Fundamentals in health care: improving the patient's experience in hospital Professor Jean White Chief Nursing Officer

This presentation • • • • •

Welsh Government priorities Fundamentals of care Free to Lead, Free to Care Nutrition and hydration Dignity and compassion

New Government – New priorities • New manifesto - Programme for Government • New NHS vision - Together for Health • Focus is on delivery for the People of Wales • National Delivery Framework – dignity in care and quality of care are tier 1 priorities • Transparency now a key feature

Driving up standards • Patient safety agenda – 1000 Lives plus • Improving patient experience – Free to Lead, Free to Care initiatives; response to Older People’s Commissioner review • Healthcare Standards ‘Doing Well, Doing Better’ (2010) – Healthcare Inspectorate Wales reviews and spot-checks • Monitoring performance - move from targets to outcomes – will be supported by delivery plans • Retaining Community Health Councils in Wales – important role in speaking up for patients

The Values of NHS Wales • Putting quality and safety above all else: providing high value evidence based care for our patients at all times • Integrating improvement into everyday working and eliminating harm, variation and waste • Focusing on prevention, health improvement and inequality as key to sustainable development, wellness and well-being for future generations of the people of Wales • Working in true partnerships with partners and organisations and with our staff • Investing in our staff through training and development, enabling them to influence decisions and providing them with the tools, systems and environment to work safely and effectively

Where did the current work on patient experience begin?

Fundamentals of Care (2003) Guidance for health and social care http://wales.gov.uk/topics/health/publicat ions/health/guidance/care/?lang=en

The initiative grew out of: • Inconsistency of quality across service settings and areas. • Emphasis on service efficiency and cost, rather than quality of care. • Common themes in complaints and compliments. • Increasing expectations of service users. • Developing partnerships with service users and between organisations. • Lack of clarity for service users on what they should expect. • Increasing focus on regulation and performance. • Awareness of Essence of Care, Dept of Health, 2001.

FoC – 12 areas 1. Communication and information 2. Respecting people 3. Ensuring safety 4. Promoting independence 5. Relationships 6. Rest and sleep 7. Ensuring comfort, alleviating pain 8. Personal hygiene, appearance and foot care 9. Eating and drinking 10. Oral health and hygiene 11. Toilet needs 12. Preventing pressure sores

Free to Lead, Free to Care – Empowering Ward Sisters/ Charge Nurses • Programme arose out of clinical visits by Edwina Hart, the then Minister of Health & Social Services, in 2007. • Task & Finish Group began Nov 2007 • Report with 35 recommendations published June 2008 • Implementation group ran until March 2011. • Now replaced by a standing Board that oversees national programmes to improve patient care, reporting directly to the Chief Nursing Officer (http://wales.gov.uk/topics/health/ocmo/professionals/officec hiefnursing/cnopublictions/free/?lang=en )

Free to Lead, Free to Care – major changes • Development of FoC Audit Tool • Introduction of nurses and midwives national uniform • National nutrition and hydration care pathway, supported by posters and standardised charts • Cleanliness standards and training • National development programme for ward sisters/charge nurses – aspiring and in-post • More authority to act, eg visiting times, protected meal times

FoC Audit Tool • Electronic, ward based tool completed by ward sister/charge nurse • Can be completed in full or part as often as ward staff think necessary but must be done once fully each year • Includes opinions of patients and other users • Action plans can be generated locally • Reports go to Nurse Director – analysis goes to the organisation’s Board once a year • All organisations report to CNO annually – composite report published – this year it will be available to the public

Next steps – Care metrics & dashboard Enables nurses from “ward to board” to review the quality of care being delivered in their clinical area, organisation or across Wales – real time information. Data to populate the All Wales Nursing Dashboard will be captured through a new Care Metrics module, created within the Fundamentals of Care audit tool. Definitions are agreed nationally. This will mean that nurses can be sure the data they are collecting is standardised across Wales.

The Care Metrics module became available to early adopter (pilot) sites from 1st April 2011 and training is currently being delivered. Goes live April 2012.

Dashboard Indicators • WHO 5 Moments (Hand Hygiene) • Healthcare acquired pressure ulcers • Nutrition score completed and appropriate action taken • Complaints regarding nursing care • Compliance with nursing cleaning schedule • Percentage of nurses who have had an Appraisal and Personal Development Plan completed within the Previous 12 Months

Catering and nutrition • 2009 – All Wales Nutrition Pathway introduced to all wards in Wales – national food chart and fluid balance sheet, posters, requirement for assessment • Supported by Nutrition Awareness campaign run by RCN • 2010 – revised Healthcare Standards has specific standard (14) for nutrition and catering • Sept 2011 – e-learning tool for all nursing staff launched • Oct 2011 - All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients. They set nutrient and food based standards for meals, snacks and fluid. A group of dietitians and caterers has been established to develop a national database of nutritionally analysed menus and recipes that comply with the Standards.

Protected meal times • Protects time for patients from non urgent medical interventions – tests, consultant ward rounds, etc • Should not exclude patients’ relatives who want to assist the patient in eating and drinking at meal times.

So with all these standards and initiatives is there more work to do?

Recent Reports

Mid Staffordshire Trust failures Vale of Leven failures (C.difficle infection outbreak) „Dignified Care?‟ Older People‟s Commissioner‟s Report (2011) „The Lottery of Dignified Care‟ Patients‟ Association Report (2011)

Example: Dignity & Respect • Key priority for Welsh Government – monitored in monthly meetings • Audit & inspection - can go just so far • NHS Redress, action on complaints • Whistle-blowing • Action plans following audits and reports, such as Older People’s Commissioner review of care in hospital

What is at the root of poor care?

What holds us back? Is it… • Lack of knowledge and skills in workforce? • Limited resources? • Staff burnout? • Poor clinical leadership? Or… • Complacency? • Acceptance of poor practice – it’s just the way things are done around here? • Value base is wrong?

Free to Lead, Free to Care – current programme • Professionalism • Improving oral health and hygiene • Continence care • Expanding FoC audit tool • Further work on cleanliness standards • Reviewing documentation

Getting the user’s perspective • Wide range of local surveys used • HIW and CHC talk to users • New Household survey asks questions about care • Considering developing a national patient satisfaction survey We need to know what people think of services to help us improve them.

Questions?