Priority Two: Reducing Harm from Pressure Damage Executive Lead: Director of Nursing Milestones/ Where will the Key Objective Suggested Outcome measures Comments / Next Steps Trajectory data be collected To reduce the number of Reduction by 25% of Grade 2 Further education of staff in the Safety By March Grade 2- 4 hospital hospital acquired pressure injury prevention and identification of thermometer 2019 a acquired pressure injury. pressure injury. data. reduction of Grade 3 50% reduction – 25% Grade 2, Grade 4 100% reduction. – Work across BNSSG community Datix validated 50% Grade 3 on improvement in identification pressure injury. and 100% Days since last pressure injury and care in order to prevent Grade 4 from per ward (Grade 2,3,4 ). further deterioration of injury Monthly 2017/2018. when admitted to hospital. reporting by ward. Increase staff Directorate Level SWARM (a Improvement in accuracy of Completion of By December knowledge and rapid review of an incident reporting and a Reduction in SWARM stickers 2018 responsiveness to immediately post identification) number of pressure ulcers in patient notes improvement pressure injury. for all Grade 2. occurring. Completed 72 in accuracy of hour reports validated Executive Level SWARM Sharing of root cause analysis confirming pressure completed every Grade 3 or 4. and action plans. SWARM Grade damage. – 3/ 4. Multi professional involvement, increased visibility at the bedside Audit through All wards by Senior Nurses and Tissue Perfect ward. completing Viability Nurse. monthly audits Action Points by March Increase in resource for Tissue discussed at 2019. Viability Service required. Ward Sisters meeting named Ward Wednesday.
Priority Two: Reducing Harm from Pressure Damage Executive Lead: Director of Nursing Key Objective Suggested Outcome measures Comments / Next Steps Where will the data be collected Milestones/ Trajectory To reduce the number of Grade 2- 4 hospital acquired pressure injury. Reduction by 25% of Grade 2 hospital acquired pressure injury Grade 3 – 50% reduction Grade 4 – 100% reduction. Days since last pressure injury per ward (Grade 2,3,4 ). Further education of staff in the prevention and identification of pressure injury. Work across BNSSG community on improvement in identification and care in order to prevent further deterioration of injury when admitted to hospital. Safety thermometer data. Datix validated pressure injury. Monthly reporting by ward. By March 2019 a reduction of 25% Grade 2, 50% Grade 3 and 100% Grade 4 from 2017/2018. Increase staff knowledge and responsiveness to pressure injury. Directorate Level SWARM (a rapid review of an incident immediately post identification) for all Grade 2. Executive Level SWARM completed – every Grade 3 or 4. Improvement in accuracy of reporting and a Reduction in number of pressure ulcers occurring. Sharing of root cause analysis and action plans. Multi professional involvement, increased visibility at the bedside by Senior Nurses and Tissue Viability Nurse. Increase in resource for Tissue Viability Service required. Completion of SWARM stickers in patient notes Completed 72 hour reports confirming SWARM Grade 3/ 4. Audit through Perfect ward. Action Points discussed at Ward Sisters meeting named Ward Wednesday. By December 2018 improvement in accuracy of validated pressure damage. All wards completing monthly audits by March 2019.
Quality%20Account%202017-2018%20v10.docx