Patient Safety and Quality Improvement
Swansea Bay University Health Board is placing quality and safety at the centre of its service. This publication illustrates how mortality and life expectancy are measured and scrutinised.
One of the key elements of our Quality Improvement programme is analysing and understanding all available information we have about people who die in our hospitals.
Over half of the deaths of people in our communities take place in hospital, mainly because many people who are at the end of their lives come into hospital during their final days.
Just over 3,000 people died in hospital in Swansea, Bridgend, Neath and Port Talbot in 2017, accounting for 51% of all deaths. In addition, 362 people died in our hospices. In total, 57.3% of deaths took place in ABMU hospitals or hospices.
However, we are aware that in some cases, people died in hospital when it may have been better for them and their families if they had been able to die at home, in familiar surroundings.
For this reason, we are supporting Care Pathways to be used at the end of life which enable more people to have the choice to die at home, if it is their wish.
Patient feedback is collected in 376 areas across Swansea Bay. Collection numbers can range from 850 to 1,000 per week.
The patient experience department records and reports the number of ward areas providing feedback from each of the four main hospital sites.
Each of the Service Delivery Units receives a monthly detailed report identifying the themes and develop action plans for improvement at SDU level.
The patient experience friends and family system had 4,141 responses overall during the month of March with 54 people declining to answer the extremely likely/likely question. 95% of people said they were extremely likely/likely to recommend the service to friends or family who need similar care or treatment.
The patient experience friends and family system had 7,150 responses overall during the months of April and May 2019 of which 63 people declined to answer the extremely likely/likely question. 96% of people said they were extremely likely/likely to recommend the service to friends or family who need similar care or treatment.
Also during March ABMU received 198 responses to the All Wales Patient Experience Survey. Communication is at 92%, Cleanliness 92%, Dignity 96%, Privacy 92% and Overall Satisfaction was 89%.
During April and May Swansea Bay received 283 responses to the All Wales Patient Experience Survey. Communication is at 97%, Cleanliness 91%, Dignity 97%, Privacy 97% and Overall Satisfaction was 87%.
Get up and Go campaign/End PJ paralysis
Morriston and the Princess of Wales hospitals have been proactive in encouraging patients to be as mobile and independent as possible while in hospital. Ten days of bed rest for an elderly patient can age their muscles by 10 years, leaving some unable to walk. To avoid this the two campaigns, Get Up and Go and End PJ Paralysis are aimed at encouraging patient to get out of bed, dress in their own clothes and keep moving, so they retain their mobility and are less likely to need to go into a care home after they leave hospital.
Don’t Be a Slipper Tripper
The health board recently ran a Don’t be a Slipper Tripper campaign to advise the public on the danger of buying lose or sloppy-fitting slippers, and how they can lead to falls. Last year more than 4,000 people aged over 75 were admitted to ABMU hospitals after having a fall, and loose slippers were the cause in some cases. Unfortunately, falls are the number one case of injury and injury-related deaths for older people.
The campaign was timed to fit in with Christmas shopping, and relatives buying slippers for elderly relatives as gifts. It gave advice about the right style of slipper to improve older people’s stability.
Patients Know Best
The provision of a patient portal is a key component of the National and Health Board Digital strategy and is an enabler for the delivery of a Healthier Wales, empowering patients with their own online patient controlled record, to support their health and well-being. PKB went live on 10th July 2018 initially in Princess of Wales Hospital and has now extended to Morriston, Singleton and Neath Port Talbot Hospitals.
Swansea Bay is the first Health Board in Wales to offer patients PKB, which currently allows patients access their pathology results. Development work is underway to send a copy of SBUHB clinic documents and appointment events to the patient’s PKB record.
SBUHB are now live in 12 services with 848 patients sign up across the Swansea Bay, including Princess of Wales hospital.
As well as having 24/7 access to their records, patients can now choose who they want to share the information with, and work much more closely and easily with clinicians to manage their future care as a team. Care plans can be created digitally with input from patients and clinicians, and videos and other media content to help patients better understand their condition and manage care are also available.
By making it simpler for patients to choose who can see their information, patients can easily share it with other agencies or healthcare professionals, smoothing the way for much easier cross-boundary or multi-agency care. They can also share the information with relatives and carers.
As an example of where benefits have been introduced through the introduction of PKB, the dermatology team in Singleton hospital are using PKB to work closely with the systemic patients who need regular blood monitoring. Each of these patients would normally come to hospital every 12 weeks for an outpatient appointment. With the introduction of PKB patients can be reviewed virtually without the need to attend a clinic appointment and will allow the team to free up 3 appointment slots per patient per year. These slots can be allocated to patients that need a face to face appointment.
Patient Safety Huddle
A new technology system is freeing up managers and clinicians at Morriston Hospital from hours of number crunching - allowing them to concentrate on safer patient care instead.
A big screen is at the heart of the new Patient Safety Huddle which gives an at-a-glance helicopter view of what’s going on in the very busy hospital. Key information about patient discharges, bed numbers, staffing, numbers of patients in department etc. are gathered onto an electronic dashboard, providing an instant snapshot.
The screen, in the hospital’s coordination centre, is updated every 15 minutes, so it keeps bed managers and others fully informed. It combines automatic feeds from other electronic products like the Welsh PAS and the ABMU Clinical Portal, with regular data inputted directly from wards and departments.
Before the new system arrived in October, this information was collated manually into a long document, and three meetings a day were held, with much of the meeting time spent just collecting this data.
Now just one daily 8.30am meeting – the Safety Huddle - is held, and with all the information in front of them, clinicians and managers can focus instead on what they need to do that day to provide the safest care.
Staff from additional services and departments within the hospital are now able to attend - promoting teamwork - and with fewer meetings people also have more time to get on with their jobs.
Clinicians and staff across the hospital feed data into the Safety Huddle system regularly, ensuring it is kept up to date. In return, they are no longer approached several times a day for figures, allowing them to care for patients without being disturbed.
We believe that all deaths, whether anticipated or not, that occur in hospitals should be reviewed so that we can be confident that the best possible care has been provided to our patients and ensure that where issues with care are identified we learn from these. We started using a 2-stage review process in 2010; currently the care of more than 90% of the patients who died in hospital is being reviewed across the Health Board, with some of our hospitals regularly achieving 100% for the first stage of the process. The questions that doctors answer in the first stage review are now the same across Wales (the Universal Mortality Review questions) so we can learn lessons from other organisations’ experience of undertaking these, as well as using our own reviews to help us improve. Each month between 15 and 20 first stage reviews indicate that in-depth review would help us to learn more and so these are reviewed by a consultant. We aim to get these in-depth reviews completed within 2 months of the patient’s death. We are working with other Health Boards and Trusts in Wales to standardise the consultant reviews, and adopt a single All Wales system to store and analyse the information that we get from mortality reviews. This will help us learn from the whole mortality review process together
Our completed in-depth (Consultant) mortality reviews continue to tell us that communication problems between teams and individuals, infections and falls are the main areas where we need to direct our improvement work. It is important to say that we have not shown that these things contributed directly to the patient’s death. There is already a lot of work going on in the health board to reduce falls in hospital and infections, both in the community and in hospital, so we are making sure that we are linking the mortality review findings with those projects. We are focussing on improving communication between teams and individual staff as part of our wider project to enable staff to recognise patients who need extra support, and ensure that senior staff are available quickly.
In addition, we also closely monitor and review other information such as infection rates, incidents, concerns and mortality data.
Review of Hospital Mortality Indicators
An independent review of hospital mortality indicators was undertaken by Professor Stephen Palmer, professor of epidemiology at Cardiff University, which examined whether risk-adjusted mortality, which is used in hospitals across Wales, is reliable and how it is being interpreted. The review found that mortality data can be misleading and does not provide an accurate measure of the quality of care.
Prof Palmer concluded that the current risk adjusted mortality index (RAMI) is not a meaningful measure of hospital quality. He believed the process of reviewing the medical records of all patients who died in hospital in a standardised way – a system pioneered in Wales – provided a better, more robust way of assessing safety and quality of care at a hospital. (Please see 'Mortality Reviews' section above)
A written statement published in July 2016 by The Welsh Government acknowledged the work undertaken by Prof Palmer and concluded that, following the implementation of a range of actions previously recommended in the Palmer review (2014), the publication of RAMI indicators was no longer required.
Whilst these indicators will no longer be published, the Health Board will continue to monitor and scrutinise all available mortality information on a regular basis to identify and investigate any unusual patterns or clusters which may be a cause for concern.