Contents
FOREWORD
Introduction from the Chief Executive
2
BACKGROUND
3
OUR TRUST VALUES
4
OUR AIMS FOR QUALITY
5
- Our achievements so far
- Our aims for quality 2017 – 2020
AIM 1:
AIM 2:
AIM 3:
AIM 4:
Reducing Mortality
Preventing Harm
Enhancing Patient and Carer Experience
Creating a Continuous Learning Culture
HOW WE MEASURE QUALITY
16
DELIVERING THE QUALITY IMPROVEMENT STRATEGY
Methodology and Enablers
17
- Our Quality Improvement Methodology
- Quality Improvement capability building
- Enabling resources
STRATEGY GOVERNANCE AND DELIVERY
20
COLLABORATION WITH PARTNERS
20
Foreword
Introduction from the Chief Executive
I’m delighted to be introducing our second
Quality Strategy for Bolton NHSFT having
made excellent progress together over
the past three years. I think it’s important
that we take this opportunity to stop and
reflect on our journey as well as to refresh
our objectives for the next three years.
Over this time we have seen a tremendous
commitment from our staff who, no matter
where they work in the organisation, have
come to work every day to contribute to,
or deliver, high quality care in order to
secure the best outcomes and experience
for our patients. The outcome of “Good”
following this year’s Care Quality Commission
inspection was a ringing endorsement of that
commitment and an absolute credit to all our
staff. We now need to turn our attention to
the future and an ambition of achieving
“Outstanding” which I personally believe
is absolutely possible. This strategy aims to
set out clear objectives and further enablers
to help us get there; it once again sets the
direction of travel for quality improvement
for the next three years.
So I look forward to seeing the continued
improvement of all the quality and safety
metrics and to knowing that the care we
provide here is the best it can possibly be.
I truly believe that we can become one of the
best, if not the best, provider of high quality
healthcare in the country and this strategy
once again, gives us the road map to get
there.
Best wishes
Dr Jackie Bene
Chief Executive
2
How we developed this strategy
At Bolton we believe our staff have two jobs,
to deliver quality care and to continuously
improve how that care is delivered to and
in partnership with our patients and carers.
Our staff are the experts in their field of
work and in conjunction with patients and
relatives are best placed to develop and lead
ideas for improvement.
This Quality Improvement Strategy builds
on the foundations and achievements from
the previous strategy; and was developed
in collaboration with members of staff,
whilst highlighting further areas of quality
improvement. Staff from all areas of the
organisation were invited to provide their
thoughts on key areas the organisation
should focus it’s quality improvement efforts;
this was then collated and merged with the
ideas developed from senior leaders in the
Trust. Furthermore, trends and feedback
from the rich sources of information such as
patient, families and carers, patient and staff
surveys and governance intelligence sources
such as complaints and incident reports gave
us the direction for this re-envisioned Quality
Improvement Strategy: Better Care Together
2017 - 2020.
3
Our trust values
Our Trust values, associated practices
(behaviours) and effective leadership will
support the delivery of our new Quality
Improvement Strategy and the provision of
high-quality care to our patients and their
families.
In terms of our new Quality Improvement
Strategy, the key values are VISION and
EXCELLENCE. This strategy represents our
VISION for the organisation, outlining our key
aspirations, intended actions and measureable
outcomes in terms of quality. EXCELLENCE is
about putting quality and safety at the heart
of all our services and processes, ensuring
we strive for continuous improvement in the
standards of healthcare we provide here at
Bolton.
Our Trust Values were refreshed in 2016
following a consultation process with our
staff. We sought their views on what values
represented Bolton NHS Foundation Trust
now and the type of organisation they
wanted it to be in the future; from which
the following values were chosen, forming
the acronym ‘VOICE’:
But we also want our staff to live the
other three values in their everyday work.
COMPASSION underpins our approach to
patient care; we take a person-centred
approach in all our interactions with
patients, families and our staff. We actively
encourage a culture of OPENNESS where our
staff can communicate clearly with honesty,
encouraging feedback both positive and
negative to help drive further improvements.
Furthermore, we expect our staff to act with
INTEGRITY, demonstrating fairness, respect
and empathy in their interactions with
others - taking responsibility for their actions,
speaking out and learning from any mistakes.
• VISION
• OPENNESS
• INTEGRITY
• COMPASSION
• EXCELLENCE
COMPASSION
“ Myhowroleweiscanaboutcontinue
to deliver safe and
quality services
for patients and
their
families.
“
4
“ areMy atpatients
the
heart of
everything
I do.
“
VISION
“
Our aims for quality
We are striving to be an organisation that
delivers safe, effective and compassionate
care to every patient; every time they access
our services; and are committed to putting
the needs of our patients, their families and
carers first. In order to do this we will build
on the foundations and achievements from
the previous Quality Improvement Strategy
and work in collaboration with our patients,
our staff and other partners to ensure we
deliver “Better Care Together”. Achieving
the ambitious goals outlined in this strategy
will give Bolton NHS Foundation Trust a
national reputation for high quality patient
care delivered by staff with high levels of
staff engagement, ensuring our patients
and public receive the highest quality of
healthcare they deserve.
These four key aims are:
• Aim 1:
Reducing Mortality
• Aim 2:
Preventing Harm
• Aim 3:
Enhancing Patient and
Carer Experience
• Aim 4:
Creating a Continuous
Learning Culture
The strategy outlines four key quality
improvement aims and under each aim
will be a portfolio of work streams that
will lead to demonstrable improvements in
outcomes, safety and patient experience.
Each work stream will involve patients and
staff from across the organisation, working
systematically, sharing best practice and using
proven quality improvement methodology
to ensure consistent delivery of improved
quality and performance.
Reducing
Mortality
Preventing
Harm
Better Care
Together
Quality Improvement
Strategy
Enhancing
Patient
and Carer
Experience
Creating a
Continous
Learning
Culture
5
Our achievements so far
The previous Quality Improvement Strategy helped the Trust achieve a CQC rating of ‘Good’ in
August 2016 and realised a number of key quality improvement achievements including:
Reducing mortality:
Since the launch of the last strategy our mortality rates have fallen year on year, demonstrated
by the following:
• A reduction in annual deaths from 1348
(2012/13) to 1161 (2015/16) representing a
14% improvement.
• Our chosen risk adjusted mortality
indicator, Standardised Hospital Mortality
Index (SHMI) has reduced from 107 to
100 (latest data April 2015 – March 2016).
The lowest on record representing a 7%
improvement.
• The reduction in crude mortality from
2.4% to 1.9% represents a 21%
improvement.
Reducing harm:
Focussed work to strengthen the infection control culture in the organisation, including
infection control champions in all clinical departments has enabled us to deliver a reduction
in Clostridium difficile cases from 38 (2013/14) to 21 (2015/16).
We have also had demonstrable improvements in reducing other types of harm including:
• 40% reduction in preventable falls with
harm *
• 47% reduction in falls where patients
experience severe harm*
*Comparing data from April 2014-March
2015 with April 2015-March 2016
Crude in-hospital mortality rate
3.0%
Percentage of discharge
2.8%
2.6%
2.4%
2.2%
2.0%
1.8%
Source: HED
1.6%
2009/10
2010/11
2011/12
2012/13
Bolton NHS Foundation Trust
6
2013/14
North West
2014/15
England
2015/16
Improving patient experience
In order to ensure we are providing a good quality patient experience we must actively seek
and learn from what our patients’ and their families are telling us about the services we
provide. We have made good progress in not only widening the opportunities for feedback,
but displaying improvements made as a result of this feedback. This has helped us achieve the
following:
• We are particularly proud of the fact that
in the latest National Inpatient Survey
(2015) our patients rated us amongst the
best in the country (31st out of 148 trusts)
and placed us 15th for the care and
treatment we provide.
boards on each ward to demonstrate
to patients and their carers’ response to
feedback and action taken as a result.
• 96.3% (average Jan 15 – Mar 16) of
responding patients rate “extremely likely
or likely” when asked “How likely are
you to recommend our service to friends
and family if they needed similar care or
treatment?” (FFT)
• Monthly Friends and Family Test (FFT)
dashboard have been developed for each
ward, alongside – “You said we did”
Responding and learning
Since 2014 there has been a demonstrable
rise in the number of incidents reported,
which puts Bolton in the top 25% of Trusts
for the first time. We welcome this rise as
evidence suggests an increase in incident
reporting is an indication of an increased
level of awareness of safety issues amongst
healthcare professionals. In addition, we
distribute monthly learning slides to every
member of staff in the Trust to facilitate
trust-wide learning from incidents,
complaints, inquests and other issues.
Whilst we acknowledge these achievements, we recognise further work is required and this
strategy aims to refocus and reinvigorate our quality improvement efforts.
7
Our aims for quality 2017 - 2020
Aim 1 – Reducing mortality
We have made good progress in relation to reducing the overall number of patients who die
whilst in our care. However, we accept further work is required to achieve our goal of no
needless deaths.
How we measure mortality:
Key ambitions for improvement:
We use a variety of methods and sources
to measure patient mortality, which is
monitored monthly and used to investigate
how further improvement can be made;
these include the following:
By the end of 2020 we aim to:
• Reduce our Standardised Hospital
Mortality Index to less than 90.
• Standardised Hospital Mortality Index
(SHMI)
• Continue our year on year reduction in
crude mortality.
• Number of patient deaths in our
organisation (crude mortality)
• Reduce avoidable cardiac arrests
that result in death by 50%.
• The Risk-Adjusted Mortality Index (RAMI)
• Cardiac arrests
• Serious untoward incidents that result in
patient death
8
What we will do:
Work to reduce mortality is already in progress across the organisation. However, for the
duration of this strategy we will focus on the following areas:
• Mortality review process:
• Recognising and responding to the
deteriorating patient
We aim to ensure we carry out a mortality
review on all patients who die whilst
under our care; this is to highlight areas
for improvement and enable the sharing
of good practice.
Evidence shows that timely recognition
and response to patients whose condition
deteriorates improves the likelihood of
survival and reduces further complications.
This work stream is multi-factorial and will
focus on the following areas:
• Cardiac arrest root cause analysis
clinics:
• Sepsis
• Handover
These clinics involve a multi-disciplinary
team of staff that review all patients
who had a cardiac arrest whilst under
our care. The aim of this is to assess
if the level of care the patient received
was both appropriate and timely, whilst
investigating if there are any opportunities
to improve and put actions in place to do
so.
• Processes and systems to alert staff to
deteriorating patients
• End of life care
We will reliably ensure high quality end
of life care across Bolton by educating
and empowering our workforce in the
principles of advance care planning, needs
assessment and bereavement care.
We aim to ensure all patients who are at
the last stages of their life are fully
involved in the design of their care and
treatment with their preferences
accounted for including preferred place
of death. We will also work with relatives
and carers before and after death.
9
Our aims for quality 2017 - 2020
Aim 2 – Preventing harm
Harm can be defined as ‘unintended physical or emotional injury resulting from, or
contributed to by clinical care (including the absence of indicated treatment) that requires
additional monitoring or treatment.’ The previous strategy focussed on harm caused by
healthcare associated infection. However, we wish to widen this area of work to include
all potential sources of harm such as medication errors, pressure ulcers and falls; whilst
strengthening our reporting and learning system to enable our staff to recognise and prevent
potential harms occurring.
How we measure harm:
Key ambitions for improvement:
We use a variety of methods to measure
and track the level of patient harm in our
organisation, again using this information
to inform continuous improvement;
examples include the following:
By the end of 2020 we aim to:
• Achieve a 10% reduction in lapses
in care that result in the following
harms:
• Healthcare associated infections
- Pressure ulcers
• Pressure ulcers
- Inpatients falls
• Falls
- Omission of critical medicines (excluding
clinical reasons and patient choice)
• Medication errors
• Trust key performance indicators (KPIs)
• Be the top performing trust in
Greater Manchester for
Clostridium difficile rates
(measured by rate per 100,000
overnight occupied bed days)
• Harm free care panel reviews
• Never Events
• Serious untoward incidents that results in
patient harm
10
What we will do:
• Infection prevention control:
• Falls
We will continue to focus on key outcomes
relating to healthcare associated infections
including Clostridium difficile, MRSA and
MSSA bloodstream infections, CPE cases
and blood culture contaminants, improving
our understanding of infections using
critical analysis and root cause analysis.
Falls prevention continues to be a high
priority for our organisation. The Falls
Steering Group will continue to work
on areas to reduce falls; which include:
• Analysis of data to see trends and address
areas of concern.
• Falls harm free panel to understand
reasons why falls occurred and what can
be done to prevent future falls.
• Pressure ulcers
We will continue to focus on:
• Falls prevention training, use of
equipment and technology.
-
Education and training
Equipment
Innovation and evidence Based Practice
Documentation
Harm free care panel process and timely
completion of RCAs
- Analysis of data and collation of thematic
analysis
• Medication reviews – involving the
assessment for medication likely to
increase the risk of falls and adjustments
made where appropriate.
• Medication errors
We will support the Pressure Ulcer
Collaborative Group in partnership with
Bolton Clinical Commissioning Group,
enabling a whole system approach to
reducing pressure ulcers within the Bolton
Health and Social Care Economy. We will
bring together healthcare professionals and
other stakeholders across Bolton to share
learning, information and good practice, in
order to work towards a zero tolerance of
pressure ulcers.
The Medicines Safety Group will continue
to focus on reducing the number of critical
medicines missed through:
• A review of the audit process within
divisions to collect data on omitted doses.
• Thematic analysis of omitted doses of
critical medicines with clear actions.
• Trust wide education on the importance
of critical medicines and the potential
harm from omission.
11
Our aims for quality 2017 - 2020
Aim 3 – Enhancing patient and carer experience
Providing a good quality patient experience requires actively seeking, responding to and
learning from patient feedback. The Trust has a dedicated Patient and Carer Experience
Strategy and this Strategy will support the delivery of certain objectives within the Patient
and Carer Experience Strategy.
How we measure patient and carer experience:
Some examples of how we measure patient and carer experience include:
• National patients survey
• Friends and family test (FFT)
• Ward/departmental specific patient surveys
• Patient and carer stories
• Complaints
• Trust key performance indicators (KPIs)
• Bolton System of Care Accreditation (BoSCA)
Key ambitions for improvement:
By the end of 2020 we aim to:
• Be in the top 10% of NHS trusts in the
National Patient Survey.
• Increase the number of patients
completing the Friends and Family Test in
all areas by 50%.
• Increase the number of wards that are
accredited Bronze, Silver and Gold BoSCA
status by 10% each year.
12
What we will do:
The Patient Experience Feedback Group will focus on a range of interventions that will not
only increase patient and carer involvement, but aim to enhance the experience of our
patients and their families whilst under our care. These include:
• Capturing and responding to patient
and carer feedback
• Patient and carer representation
We aim to ensure by the end of 2020
there will be patient or carer
representation on every committee; thus
ensuring the active participation of patients
and carers in the future direction of the
organisation. Furthermore, we will
continue to use patient stories in our
committee meetings.
We will implement a sustainable patient
feedback mechanism to capture and
increase the level of real time feedback
and demonstrate change as a result of this
feedback.
• Always Events:
“Always Events” – are aspects of care or
experience that our patients and their
carers should “always” expect to receive.
We will work with our patients and carers
to develop and launch our “Always Events”
and work with our wards, departments and
community teams to ensure they are
reliably embedded at a local level.
• Learning from complaints:
Unfortunately we recognise there are
occasions when we do not provide
the service our patients and their carers
expect. It is important that we review both
favourable and less favourable feedback in
order to highlight themes and address
areas for improvement. Our aim is to
rebalance the focus from complaints
managements to pro-active patient
experience improvement, by identifying
opportunities to enhance patient
experience so that complaints can be
avoided. We will do this by supporting our
staff to ensure they are confident to
address challenges when they occur, rather
than letting the matter escalate.
13
Our aims for quality 2017 - 2020
Aim 4 - Creating a continuous learning culture
Our previous strategy focussed on responding to and learning from harm and errors, and we
have made great progress in this area. However, we also recognise we should be capturing
and learning from the opposite of incidents (i.e. when things go right). We recognise that
our staff have a wealth of knowledge and expertise in their profession and want to empower
them to identify and lead improvements in their own area of work; providing them with the
knowledge, skills and support to do so.
How we measure continous learning:
Key ambitions for improvement:
Some examples of how we measure
learning for improvement purposes include
the following:
By the end of 2020 we aim to:
• Have 100% of priority R1
recommendations from Serious Incidents
to be implemented within agreed
timescales (R1 recommendations relate to
the root cause of the incident and must
be urgently addressed)
• Complaints
• Incidents and investigations
• Staff experience metrics
• Audits
• Trust compliance with NICE guidance
• Be in the top 10% of NHS Trusts for
staff feeling able to contribute towards
improvement at work (NHS Staff Survey
KF17 score)
14
What we will do:
We will continue to encourage incident reporting and ensure we learn from complaints,
incidents and investigations. We will also widen our reporting system so we can learn from
occasions where our patients have received exemplary care or members of staff have put
ideas for improvement into practice that could benefit the wider trust. We aim to do this via
the following:
• “Idea for Improvement” and sharing
good practice
We will establish mechanisms to allow
members of staff who have ideas for
improvement to put these ideas forward.
This would be strengthened by the
development of an Innovation Forum;
where individuals and teams can bring
their idea for improvement to an arena for
advice and assistance on how it can be
taken forward, whilst also hearing case
studies of improvement in action.
• Quality improvement skills transfer
In order to enable staff to make
change happen they will be supported
by improvement experts who will provide
training in improvement methodology and
mentoring support to allow them to put
their idea for improvement into action.
15
How we measure quality
Measurement for quality improvement:
The ability for our organisation to deliver on all aspects of this strategy also depends on
our ability to measure progress. It is important to measure performance for improvement
purposes as it enables us to fully understand the processes we are looking to improve, but
also allows us to provide evidence that ideas for improvement work in practice and as a result
increases the appetite for improvement amongst our staff.
For all our quality improvement work streams and projects we will use Statistical Process
Control (SPC) charts, a method wisely used in the science for improvement arena. A SPC
chart is used to study how a process changes over time, from which conclusions about an
improvement intervention can be made based on statistics.
In addition to the specific metrics set against each aim, we will also use the following
mechanisms to measure and track quality improvement in the organisation:
• Trust key performance indicators (KPIs)
• Bolton System Of Care Accreditation
(BoSCA)
Delivering high quality and appropriate
care to patients is of paramount
importance; one method of measuring the
quality of care we provide and highlighting
areas for continuous improvement is the
monthly Key Performance Indicators (KPIs).
The process involves a number of audits to
assess the quality of care provided and are
undertaken with the ward manager and an
external ‘buddy’ to enhance objectivity,
transparency and standardisation. The
process is underpinned by a clear
performance framework which includes an
escalation process in the events of
non-compliance. This information is used
as supporting evidence for the Bolton
System of Care Accreditation (BoSCA).
The Bolton System of Care Accreditation
(BoSCA) is a multidisciplinary structured
assurance framework designed to support
nurses and clinicians to monitor the quality
of patient care they deliver, identify what
works well and where further
improvements are needed. BoSCA is the
vehicle we will use to help us continuously
raise the standards in patient care.
The BoSCA framework is based on the
Trust’s Better Care Together approach to
service delivery and incorporates Essence
of Care standards and key clinical
indicators, whilst also providing evidence
for the Care Quality Commission’s Core
standards. The process also takes into
account retrospective KPI data and other
key audits and includes a thorough
inspection of the ward/departmental area.
Following review the area is given a
grading of White, Bronze, Silver, Gold or
Platinum.
Trust KPIs are now established in ward areas,
with the roll-out to Community Teams,
Theatres, A&E and non-clinical departments
by 2017.
The BoSCA framework was launched in
2016 and is now in operation across all
inpatient wards and Community/District
Nursing Teams with future plans to roll-out
to Theatre and non-clinical departments.
16
Delivering the strategy
Our quality improvement methodology
We are committed to ensuring all our staff are empowered to make improvements for the
benefits of our patients and their families. At Bolton, we will use the Model for Improvement
as our framework for quality improvement; but will also use other appropriate quality
improvement methodology as required on a project by project basis.
Model For Improvement:
The Model for Improvement is a framework for improvement widely used in NHS
organisations. The framework has three fundamental questions:
1. What are we trying to accomplish - Setting an aim for improvement
2. How will we know that change is an improvement - Measurement for improvement
3. What change can we make that will result in improvements - Ideas for improvement
Ideas for improvement are then tested and refined prior to implementation through the use
of PDSA cycles:
• Plan:
Planning the test, predictingwhat will happen
• Do:
Running the test
• Study: Learning from the test
• Act:
Based on learning adapt, adopt, abandon the test
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make
that will result in improvement?
Act
Plan
Study
Do
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Quality improvement capability building
We recognise improvement is more likely to succeed and be sustained if it is designed and
led by the staff doing the job. In order to enable staff to make change happen they will
be supported by improvement experts and quality improvement will be applied via the
following mechanisms:
• Breakthrough Series Collaborative
Model (BTS):
• Improvement mentoring
Improvement mentoring is available for
teams or individuals who have an idea for
improvement they would like to
implement. The idea is two-fold; to
spread improvement capability via the
mentoring whilst working on an idea
for improvement selected by the team.
The Breakthrough Series Collaborative is an
improvement model which brings together
front-line teams enabling them to learn
from each other and experts relating to a
specific area highlighted for improvement.
The emphasis of the BTS cycle is
collaborative learning, testing ideas for
improvement and collecting data to
validate the impact of improvement, prior
to trust-wide roll-out of ideas.
• Quality improvement capability
building:
Training sessions on the Model for
Improvement and other key improvement
tools will be available; supported
with on-line training material. Quality
improvement also features as a key
component in leadership programmes
offered at the Trust.
• Improvement events:
This is a focussed, short term period of
time where members of staff test change
in a real work setting and refine that
change so that by the end of that focussed
period the change is fit for purpose and
implemented.
18
Enabling resources
• Business intelligence:
• Trust Quality Lead (Patient Safety Lead)
and Quality Improvement Programme
Manager:
As mentioned previously, it is crucial we
measure performance for improvement
purposes, and with the support of our
Business Intelligence Department we will
use specialist measurement for
improvement techniques and
methodologies to develop a Quality
Improvment Dashboard to allow us to track
progress against our aims. Furthermore,
over the next three years our BI
Department will develop closer
working relationships with our teams
and departments to help transfer learning
regarding measurement for improvement.
Linking back to our Trust values, we expect
all our staff to put quality and safety at the
heart of all we do and to strive for
continous improvement in the standards of
healthcare we provide. However, we do
recognise the need for key individuals to
lead the quality improvement programme
at the Trust. We have a senior clinical
Quality Lead whose role is to engage
clinical staff in patient safety and quality
improvement. In addition, the Quality
Improvement Programme Manager will
oversee the delivery of the quality
improvement work streams we have in
place.
• Clinical Effectiveness:
Our Clinical Effectiveness Department
is crucial to the delivery of this strategy,
The Clinical Audit Plan will support and
prioritise audits related to the four aims of
this Strategy. The audit template for
support will ask which aim the audit
relates to - this will drive up interest and
interconnectivity between the QI Strategy
and clinical audit.
19
Quality improvement strategy governance and measurement
Governance and delivery
The Better Care Together Group will oversee the operational delivery of improvement areas
in this strategy and will report to the Clinical Governance and Quality and Quality Assurance
Committees.
A number of key work streams have been highlighted that clearly link to each aim of the
Quality Improvement Strategy, these will sit under the remit of the Better Care Together
Group and will use a robust quality improvement project framework comprising of a
project initiation document, driver diagram, clear aims and measurement strategies to drive
improvement forward.
Working in collaboration with our partners
This strategy has clear links to the People, Patient and Carer Experience and Risk
Management strategies and should be read in conjunction with these strategies.
We also recognise that in order to achieve our aims outlined in this Quality Improvement
Strategy, collaborative working with our partners is essential. Some of our partners include:
• NHS Bolton Clinical Commissioning Group
• Local Authority
• Greater Manchester Academic Health Science Network
Bolton Clinical Commissioning Group
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