SIP Poster - Alison WEB.pdf
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The improvement of services, for the people we serve, is at the heart of professional practice. This is why we have designed a Master’s degree to include a focus on service improvement. The Service Improvement journey at BU is split into two Master’s degree level units: PSIP and SIP. PSIP stands for ‘Preparing for your Service Improvement Project’. Successful completion of PSIP is a pre-requisite for moving on to the SIP unit. It allows practitioners to develop a service improvement proposal over a period of about 5 months and is primarily about ‘THINKING’. SIP stands for ‘Service Improvement Project’ and is primarily about ‘DOING’ or implementing the proposal in practice. This poster is based on a SIP completed in 2014. The identified problem • DFT pre-assessment procedures were not effective in preparing patients appropriately (e.g. blood test monitoring) or identifying contraindications and potential complications. • There is little work in the literature regarding effective pre-assessment procedures for DFTs. • Redesigning the current integrated care pathway for DFTs was perceived as the solution. Aim • The overall aim of this project has been to improve patient safety and staff compliance with documentation by creating a new standardised care pathway for DFTs to identify contraindications, potential complications and subsequent actions. Methods: • All relevant staff were invited for their views on a draft of the new pathway before it was implemented. • A before and after questionnaire was developed using themes identified from the literature review to audit the new care pathway documentation. • After removing my documentation, I completed the audit and a colleague outside the team doubled- checked the reliability of my analysis. Service Improvement • The audit demonstrates considerable improvements in documenting contraindications and potential complications and all patients, after the new pathway had been implemented, had appropriate pre-assessment preparation. • Colleagues have found the new care pathway easy to use and no negative views have been voiced. • My team leader comments ‘this [project] has demonstrated a significant service improvement’. Critical Reflection • Further audit over time is required to determine the extent of initial project success. • Pre-assessment procedures should be reviewed for all patients undergoing any electrophysiology and device procedures to ensure wider patient safety. References Middleton, et al., 2005. Reviewing recommendations of root cause analyses. Australian Health Review, 31, 288-296. RCN (2010) Record keeping guidance. Available online from: http:// www.nmc.uk.org/Documents/NMC-Publications/NMC-Record-Keep- ing-Guidance.pdf [accessed 12.9.14]. Context and rationale • I am an Arrhythmia Nurse Specialist working in secondary care with patients who have abnormal heart rhythms. • Part of my role is to manage the list for and perform the Defibrillation Threshold Test (DFT). • DFTs involve inducing a life threatening heart rhythm under general anaesthetic and then returning the patient back to a normal rhythm. • The DFT process required urgent improvement after 2 adverse incidents that could have caused harm to patients. Communication, including the use of documentation, has been identified as contributing to approximately 50% of all adverse events for patients (Middleton et al. 2005; RCN 2010). For more information, please visit us at www.ncpqsw.com or phone 01202 964765 Supporting social work and health practitioners to improve services … one setting and one service provider at a time. Service Improvement Projects The National Centre for Post-Qualifying Social Work and Professional Practice (NCPQSWPP) Professional education at the National Centre for Post-Qualifying Social Work and Professional Practice is centred on a commitment, passion and dedication to develop healthcare and social work practice. We believe that by improving the quality of services through partnering with practitioners and employers across the health and social care arena we make a vital contribution to society in general and vulnerable people in particular. Over 10,000 practitioners have successfully undertaken our programmes since the year 2000 and we have won a total of 9 prestigious teaching awards during this time. Visit us at: www.ncpqsw.com The National Centre for Post-Qualifying Social Work and Professional Practice Patient safety: improving care pathways for the defibrillation threshold test Author: Alison Parish Royal Bournemouth and Christchurch Hospitals NHS Trust
Transcript of SIP Poster - Alison WEB.pdf
The improvement of services, for the people we serve, is at the heart of professional practice. This is why we have designed a Master’s degree to include a focus on service improvement.
The Service Improvement journey at BU is split into two Master’s degree level units: PSIP and SIP.
PSIP stands for ‘Preparing for your Service Improvement Project’. Successful completion of PSIP is a pre-requisite for moving on to the SIP unit. It allows practitioners to develop a service improvement proposal over a period of about 5 months and is primarily about ‘THINKING’.
SIP stands for ‘Service Improvement Project’ and is primarily about ‘DOING’ or implementing the proposal in practice. This poster is based on a SIP completed in 2014.
The identified problem• DFT pre-assessment procedures were not effective
in preparing patients appropriately (e.g. blood test monitoring) or identifying contraindications and potential complications.
• There is little work in the literature regarding effective pre-assessment procedures for DFTs.
• Redesigning the current integrated care pathway for DFTs was perceived as the solution.
Aim• The overall aim of this project has been to
improve patient safety and staff compliance with documentation by creating a new standardised care pathway for DFTs to identify contraindications, potential complications and subsequent actions.
Methods:• All relevant staff were invited for their views
on a draft of the new pathway before it was implemented.
• A before and after questionnaire was developed using themes identified from the literature review to audit the new care pathway documentation.
• After removing my documentation, I completed the audit and a colleague outside the team doubled-checked the reliability of my analysis.
Service Improvement• The audit demonstrates considerable
improvements in documenting contraindications and potential complications and all patients, after the new pathway had been implemented, had appropriate pre-assessment preparation.
• Colleagues have found the new care pathway easy to use and no negative views have been voiced.
• My team leader comments ‘this [project] has demonstrated a significant service improvement’.
Critical Reflection• Further audit over time is required to determine the
extent of initial project success. • Pre-assessment procedures should be reviewed for
all patients undergoing any electrophysiology and device procedures to ensure wider patient safety.
ReferencesMiddleton, et al., 2005. Reviewing recommendations of root cause analyses. Australian Health Review, 31, 288-296.
RCN (2010) Record keeping guidance. Available online from: http://www.nmc.uk.org/Documents/NMC-Publications/NMC-Record-Keep-ing-Guidance.pdf [accessed 12.9.14].
Context and rationale• I am an Arrhythmia Nurse Specialist working in secondary care with patients
who have abnormal heart rhythms.• Part of my role is to manage the list for and perform the Defibrillation
Threshold Test (DFT).• DFTs involve inducing a life threatening heart rhythm under general
anaesthetic and then returning the patient back to a normal rhythm.• The DFT process required urgent improvement after 2 adverse incidents that
could have caused harm to patients. Communication, including the use of documentation, has been identified as contributing to approximately 50% of all adverse events for patients (Middleton et al. 2005; RCN 2010).
For more information, please visit us at www.ncpqsw.com or phone 01202 964765
Supporting social work and health practitioners to improve services … one setting and one service provider at a time.
Service Improvement Projects
The National Centre for Post-Qualifying Social Work and Professional Practice (NCPQSWPP)
Professional education at the National Centre for Post-Qualifying Social Work and Professional Practice is centred on a commitment, passion and dedication to develop healthcare and social work practice.
We believe that by improving the quality of services through partnering with practitioners and employers across the health and social care arena we make a vital contribution to society in general and vulnerable people in particular.
Over 10,000 practitioners have successfully undertaken our programmes since the year 2000 and we have won a total of 9 prestigious teaching awards during this time.
Visit us at: www.ncpqsw.com
The National Centre for Post-Qualifying Social Work and Professional Practice
Patient safety: improving care pathways for the defibrillation threshold test
Author: Alison Parish
Royal Bournemouth and Christchurch Hospitals NHS Trust
