guide on
ward 13
Ice machine in ED
plaster room missing
label 'not for human
consumption 47
Gaps in wardsafety
checklists 59
3 4 5
Limiteduseof lone
worker devices in
Chaplaincy 131
No chaplaincy leaflet in
circulation 158
Expiry date of 02
cylinders not on
ResuscitationTrolley
checklist 23
Gaps in staff knowledge
about whistleblowing processes 164
Radios on at nighton
wards 215
Entrances to wardsnot
always secure 91
9
Not all areaschallenge
visitors on ID and
reason for visit 177
Support to prepare
EOLCLead forCQC
218
ET tubes removed
from packaging and
pre-cut in DSU 74
Safeguarding/DoLs/
MCA - understanding
and documentation
compliance 20
Gundulph: trailing
cables at nurses
station 318
Variable clinicalskill
levels of junior
Bullyingculture
reported 63
delays 154
Gaps inDNACPR forms including
documenting discussions 54
Bullybehaviour
reported 40
42
acceptingreturns
127
Unsecuredpatient
notes 75
Gundulph:cracked
tiles and sinkby
Compliance of Health & Social CareAct
Unsafe Medical staff
numbers due togaps
and sickness 1
Complaints backlog
(Must Do ShouldDo)
30
of Dutyof Candour
and documentation 18
Review dosageon
End of Life Care
Algorithm 28
Limitedinvolvementof
Spiritual Care inEndof Life Care plans 157 doctors 31
Out of date workplace Gaps in EoLC training(ward) risk assessments for staff 36
Liverpool Care
Pathwayleafletson
ward 68
Limited Mortuary
capacity and flow 44
Limited knowledge about Medical staffing at
incidents, themes and night 51trends 22
Secure IV fluid storage 70 Variable pharmacy
support to wards 106
3 Gaps in EOLC care plans
No Help Alarm inED
waiting room 110
Congested theatre
flow delaying#NOF
cases 146
Staff reportingstaffing
levels worse 73
DeterioratingPatient
not featured in Site
Meetings 25
Variable use ofgloves
and gowns 76
Community Midwifery
folder missing PGDs
45
Staff reporting1:13
staff ratios 15
Empty/Missinghand
gels 333
Staff understanding of
escalation pathway to
CriticalCare
OutreachTeam 162
CompletionofNEWS
Scores 192
RecordingofNEW S
scores escalation
actions 189
Medical Outliers on
T&O not covered by medical consultant 39
Gaps in Sepsis
boxes checks 50
Limited visibility of
senior nurses 72
Unlabelled sedation Out of Hours x-ray
delayingED &
Theatre 117
Variablecompliance
with Stat & Mand
training 33
Leaking air-conin O2 prescribing 61
Imagingdepartmentnursing station 328 116
57
Broken blinds in
clinical areas 346
handover
environment 49
Review IP&C
Governance
arrangementsWard
to Board 19
Side room door not
closed when patient
in isolation 99
Allergies not
recorded ondrug
charts 400
Unsafe storageof Missing weightsonmedical gas cylinders drug charts 34
Drug chart legibility
401
Pharmacy reviewof drug charts and
medicines reconciliation 95
CD cupboardnot
large enough -
Phoenix 125
Not all wards
receiving daily
pharmacy visit 342
Poorprescribing
practice 130
Poorly writtendrug
charts 58
Consent - staff
understandingof who
can take it and
supporting
documentation 48
Variableappraisal
rates 27
Excess midazolam on
Milton 208
Storage of IV dilutents 64 Mislabelled drugs
patients ownas stock1Li6m1ited sharing of
learning from incidents 14
Review and replace
CD drug books 46
Omitted drug doses
not followed up 53
Out of dateward
stock list 38
Drugs out of original
packaging 35
Out of date PAT testing 10
Blocked fire exit ED 12
ED fire exit open due to
department temperature
121
Mental health pathway Out of Hoursaccesstomanagement
support 60
Frequency of medical Noisy doctorreviews of medcial
outliers 24
POCU brokendrug
door hinge 65
Staff awarenessof Staff discouragedtodepartmental risks ED develop
professionally 77
Limited evidence of
MCAdocumentation
103
ED sluicecupboard
door broken 321
No medical EoLClead
69
No CO2 monitoring on Pharmacy notLMA airways 32
Limited use of
safeguarding
processes tosupport
staff on the front line
55
Structure and content
of site meetings 71
Dischargedelaysfor
#NOF patients 137
Drugs stored incars
overnight 201
Staff reporting
dangerous staffing
levels 5
Magpie - unsecured
emergency drugs
storage 80
High temperaturesin
Clinic Rooms 8
Variable understanding Areas of highstress/low morale 56 drugs in syringes 7 coverlimited,
Poor patient flowED
16
London Ambulance Service NHS Trust
2017-18 CQC ratings: Good and
removal from special measures
London Ambulance Service NHS Trust 24
The Road to Outstanding:
Embedding and sustaining
change, reducing variation
London Ambulance Service NHS Trust 25
LAS Quality Road to
Outstanding
To make the journey from Good to Outstanding we will:
• Continue to accept the challenge at Executive level and across the Trust
• Prioritise our activity and allocated resources to achievement based on revised gap analysis
• Manage delivery dependencies effectively• Fully deliver the Quality Improvement Plan – One Plan• Deliver on the Trust Strategy and Transformation Programmes which
support the journey to Outstanding• Embed QI build capacity and capability• Continue to develop quality assurance processes• Leadership development, cultural change focus – staff survey
champions
• Quarterly Staff Surveys….!!!
QI capability model for LAS – by staff group and role
Total
potential5,000 • Introduction to improvement
& model for improvement
• Identifying issues,
developing & testing ideas
• Measurement & variation
Knowledge/skills needed
1. Front line
staff2. Clinical &
operational
leaders
3. Coaches*
4. Exec &
Board
Eventual
coverage
needed100% • Introductory e-learning
sessions (incl. at induction)
• Online/self-accessed
What’s involved
400 • Deeper understanding of
improvement methods,
variation and measurement
• Goal-setting, leading and
managing for improvement
100
n/a • As above, plus
sophisticated enabling and
coaching skills for
individuals and teams
50 • Applied learning and
reflection in coaching teams
supported by classroom
programme3 • Direction-setting, “mood” &
leading for improvement
• Link to strategy and overall
priorities; appreciation of
systems; making variation
and trends visible
• Self-determined but
typically includes: mix of
individual/group; sessions
with external experts; peer
visits/”Board-to-Station”;
quality assurance visits”n/a • Deep Dive methodology
incl. of QI theory and
science
• Spread and implementation
• Coaching/mentoring,
teaching
• Knowledge-generation and
At least
50
• Careful objective-setting,
review and planned (career)
development
• Applied learning through
doing/coaching
• Reflection and peer support
• “Masterclasses”
* Coaches drawn from wide variety of professions and grades
• Applied learning in teams over
time linked to opportunities in
real work
• Access to coaching
• Embedding into existing
programmes
Two key aims:
1. To accelerate delivery of the
highest quality, best value care, and best
staff experience across LAS by 2020
2. To embed continuous
improvement into daily operations at LAS and to ensure
best support to services across LAS
Build will
Create alignment and deploy
infrastructure
Apply, monitor assure
1. Listen to staff and patients to determine priorities2. Develop and tell our quality/QI narrative3. Celebrate successes, showcasing existing work4. Hold learning and awareness events5. Visits to exemplar sites6. Set up QI microsite (intranet and internet)7. Develop a network of Quality Champions
1. Have patient/carer involvement in all improvement work2. Align service strategies, objectives, expectations and reporting with improvement
aims; also align key trust initiatives, e.g., Quality Account, Clin Quality indicators, 3. Align individual goals/time with improvement aims (job plans, appraisal, prof.
development, revalidation)4. Develop informatics & analytics to support improvement
Through two main tracks – with rigorous measurement of quality and efficiency/quality assurance framework1. Major trust initiatives, incl: Patient and staff /volunteers involvement
programme; Strategy LAS Vision2020: QIP, service/pathway redesign 2. Local priorities: Each sector/station to work to a local QI objective
Build improvement capability and
capacity
1. Initial assessment of current capability, gaps & priorities2. Recruit core QI team & establish internal secondments3. Find and train experts4. Build capability & capacity in different intensities & formats
a. Introductory trainingb. In-depth longitudinal/applied training for teamsc. Develop coaches to support teams & initiatives
5. Executive and Board development6. Embed in professional and leadership education
Outline plan
LAS Quality Road to
Outstanding
We will also need to continue to ensure:
• Systems & Processes are developed to fit recognised best practice
• Culture, specifically, attitudes and behaviours are developed to support outstanding quality performance
• Trust performance in its Use of Resources will have to be upper decile with no drop off in quality or patient care and experience
• Makes use of digital technology and systems to ensure leading edge and innovative and patient focussed
• Continue to embed ‘business as usual practices’ with on-going and continuous monitoring using measurement for improvement statistical techniques
Conclusion:• Need to ensure you are getting feedback regularly from your staff
and act on it…
• Communication strategies that work…
• Use different approaches to focus on high risk issues and those that
ensure rapid improvement
• Build approaches to engage with staff
• ‘Sell’ governance and assurance
• Leadership stability and development are critical
• Maintain the momentum
• Requires relentless focus, pace and hard work!!
London Ambulance Service NHS Trust 30
Breakout session 3 • Procurement’s lean methodology journey (Bishopsgate 2)
• Transforming organisational culture in patient safety (London Wall)
• Beyond patient experience – rhetoric into reality (Bishopsgate 1)
• Creating a culture of continuous improvement to deliver high quality care
(Broadgate 1)
• Embedding quality improvement – the role of QI academies, leadership, governance
and values (Broadgate 2)