Appendix 3 Example to be completed in full following completion of implementation plans – – From…. ….To QUALITY MATTERS you all the for you First Time, Every ‘With way’ ‘Right Time’ 2014/15 2015/16 2016/17 Lower quartile in peer group Upper quartile in peer group for patient NCEPOD report for sepsis Post-1 hour sepsis Sepsis care bundle for patient safety incident safety incident reporting. expected August 2015 pathway to be Safety re-launched for reporting. implemented Sepsis care bundle adults. No patients suffering severe harm or implemented or children & Reasons for poor Patients have been caused death from a preventable fall. maternity patients patient safety incident severe harm or have died as Identify staff groups who reporting identified. a result of a fall over the last Continued learning & good performance are low incident reporters New governance 2 years. with health care acquired infections, & support improvements structure/practices medication errors & pressure ulcers. Weekly Patient Safety Strong performance in meeting Exec Lead infection prevention & No failure to rescues relating to sepsis. – control. Better than peers for pressure ulcer prevention. Mortality within expected Mortality consistently below expected Areas for length of stay Clinical Strategy ranges overall, with some range on all sites, for all specialties. reductions identified & Steering Group variation across services & plan implemented identified priorities & Effectiveness sites. Top 20% for all benchmarked clinical Implementation of plans data sets outcomes. for reduction in delayed Care bundles Good clinical outcomes discharges identified overall with some areas for Demonstrable improvements in chosen Baseline process & Implement NICE improvement. care bundles with no failure to rescues outcome measures for all workplace health relating to acute kidney injury. identified Care Bundles programme for ED at DMH to have 2 employees entrances Variable quality of dementia All identified clinical areas to be Develop & implement friendly environments across dementia friendly. Dementia Strategy the Trust. Include Dementia and End Experience Dementia aware, skilled & of Life Training in Trust No dementia strategy. knowledgeable staff contributing to a TNA & deliver training dementia friendly community. Recently signed up for the to initiative for Patients nearing the end of life to be ‘Right Decide’ End of Life care. End of Life consistently confident in our ability to care variable across the meet their preferences in relation to care Trust. & support provided. Variability in practice for Consistency in achieving nutrition & nutrition & hydration hydration standards. Our Values Working together for patients Respect & Dignity Compassion Commitment to Quality of Care Improving Lives Everybody Counts
Appendix 3 – Example – to be completed in full following completion of implementation plans From…. ‘With you all the way’ QUALITY MATTERS ….To ‘Right for you First Time, Every Time’ 2014/15 2015/16 2016/17 Lower quartile in peer group for patient safety incident reporting. Patients have been caused severe harm or have died as a result of a fall over the last 2 years. Strong performance in infection prevention & control. Better than peers for pressure ulcer prevention. Safety Sepsis care bundle re-launched for adults. Reasons for poor patient safety incident reporting identified. New governance structure/practices Weekly Patient Safety meeting – Exec Lead NCEPOD report for sepsis expected August 2015 Sepsis care bundle implemented or children & maternity patients Identify staff groups who are low incident reporters & support improvements Post-1 hour sepsis pathway to be implemented Upper quartile in peer group for patient safety incident reporting. No patients suffering severe harm or death from a preventable fall. Continued learning & good performance with health care acquired infections, medication errors & pressure ulcers. No failure to rescues relating to sepsis. Mortality within expected ranges overall, with some variation across services & sites. Good clinical outcomes overall with some areas for improvement. Effectiveness Clinical Strategy Steering Group identified priorities & data sets Care bundles identified Implement NICE workplace health programme for employees Areas for length of stay reductions identified & plan implemented Implementation of plans for reduction in delayed discharges Baseline process & outcome measures for all identified Care Bundles ED at DMH to have 2 entrances Mortality consistently below expected range on all sites, for all specialties. Top 20% for all benchmarked clinical outcomes. Demonstrable improvements in chosen care bundles with no failure to rescues relating to acute kidney injury. Variable quality of dementia friendly environments across the Trust. No dementia strategy. Recently signed up for the ‘Right to Decide’ initiative for End of Life care. End of Life care variable across the Trust. Variability in practice for nutrition & hydration Experience Develop & implement Dementia Strategy Include Dementia and End of Life Training in Trust TNA & deliver training All identified clinical areas to be dementia friendly. Dementia aware, skilled & knowledgeable staff contributing to a dementia friendly community. Patients nearing the end of life to be consistently confident in our ability to meet their preferences in relation to care & support provided. Consistency in achieving nutrition & hydration standards. Our Values Working together for patients Respect & Dignity Compassion Commitment to Quality of Care Improving Lives Everybody Counts