REPORT SUMMARY SHEET Meeting: Date:

Trust Board 28

th September 2017

Title:

Executive Director of Nursing Report

Lead Director: Mrs Angela McVeigh, Executive Director of Nursing / Director of OPPC

Corporate Objective: Safe, high quality care

Purpose:

Assurance

Summary of Key Issues for Trust Board

High level context:

Background to the development of Trust Nursing Quality Indicator Framework

Data on the first audit cycle of the revised Nursing Quality Indicator Framework (Based on research findings attached)

Key issues/risks for discussion:

Trustwide Nursing Quality Indicator Quality Improvement Plan

Executive Director of Nursing NQI Report Structure

Summary of SMT challenge/discussion:

Management of NQI Spread Plan to Implement NQI to all areas of Nursing

Challenges with measuring uni-professional quality within integrated teams

Incorporation of co-design approach

Intergration of Regional Nursing KPI requirements within NQI Framework

Internal/External Engagement:

Senior Management Team

Directorate Lead Nurses

Nursing Governance Coordinators

Nursing Quality Indicator Steering Group

Public and Patient Involvement

Public Health Agency

Chief Nursing Officer

.

Table of Contents Page

Introduction – Background to the NQI Framework 2

NQI Audit Report – Quarter 1 207/18 (April – June) 5

NQI Quality Improvement Plan 11

Appendix 1 (Attached)

1

.

1. Introduction

1.1 Background to the NQI Framework

Nursing Quality Indicators (NQIs), also known as nursing metrics, are used worldwide to monitor

compliance with nursing care processes, impact on patient safety and the quality of nursing care.

They provide quality improvement tools that enable comparisons on care quality across

organisations. UK drivers include Darzi’s focus on safety, effectiveness and compassion in nursing

care and the Francis Report which called for comparable data on nursing outcomes.

In 2011 the Trust developed a range of Nursing Quality Indicators aimed at measuring compliance

with nursing care processes. Each operational directorate developed indicators relevant to their

care setting which are reported annually to Trust Board.

Following a period to test and review the 2011 framework the EDN took the decision to streamline

the Trust Nursing audit plan into a single NQI structure that could be linked to existing internal and

external audit reporting.

In 2014 the Executive Director of Nursing (EDN) commissioned research which aimed to identify

additional elements which should be included in measuring the quality of nursing care. The

research findings proposed a framework which included measuring the quality of a patient’s

journey across four domains:

• Nursing Care Processes

• Patient Outcomes

• Patient Experience

• Nurse’s Knowledge of Care Needs

(See Appendix 1 for copy of article published in International Journal of Healthcare Quality

Assurance).

1.2 Report Content

This report provides an update on the implementation of the Nursing Quality Indicator (NQI)

Framework within acute and non-acute in-patient wards supported by data showing documentation

compliance figures and patient and staff feedback. Work is ongoing to integrate a range of patient

outcome data into the NQI reporting framework for future assurance reporting.

2

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1.3 NQI Framework Structure

The NQI Framework Structure combines process, outcome, patient experience and nurses’

knowledge indicators as applied to individual patient journey. The Framework Domains are set out

below:

Domain 1

Safe and Effective Process Indicators

(Documentation domain)

The elements of this domain are aligned to the

areas included in the regional nursing key

performance indicators and regional patient

safety Quality Improvement Programme.

Compliance is assessed through nursing

documentation.

National Early Warning Scoring (NEWS)

Falls

Pressure Ulcers

Nutrition

Omitted medicines

Domain 2

Safe and Effective Outcome Indicators

(Documentation domain)

Core outcome NQIs selected were linked to the

process NQIs and based on the premise that there is

a relationship between processes and outcomes.

Cardiac arrest rate

Fall with an injury

Pressure Ulcer grade 2 and above

Unintentional weight loss

Additional monitoring or treatment as a result of

omission of a critical medicine

Incorporation of Domain 2 in reporting is under

development

Domain 3

Patient Experience

Failure to listen to patients’ and relatives’

experiences has been implicated in investigations

as a key factor in failing hospitals (Francis, 2013).

Questions are linked to

The patient client standards

Fundamentals of nursing care

The Patients views on what aspects of

nursing care are good, could be better

and how the ward could be improved.

Domain 4

Nurse’s Knowledge of patient needs

The nurse responsible for the patient’s care should be

able to articulate the nursing care required to meet the

patient’s needs.

The purpose is to ascertain if the nurse is

knowledgeable about their patient, the fundamentals

of nursing care for their patient and discharge

planning arrangements.

Questions are linked to

What nurses do like / dislike about the ward

What would make the ward better

The improvements nurses would most like to

see in the ward.

Further development of Domain 4 is ongoing to quantify

the quality of nursing knowledge within the framework

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1.3 NQI Audit Cycle

The NQI audit cycle is a 3 monthly cycle which audits five randomly selected patient journeys on

each inpatient ward. Each audit is undertaken by the Lead Nurse for the area using an electronic

audit tool which remains under development.

The first test of this approach took place across the 25 inpatient acute and non-acute wards

between 1st January and 31st March 2017 with a ‘live’ audit conducted 1st April to 30th June (results

included in this report).

1.3 Quality Improvement Approach

Following each audit the lead nurse and ward manager produce a Local Ward Quality

Improvement Plan which considers areas of good practice, areas for improvement and areas for

immediate action which are reviewed every three months. This plan is led by the lead nurses and

progress on implementation is monitored and overseen through existing operational and

professional governance arrangements. Any immediate patient safety issues highlighted through

the NQI audit process will be managed within the operational governance structures.

A Trustwide NQI Quality Improvement Plan informed by trends and findings from local audits is

developed which will be used to inform Quality Improvement activities and priorities through

existing Trust integrated governance and quality improvement arrangements.

1.3 NQI Framework – Areas for Improvement and Development

The NQI Steering group are presently considering the following to improve domain content and

design:

Patient Client Experience – Further development of Patient Client Experience Questions

to strengthen links to Person Centred Care Planning, Patient Client Experience Steering

Group Workplan and Patient / Nurse communication

Patient Outcomes – Patient Outcomes links to the Trust Quality Indicator Dashboard

Nurse Knowledge – Further development of Nursing Knowledge domain to capture cultural

and behavioural nursing practices

Management of NQI Spread Plan – Implementation of NQI to all areas of Nursing

Measuring Uni-Professional Quality - Challenges with within integrated teams

Incorporation of co-design approach – Consideration of co-design approach in future NQI design

4

2. NQI Audit Report – Quarter 1 207/18 (April – June)

Domain 1 – Nursing Documentation through NQI framework

NEW

S El

em

en

ts (

12

2

Ch

arts

Au

dit

ed

) Vital Signs

NEWS score

correct

Frequency of observations recorded on

chart

Frequency correct

Observations recorded to frequency prescribed

Respiratory Rate

SpO2 Inspired

O2 Temperature

Blood Pressure

Heart Rate

AVPU

89% 91% 94% 79% 89% 89% 93% 95% 92% 93% 75%

Falls

A E

lem

en

ts

(12

2 C

har

ts

Au

dit

ed

)

Asked about

history of falls in the

last 12 months

Asked about fear of falling

Urinalysis performed

Call bell in sight

and reach

Safe footwear on feet

Personal items in

reach

Free from

Slip or trip

hazards

95% 97% 83% 98% 100% 100% 100%

Falls

B

Ele

me

nts

(9

0

Ch

arts

A

ud

ite

d) Cognitive

Screening

Bed rails assessment completed

Lying and standing Blood

Pressure recorded

84% 99% 44%

Trust Level Action: Local Quality Improvement Plans have been

put in place to address this non-compliance. The EDN and

Medical Director have approved the development of an Early

Warning Subgroup to review the Trust’s use of Early Warning

Scores. This area has been highlighted recently via a coroner’s

inquest.

Trust Level Action: NQI Working Group (Lead Nurses) have considered the Royal College

of Physicians approach to the correct method of taking lying and standing Blood

Pressure and are developing guidance for Nursing staff. This work will be shared both

internally in the Trust and with the regional Falls steering group for consideration for

regional implementation.

5

Elements that are recorded as amber are being

addressed via ward level NQI Quality

Improvement Plans

.

Pre

ssu

re U

lce

r El

em

en

ts

(36

Ch

arts

Au

dit

ed

) Mattress

type recorded

Equipment fit for

purpose

Skin inspected

Changes reported

Toileting assistance

offered

Continence products

used

Kept clean and

dried

Nutrition tool

applied

Fluid balance

Food chart

updated

Assistance given with eating and

drinking

100% 83% 100% 94% 100% 83% 94% 86% 94% 78% 86%

Om

itte

d M

ed

icin

es

-

Nu

mb

er

of

do

ses

pre

scri

be

d (

19

91

do

ses)

Number of ‘Blank’ doses within

previous 24 hour period

Number of ‘Blank’ doses that were critical

medicines

Number of Medicine Kardex with reason for

omitting medicine dose(s) recorded

23 (1.1%) 6 (0.3%) 103 (85%)

Nu

trit

ion

Ele

me

nts

(7

0

Ch

arts

Au

dit

ed

)

Was MUST Tool completed within

6 hours of admission

90%

6

.

Domain 3 – Patient Experience captured through NQI framework

As part of the Nursing Quality Indicator processes the following questions are poised to patients:

What has been your experience of the nursing care you have received?

What aspects of nursing care were good?

What aspects of nursing care could be better?

How could the ward be improved?

The table below sets out the responses to the above questions and indicates areas highlighted by patients to inform improvement plans

What has been your experience of the nursing care you have received?

What aspects of nursing care were good?

[Name] is fantastic very caring knows patients very well, this is filtered down through all staff

All staff too many to name.

Pt is urology therefore not on correct ward but has no complaints

"well looked after" great staff

Excellent care no complaints

The attention given to patients nothing is ever a problem nurses go out their way to help

The dedication nurses show to their job very good care and attention given to me great team very professional

Excellent care staff should be paid more

Areas identified by patients for improvement

None

Comments requiring immediate action

None

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.

What Aspects Could Be Better?

What aspects of nursing care were good?

The attention the nurses and staff give us all

Kindness, professionalism making everyone feel calm and listened too, explaining all aspects of care,

treatment and recovery very well.

All

Overall an excellent ward well managed with helpful,

Knowledgeable staff nurses always make time for you and all my medications etc are always given on

time, I have been on many wards and this is the best by a mile.

All of it very careful and caring

Nurses and support staff are fantastic even doing make up which is very important for my granny, this

meant a lot to her. Making me comfortable and giving me pain relief promptly

Good at calming me when I panic they are very compassionate and calming

Areas identified by patients for improvement

Friendly staff try their best even when they have not enough staff

Busy

I feel at times the nurses are overworked with trying to care for so many patients at once and could do with more help it is good as it is but maybe less bed moving if possible

have windows that can be opened

More fans for patients as it gets too warm

could sometimes answer bells quickly but they are so, so busy

staff have difficulty answering call bell at times as they are so busy

sometimes staff are so busy they cannot come straight away to help me to the toilet

would like to get to the toilet as soon as I need to

Comments requiring immediate action

None

8

.

What aspects of nursing care could be better?

What aspects of nursing care were good?

As a patient I could not be anything else only pleased about every aspect of the care none in my

opinion, thank you so much for all your professional care and attention n/a i have had no negative

experience during of my treatment to date

It could not be better

Areas identified by patients for improvement

Air Con in building

The only issue is that I do not like the unisex toilets

Beds/ Area for family when patient is very ill, it is like a waiting room

more staff so nurses could have more time to spend with these patients

More Fans

Longer visiting hours

TV

staff are always busy and run off their feet

More help

Likes breakfast earlier and gets it at time he likes

*ALL ISSUES ARE NOTED FOR CONSIDERATION ON LOCAL NQI QIP

Comments requiring immediate action.

Family had appt with consultant and he didn't come.. not happy One of the staff was very inconsiderate I was in a lot of pain, she didn’t seem to care it was

very stressful on me I wouldn’t remember her name she seemed to be with an older one. I hope if she is not a nurse that she never becomes one

*BOTH ISSUES ADDRESSED IMMEDIATELY BY LEAD NURSE UNDERTAKING AUDIT

9

.

Domain 4 – Staff Experience captured through NQI framework

Nursing staff were who were caring for patients who were included in this audit were asked the following questions (total 68

responses)

What improvements would you like to see on your ward?

What could change to make your ward better?

The following trends were identified and have been incorporated into the Trust NQI Quality Improvement Plan (Section 3)

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3. Trust NQI Quality Improvement Plan

Area/Trend Position Current Status Date for Completion

Nursing Staff Feedback - Nurse Staffing Levels

On Corporate Risk Register and control measures are in place, for example:

1. Escalation processes are in place within each Directorate to respond to immediate Registered Nurse shortages

2. Well established Nurse Bank in place for open registration

3. International recruitment plan 4. Open recruitment campaigns 5. There are mechanisms in place

regionally to maximize approaches and resources in relation to local recruitment.

6. The Trust has in place an ‘open advertisement’ for Band 5 Adult Nurses

7. Nurse recruitment is a regional and national issue at present. Further correlation through the NQI data is required to determine the effect of the above on nursing quality and staff wellbeing.

Continue Communication to Nursing Staff on the Trusts response to Regional and National Nursing Workforce issues

Further develop the NQI framework capability to correlate the impact of staffing levels on nursing quality and staff wellbeing.

Ongoing

11

.

Nursing Staff Feedback – Need to improve communication pathways within nursing teams and with clinical colleagues

‘Timeout for Teams’ has been endorsed by the Trusts Senior Management Team

The Trust has facilitated a number of leadership programmes which incorporate methods to improve communication

Quality Improvements to communication within patient flow have implemented.

Communication is the corporate quality improvement priority (2017/18). A number of Quality Improvement projects have been completed which focused on improving communication.

Lead Nurse local improvement plans in place to work with ward sisters and staff nurses to improve the flow of communication to staff

The Trust are implementing a number of Always Events focusing on improving communication between patients and staff

Ongoing

Nursing Staff Feedback – Need for more dementia / delirium training

A programme of training for dementia and delirium is in place

Training needs analysis to be undertaken to assess nursing training needs in this area of practice.

June 2018

Nursing Documentation - Observations recorded to frequency prescribed

Local Quality Improvement Plans have been put in place to address this non-compliance.

The EDN and Medical Director have approved the development of an Early Warning Subgroup to review the Trust’s use of Early Warning Scores. This area has been highlighted recently via a coroner’s inquest.

April 2018

Nursing Documentation - Lying and standing Blood Pressure recorded

NQI Working Group (Lead Nurses) have considering the Royal College of Physicians approach to the correct method of taking lying and standing Blood Pressure and developing guidance for Nursing staff.

Guidance will be shared both internally in the Trust and with the regional falls steering group for consideration for regional implementation.

September 2018

12