Patient Safety Strategy 2016 – 2018

1 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

Contents 1.

Introduction................................................................................................................................ 3

2.

The Aim of this Strategy .......................................................................................................... 4

3.

The National Pursuit of Harm Free Care .............................................................................. 4

4.

Priority Areas for Action........................................................................................................... 5

5.

Responsibility for delivery of the Strategy .......................................................................... 20

6.

Monitoring ................................................................................................................................ 20

7.

Next Steps ............................................................................................................................... 20

8.

Summary ................................................................................................................................. 20

9.

References .............................................................................................................................. 20

2 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

1. Introduction Humber NHS Foundation Trust provides a range of community and in-patient mental health services, learning disability services, community services (including therapies), children's and addictions services to people living in Hull, the East Riding of Yorkshire and from April 1st 2016 Whitby, North Yorkshire. The Trust also provides specialist services for children including physiotherapy, speech and language therapy and support for children and young people and their families experiencing emotional or mental health difficulties. Patient safety is fundamental to the provision of high quality services. Our vision for 2016 – 2018 is to ensure that all our staff understand, collaborate, develop and share learning in relation to patient safety across the organization in conjunction with patients, carers and wider agencies and partners. Embedded within the Trust approach to patient safety is the requirement that every person working in Humber NHS Foundation Trust is aware of their responsibilities in relation to maximizing safeguarding for our patients, carers and families and takes appropriate action to maintain safety in our most vulnerable service users.. The Health Foundation1 have learnt over many years and studies that a number of systems in health care are not designed with safety in mind, meaning that it is only the skill and resilience of health care professionals that prevents many more episodes of harm. They note that many care processes are unreliable, which can mean that the right equipment isn’t available, or the wrong drug is given to a patient. They also learnt that many institutions don’t have a complete picture of safety, because they focus largely on past events rather than current or future risks. For instance, front-line teams consistently come up against big issues such as inadequate information technology, inconsistent staffing and challenging established cultures. Yet these issues are far beyond the scope of individual teams, and the scope of quality improvement methods alone, to address. This strategy recognises the need for the Trust as a whole to recognise and work together on our patient safety priorities. We know that by continuously seeking to improve safety and developing an organisational commitment to build on our safety skills and knowledge is costly; however we also recognise that in building the case to further develop safety skills and knowledge we can reduce costs through: • Recognising unreliable and unproductive systems that waste time where staff develop ‘work arounds` which may increase the risk of harm and contribute to a draining of energy and morale • Reducing litigation as unsafe care is expensive; the NHS litigation authority estimates that a cost of £1.4bn per year to be paid out in claims for patient harms1 (this cost does not include the emotional harm caused, costs of increased length of stay nor investigation fees and time used by individual organisations. Safety improvements can reduce costs alongside improving quality of care providing good safety methodology is utilised during project design and development 3 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

This strategy will link in with the Strategy for Clinical Audit & Effectiveness to develop, provide and audit the outcomes that provide assurance of clinical quality across all the services we provide. This will be achieved by ensuring we implement the right things, in the right way, at the right time; making sure our teams base their practice on the best available evidence. To deliver this strategy we know it is vital to involve those who use our services, as patients or carers and those who commission our services. We will align to the pledges made within the patient and carer experience strategy to ensure the voice of our patients and carers is heard within the action areas.

2. The Aim of this Strategy The aim of this strategy is to set out the Trust actions and ambitions to maximize safety and reduce harm experienced by people receiving care within Humber NHS Foundation Trust. It has been designed to support delivery of the Trusts strategic aims: •

Deliver high quality, safe and effective services

•

Deliver care closer to home to avoid hospital admissions wherever possible

•

Prioritise prevention, early intervention, recovery and rehabilitation

•

Integrate health and social care, mental and physical health and well-being and involve patients and carers in managing their care

•

Listen to and actively engage our patients and service users and their carers and families in the development, delivery and evaluation of the services we provide.

•

Work with the communities we serve, our partners and our members to design the services that will best serve their needs

•

Maintain a sustainable business to ensure that we can continue to care in the future

This strategy aims to deliver some of these aims by promoting a quality harm free experience for patients and carers, to ensure the Trust is sustained to deliver high quality, safe care, well into the future.

3. The National Pursuit of Harm Free Care Key to supporting this strategy is the Sign up to Safety Campaign. Sign up to Safety is a national initiative that aims to harness the commitment of staff across the NHS in England to make care safer. The initiative requires an organizational commitment to signing up to five safety pledges as follows: Put safety first We commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally within this strategy 4 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

Continually learn We commit to making our organisation more resilient to risks, by acting on the feedback from patients and carers and by constantly measuring and monitoring how safe our services are. Honesty We commit to being transparent with people about their progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong. Collaborate We commit to taking a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use within the Humber region Support We commit to help people understand why things go wrong and how to put them right. We will give staff the time and support to improve and celebrate progress made under this strategy. Please refer to Appendix 1 for the Sign up to Safety Commitment.

4. Priority Areas for Action Seven Priority Action Areas have been identified that will cross cut the pledges from Sign up to Safety through associated work plans: 1. Develop a patient safety culture across the Trust 2. Increase understanding of violence and aggression within mental health services and reduce restrictive interventions in the Trust 3. Reduce Severe Self harm events & support a Zero Suicide culture within the Trust 4. Interrogate issues relating to ensuring safer staffing across the Trust to ensure our workforce is equipped with the knowledge and skills and organised in the right way to deliver optimum care. 5. Reduce the number and severity of pressure ulcers acquired within our care 6. Improve medicines management and knowledge within the Trust 7. Reduce communication errors and associated patient harms through appropriate electronic technology for patient records Each of the priority action areas is explored in more detail below and examined within the context of Humber NHS Foundation Trust. Each priority area will have a designated working group with a patient safety lead and meeting structure. The group will be expected to develop and report upon a work plan under key themes.

5 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

4.1 Priority Action Area 1. Develop a Patient Safety Culture across the Trust : Delivering the Sign up to Safety Pledges Lead Deputy Lead

Director of Nursing Assistant Director of Nursing

“The pursuit of safety is not for the timid.” The Health Foundation suggests that the securing of safety is a task that cannot be ‘finished’, ever. All modern approaches to achieving safety (or reliability, for that matter) require continual attention to adjustments, resilience, adaptation and local contexts. The most important cultural characteristic is not the right technical features in place (although they should be), but rather that the organisation is full of people at all levels who can sense, change, adapt and change again in response to the ever-changing terrain of threat and challenge – and are supported by their leaders to do so. This is a cultural characteristic and behaviour that we will seek to embed within our services. It therefore follows that change is needed in: •

How safety is understood, because current approaches to measurement don’t provide the full picture;

•

How safety is improved, because existing approaches alone will not address the most intractable problems;

•

How risk is perceived, because comfort-seeking behaviours will not create a genuine culture of learning.

It is known that team or organisational cultures will overpower rules, policies, protocols and good practice if they do not align to practice. In patient safety terms this can lead to poor patient outcomes and harm. Culture does not respond well to top down management approaches, culture evolves and develops from all levels of the team and organisation. Culture requires nurturing, investment (of time, interest, skills) and leadership. Culture in our services also needs the involvement and engagement of service users,carers and other key external stakeholders ie Local Authorities/ Commissioners. This is critical across all our patient safety priorities and will be established within the cultural working group. This group will also consider guidance from `Patient Safety First’ relating to the implementation of human factors in healthcare 9 We will deliver Sign up to Safety through this priority action area is an NHS England initiative that encourages both individuals and organisations to harness the commitment of staff across the NHS in England to make care safer. The strategy requires the organisation to sign up to the following 5 key pledges : 6 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

1. Putting safety first We will  Commit to reducing avoidable harm through taking a systematic approach to safety and making public our locally developed goals, plans and progress. Priorities 2 -7 clearly outline our areas for action for 2016 - 2018.  Continue to focus on patient safety through our Organisational Risk Management Group and Quality and Patient Safety Committee within the organisation.  Develop Patient Safety Champions and Ambassadors across the priority action areas with our staff group, patients and carers  Develop patient safety work groups that focuses on reducing patient harms within the organisation across 6 priority areas which will be reported upon quarterly through our clinical risk report.  Ensure the patient safety work groups embed the principles of SU2S and developing a patient safety culture across the organisation  Support the Quality Visit methodology to review patient safety within clinical teams.

2. Continually learn. We will  Review trends and analyse incident/feedback data in patient safety groups based on our priority action areas  Join regional and national collaboratives and campaigns focussed on reducing harms to patients – a current example is the Y&H Safer Staffing collaborative for MH Trusts  Disseminate and promote best practice guidance and outcomes from the priority action areas in our strategy  Consider a review of safety training for employees through analysis of human factors training and impact on incidents.

3. Being honest. We will  Ensure our responsibilities in relation to Duty of Candour are understood across the organisation  Collect and review data in relation to Duty of Candour across all incidents and complaints  Publish quarterly data in the clinical risk report from the priority action areas to demonstrate our progress against our success criteria  Develop a training package for clinical staff that explores and facilitates confidence to be open, honest and candid with patients and carer if something goes wrong

4. Collaborate. 7 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

We will  Join regional and national collaboratives and campaigns focussed on reducing harms to patients  Contribute to Regional Public Health Initiatives across the health and social care economy  Ensure each Care Group always has attendance at the relevant working groups in order to ensure distribution and sharing of learning objectives

 Share learning and best practice with GPs, Local Authorities, Clinical Comissioning Groups, Acute Health, Police and other parties in a confidential manner to embed and improve patient safety outcomes

5.

Being supportive.

We will  Work towards a patient safety conference within the organisation to share SU2S work based from across the organisation  Develop Recognition awards for patient safety champions to reward involvement and energy in patient safety  Develop Recognition awards for teams to encourage discussion around local team initiatives and openness within caregroups about areas to improve upon  Recommend the use of reflective practice within all clinical teams in the organisation

8 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

We will know we have developed our patient safety culture as: •

Humber FT commits to the Sign up to Safety Pledges and joins the national strategy.

•

Every team has a patient safety champion to represent and promote patient safety.

•

Every member of staff can articulate how patient safety forms part of their everyday working life

•

Human Factors analysis is utilised within investigations and patient safety work which enhances clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings.

•

Patient safety initiatives will be generated across all staff groups within Humber FT and encouraged to flourish, recognition will be given by the Trust to individuals and teams for improving and understanding patient safety.

•

Patient and carer views/feedback/engagement will be embedded within the patient safety culture of Humber FT as experts by experience, ensuring that lived experience is valued within the organisation.

•

Humber has an active patient safety social media presence that contributes to

4.2 Priority Action Area 2 Increase understanding of episodes of violence and aggression within mental health services and reduce restrictive interventions in the Trust Lead Supporting leads

Assistant Director of Nursing Clinical Nurse Specialist Nurse Researcher

Restrictive interventions are often a major contribution to delaying recovery and have been linked with causing serious trauma, both physical and psychological, both to people who use services and staff. There is national evidence that shows in some cases restrictive interventions are not used as a last resort and have been used to inflict pain, punish and humiliate. In April 2014 the Department of Health published “Positive and Proactive Care; reducing the need for restrictive interventions” as a guidance framework to reduce the need for restrictive interventions and promote recovery. 9 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

Work has already commenced within the Trust to deliver on reducing restrictive interventions, however an overarching work plan and priorities will be developed to ensure Humber FT is consistently improving patient safety in this area. The work plan will include: •

Update on the implementation and effectivity of `Safewards’ within the Trust

•

Consideration of the current risk management plans for advance planning of restrictive interventions

•

Inclusion of staff and service users/carers and consideration of culture and practice

•

Review of the current training to manage violence and aggression

•

Review of restrictive interventions in use across the Trust; including use of seclusion, types of restraint specifically focusing on prone restraint, rapid tranquillization, defacto seclusion and time out.

•

Clarity on use (if any) of mechanical restraint.

•

Review of the current incident recording system and data collection with a focus on assurance and accurate recording

•

Consideration of physical environments and ability to meet the demands of patients who may require restrictive interventions to manage an episode of behavior or challenge (Clinical Environment Risk Audit)

•

Review of post incident restrictions and lessons learnt

•

Update on policies and procedures that manage restrictive interventions and alignment with best practice or changes through the work plan

This is not an exhaustive list of priorities but provides an oversight of potential areas for focus. Patient and carer involvement in this group is essential.

10 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

We will know we understand violence and aggression within the Trust and are reducing restrictive interventions through: •

The ability to give an accurate strategic oversight of the incidence, types and responses to violence and aggression will be accessible within the organisation.

•

Each service understanding potential restrictions in their area of care delivery and having clear plans to reduce restrictive interventions within their care.

•

Each ward holding an environmental risk audit that allows staff to plan care and provides the organisation with oversight of key risks and priorities to improve or enhance patient safety.

•

Every patient having the opportunity to plan their own safe care in relation to managing periods of time when they may require de-escalation or intervention.

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Debriefing with patients taking place after every episode of restraint, seclusion or rapid tranquillisation to learn lessons and further enhance care planning.

•

Training provided to staff focuses on de-escalation and confidence to manage challenging presentations in services in addition to managing physically violent incidents.

11 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

4.3 Priority Action Area 3 Reduce Severe Self harm events and support a Zero Suicide Culture within the Trust Lead Deputy Lead

Medical Director Assistant Director of Nursing & Safeguarding and Patient Safety

Zero Suicide Culture Preventing suicide is a priority area both nationally and locally within the Humber region. The recent National Confidential Inquiry into Suicide and Homicide 5 by people with mental illness revealed a number of key findings:

•

There has been a 29% rise among men who die by suicide while under the care of mental health services in the UK since 2006.

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Suicides under crisis resolution/home treatment are now three times greater than the number of deaths occurring in mental health in-patient settings in England.

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The most common type of drug taken in fatal overdose by mental health patients is now opiates, accounting for 24% of all patient suicides.

Humber NHS Foundation Trust is able to access more local data to support this working group. Significantly linked to this work are the highest rated methods of suicide being strangulation and self-poisoning. Overall in the North Yorkshire and Humber region, NCISH report that the suicide rate is 11.4%, the second highest in England. Whilst previous local and national strategies may have focussed on reducing and preventing suicides, they also carried a degree of inevitability about them. There is a growing feeling within the NHS and more broadly across mental health thinking within the United Kingdom that cultural beliefs find a number of suicides permissible. Evidence shows that learning from serious incidents does not necessarily ensure learning is embedded and that future events are prevented, partly due to this cultural belief that some suicides are inevitable. Humber NHS Foundation Trust will consider the aspirational notion that for patients within the direct & sole care of the Trust, a Zero Suicide Culture can be developed. A working group will explore this notion and link into national groups and bodies also grappling with this issue. This will mean an investment in training and skills for frontline practitioners in working with patients who demonstrate high levels of self-harm behaviour and suicidal plans. The growing number of referrals for people requiring inpatient treatment and Crisis intervention who are experiencing thoughts of self-harm and suicide indicate that our staff need the relevant training and skills to intervene. 12 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

Zero suicide cultures are not about blame or penalties, they are about changing the way that we view harms in our organisation. Humber NHS Foundation Trust can join the groups wanting to change this. However this must be led from every level of the organisation.

Self-Harm Self-harm refers to any act of self-injury or self-poisoning carried out by a person irrespective of their motivation. A wide range of mental health problems are associated with self-harm. People who self-harm have a 50-100 fold higher likelihood of dying by suicide in the 12 month period after an episode than people who do not self-harm. 4 Currently there are not the same robust systems in place for recording self-harm as accurately at a national level, however indicative local recording and discussions indicate that self-harm is a growing adverse health outcome that can occur in relation to a range of mental health problems and difficult life circumstances. Critically self-harm is a key risk factor for suicide. Self-harm is also a growing trend in young people, particularly in the community population of adolescents who will not present to mental health services. 3 In this age group, the role of the internet and social media along with the toxic factors of cyber bullying indicate that selfharm is an area for action within public health. For Humber FT and those young people seen through the Child and Adolescent Services these factors will be included in the work to address self harm.. Existing work will be incorporated into the plan, however key to include in this work plan for preventing suicides and reducing self-harm is: • • • • •

•

• • •

Engagement with public health suicide reduction plans Development of a local reducing self harm prevention strategy Inclusion of staff, service users and carers and consideration of culture and practice Review of the clinical skills training for staff on the assessment and management of selfharm and suicide within the patient population Review of the current incident recording system and data collection with a focus on assurance and accurate recording from all services to try to understand trends and hotspots. Audit and review of inpatient facilities where patients are admitted as they actively wish to take their own life or are exhibiting high levels of self-harming behavior. (Clinical Environment Risk Audit – specific reference to ligature anchor point audit) Develop procedure for removing ligatures from hanging/strangulation incidents which includes the standardized use of a ligature cutter. Ensure learning from all suicides and serious self-harm incidents are reviewed Link to any national and regional work around suicide and self-harm.

13 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

We will know we are promoting a zero suicide culture and reducing self-harm within the Trust as: •

Humber FT can clearly articulate its aspiration for a zero suicide culture and this is embedded into the training for all staff.

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Staff working in our clinical services are confident, skilled and trained to assess and plan care with patients who are experiencing thoughts to harm themselves or take their lives.

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Humber FT builds a reputation both regionally and nationally for the compassionate, responsive and appropriate management of patients who report thoughts or plans to take their life or significantly harm themselves

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Experts by experience are embedded into the training plans to further embed recognition of their contribution to staff training and development.

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The type and severity of self-harm incidents within our inpatient services reduces.

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Monitoring identifies achievement of the actions in the Strategic Suicide Prevention Plan.

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We can evidence involvement and proactive work within the wider community to promote zero suicide within Hull and East Riding

14 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

4.4 Priority Action Area 4 Interrogate the issues relating to ensuring safer staffing across the Trust to ensure our workforce is equipped with the knowledge and skills and organised in the right way to deliver optimum care. Lead Deputy Lead

Director of Nursing, Quality & Patient Experience Assistant Director of Nursing & Safeguarding and Patient Safety

In November 2013, NHS England published: How to ensure the right people, with the right skills, are in the right place at the right time - A guide to nursing, midwifery and care staffing capacity and capability (NQB Guidance) 6. This guide set out the expectations of commissioners and providers to optimise nursing, midwifery and care staffing capacity and capability so that they can deliver high quality care and the best possible outcomes for their patients. All NHS organisations are now publishing ward level staffing information on NHS Choices. Work was expected to be carried out by NICE to develop staffing guidelines for mental health wards, however this work was unexpectedly halted. In November 2015 the latest guidance from the Chief Nursing Officer (CNO and statutory bodies is as follows : Providers should be able to demonstrate that they are able to ensure safe, quality care for patients and that they are making the best use of resources. This should take account of patient acuity and dependency, time of day and local factors, such as line of sight for those caring for patients.7 Some trusts have taken innovative approaches whereby Allied Health Professionals are included in their ward based teams, and this can have a positive impact on patient outcomes. It is therefore important to look at staffing in a flexible way which is focused on the quality of care, patient safety and efficiency rather than just numbers and ratios of staff. This work-stream will therefore consider: • • • • • •

Current available guidance and tools to establish safe staffing levels within inpatient teams Regional or national initiatives to further investigate “safe” staffing Staffing is consider as a multi-disciplinary issue Staffing in relation to the community and caseloads which are an indicator of “safe” working and patient safety Impact of productive reviews to release staff from non-clinical burdens to spend time with patients in clinical activity (link to priority 7) Safer Staffing Escalation Processes

15 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

We will know we understand our staffing and how safe care can be delivered through the workforce by : •

Incidents where safer staffing is not met are quickly escalated and resolved or mitigated.

•

Unit Managers and Matrons will be confident in the safer staffing levels assigned to their wards/units

•

Unit Managers, Matrons, staff, patients and the Trust will have regular accurate and transparent information regarding safer staffing attainment.

•

The organisation will be assured that levels of staffing are agreed by clinicians and meet the expected activity standards for each individual unit/ward.

•

Community staff will have a caseload tool to utilise in monthly supervision which will enable discussions about caseload management and patient care requirements

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Humber FT will participate in and receive feedback from regional or national staffing evaluations and research.

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The multi disciplinary team and skill mix will be considered within the safer staffing discussion to ensure a richness and diversity of skills and care provision within teams.

4.5 Priority Action Area 5 Reduce the number and severity of pressure ulcers acquired within our care Lead Deputy Lead

Head of Nursing Tissue Viability Specialist

The national patient safety ambition is to eliminate the avoidable harm associated with pressure ulcers across the NHS. With an estimated 180,000 newly acquired pressure ulcers developing each year (NHS Safety Thermometer 2012) and 91,810 patient safety incident reports received by the National Reporting and Learning System in 2011 this is one of the biggest patient safety challenges facing us all in the NHS.8 16 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

There is evidence to indicate that many pressure ulcers can be avoided with some estimates suggesting that 95% of pressure ulcers are avoidable. There is also a good evidence base for how to prevent pressure ulcers and examples of where this evidence based has been applied to clinical practice pressure ulcers are prevented. Significant work is already underway in relation to understanding our pressure ulcer incidence and actions to reduce this. The work plan will ensure that this is captured and offer further support if required to the current group of leads Work currently being implemented includes: • • •

• • •

Regular forum to meet with Matrons to share the findings from the RCA’s. Matrons to take ownership of the RCA investigations working in collaboration with the Trust TVNS to develop a clear action plan for each NCS to address all areas identified from the RCA’s RCA tool reviewed by the Matron in consultation with the TVN to review the phases of care in the management of PU o Initial assessment, care delivery, deterioration of PU and review processes o Wider review of the initial assessment undertaken at first planned contact from Systmone across all NCT’s Guidance for staff on the management of the PU following the Walsall assessment to be available within Systmone to be developed The results of all RCA’s to be fed back by the Matrons to all of their locality staff and the Clinical Care Director to ensure learning updates and review of all action plans are discussed, actioned and reviewed within the Care Group Clinical Network Update the Quality Improvement Plan with Matrons and Care Group Triumvirate to ensure lessons are learnt from RCA’s

We will know we have reduced the number and severity of pressure ulcers to patients in our care by: •

Continuing the overall reduction in avoidable pressure ulcers across the Trust as reported through the Pressure Ulcer quarterly report

•

Ongoing delivery against plan through the Trusts overarching Quality Improvement Plan for 2016-18

•

Audit of patient records demonstrates adherence to pressure ulcer assessment and management for patients at risk.

17 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

4.6 Priority Action Area 6 Improve medicines management and knowledge within the Trust Lead Deputy Lead

Medical Director Medicines Safety Officer

The group will continue to focus on the following areas which can be reported through the patient safety strategy: • • • • •

Datix error reporting Pharmacy error reporting systems and links through the NHS England Competency Frameworks for registered nurses in administering medications Competency Frameworks for support staff Impact of GP Practice changes on the use of Medicine Administration Records and nurse administration

Medicine errors are reported through Datix and are within the top 5 incidents across the Trust. They are, however also recorded with no or low harm for the vast majority. Medicines management can be attributed to a range of professions and staff. We also know that a number of near misses and low level errors are reported within an internal pharmacy system that are not reported through to Datix due to issues with understanding data and complex systems. This priority action area will be managed through the existing Drugs and Therapeutics Committee which has oversight of all reporting systems and comprises of attendees from all disciplines. The lead medicines safety officer will work in conjunction with the patient safety lead to develop reporting through to Quality and Patient Safety Committee (QPAS) via the patient safety strategy.

We will know we have improved medicines management knowledge and reduced incidents within the Trust by : •

Undertaking thematic reviews of information for near misses and errors relating to medicines safety across all departments leading to the implementation of improvement plans

•

Assurance of the oversight of the staff groups involved in medicines management and training, continuing professional development and competency checks to safeguard patients in relation to medicines.

•

All staff groups having access to competency based assessments to ensure they receive appropriate training and education to ensure they deliver safe care to patients and work towards zero medicines harms 18

Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

Priority Action Area 7 Reduce communication errors and associated patient harm through appropriate electronic technology for patient records Lead Supporting leads

Head of Resilience Management Clinical Care Group Directors

Electronic patient records are fundamental to visions of future health care delivery in the UK. They are expected to provider safer, quicker and better quality patient care as a key element of modernized information systems within the NHS. Studies have demonstrated that electronic records can improve the quality of healthcare, increasing time efficiency and guideline adherence, reduce medication errors and improve communication between transition points in the care pathway.10, 11. This work stream will review the impact of the current electronic systems, consider the potential for a staff survey in respect of the practitioner functioning and impact on patient safety with a view to making recommendations about future work to utilize electronic patient records to improve patient safety and quality of care

We will know we have the appropriate electronic records to reduce communication errors and related harm to patients when : •

Clinical teams have articulated the qualities of an electronic patient record system that will support delivery of high quality care and impact positively on patient care.

•

A staff survey has identified key points of frustration and satisfaction in relation to electronic patient records

•

A case for change has been written and taken forward for consideration to the Trust board outlining the costs and benefits of an appropriate electronic record

19 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

5. Responsibility for delivery of the Strategy The Medical Director and the Director of Nursing, Quality & Patient Experience have overall executive responsibility, on behalf of the Board, for the delivery of this strategy. The Assistant Director (of Nursing) for Patient Safety and Safeguarding has delegated responsibility for overseeing each Priority Action Area identified within the strategy, to ensure that individual work plans are developed and delivered within agreed timescales. The Chief Operating Officer has executive responsibility for ensuring the Clinical Care Groups engage with and inform the relevant priority action areas to ensure policy and practice are aligned. The clinical networks and forums will support this engagement.

6. Monitoring The patient safety strategy will be integrated wherever possible into existing workstreams within the Care Groups. Patient Safety outcome metrics for each action area will be developed and will be incorporated into the quarterly Clinical Risk Management report along with quarterly reports against the priority workstreams for reporting to the Quality & Patient Safety Committee. Quarterly progress reports will be presented to the Board and to the Integrated Audit & Governance Committee for assurance purposes.

7. Next Steps Leads will be identified across each of the action areas and work plans developed to meet the success criteria. Reporting will commence against the strategy from Quarter One 2016/17 in the Clinical Risk Report.

8. Summary This document is one of a suite of new strategies which supports the delivery of safe, evidence-based care to underpin effective care for those who use our services. The strategy supports the continued programme of improvement which is led by the Quality and Patient Safety Committee. The delivery of the strategy across all our services relies on the commitment and efforts of all within teams, care groups and the wider organisation. Working together to deliver this shared vision of clinical audit and effectiveness provides the best opportunity to ensure those we care for receive the right care, in the right way by the right people. We must remember delivering care is not enough; we must aspire to do deliver the best possible care each and every time.

9. References 1. Health Foundation 2015. Continuous Improvement of Patient Safety. 2. DoH 2014. Positive and proactive care : reducing the need for restrictive interventions 3. Suicide and self-harm: Annual report of Chief medical officer, 2013. 4. Self-Harm. NICE. 2013 5. NCISH. 2015 20 Humber NHS Foundation Trust Patient Safety Strategy January 2016-December 2018

6. 7. 8. 9. 10.

NHS England ; Safer staffing A guide to care contact time, 2014 Open Letter: Safe Staffing. TDA, Monitor, CNO, CQC, November 2015 Patient Safety First: Pressure Ulcers. Accessed 2015 Patient Safety First : Implementing Human Factors in healthcare 2010 Kutney-Lee & Kelly. 2011. The effect of hospital electronic health record adoption on nurse assessed quality of care and patient safety. Journal of Nursing Admin. 4.11. 466-472

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