Posted on: 8 August 2022
In this edition, we have a lot of great improvement news to share with you including:
- Our feature Article: World Patient Safety Day 2022
- Improvement Stories: Improving medication safety @ HMP High Down
- Improvement Stories: Reducing pressure ulcers @ MK District Nursing Services
- Improvement Academy presents @ IHI/BMJ International forum on Quality & Safety in Healthcare in Sydney, Australia – ‘Meaningfully involving service users and carers in quality improvement work’
- #WMTY2022 event with CNWL Pharmacy
In addition, we also have exciting news from the Improvement Academy including links to great opportunities that are coming up.
Each month we will be sharing great examples from across CNWL where individuals and teams are improving systems and processes to ensure that we deliver the best evidence-based service user and carer experience where ever teams are delivering care across the trust.
Image Source: World Health Organisation
#WPSD2022 #WorldPatientSafetyDay
World Patient Safety Day takes place annually on 17 September each year to raise public awareness and engagement and drive worldwide intervention for the safety of those to whom we provide care. Observing this day inspires countries across the globe to prioritise patient safety within their healthcare systems. Patient safety highlights the importance of preventing or reducing the risks, errors, and avoidable harm suffered by healthcare service users and patients worldwide. World Patient Safety Day is among the 11 global health campaigns sponsored by the World Health Organization (WHO, 2022).
The topic of patient safety emerged as a result of the increasing complexity of healthcare systems and the global increase in recorded cases of patient harm (WHO, 2022). World Patient Safety Day is firmly grounded in the fundamental principle of medicine – ‘first, do no harm’.
World Patient Safety Day was created in May 2019 when the World Health Assembly adopted the resolution for global action on patient safety. The global campaign was the brainchild of a series of Global Ministerial Summits on Patient Safety conducted annually since 2016. It involved strong advocacy and commitment from major international stakeholders. Each year, a new theme is selected on a priority patient safety topic to highlight its importance and call for urgent action to address the issue.
WHO (2022) highlights that unsafe medication practices and medication errors are a leading cause of avoidable harm in health care across the world. Medication errors occur when weak medication systems, and human factors such as fatigue, poor environmental conditions or staff shortages, affect prescribing, transcribing, dispensing, administration and monitoring practices, which can then result in severe patient harm, disability and even death (WHO, 2022).
WHO (2022) have highlighted that the ongoing COVID-19 pandemic has significantly exacerbated the risk of medication errors and associated medication-related harm. WHO (2022) believes this to be a huge burden of harm, therefore “Medication Safety” has been selected as the theme for World Patient Safety Day 2022. The theme builds on the ongoing efforts of the WHO Global Patient Safety Challenge: Medication Without Harm. WHO (2022) believe that this campaign will provide much-needed impetus healthcare system leaders to take urgent action for reducing medication-related harm through strengthening systems and practices of medication use.
In the lead up to #WPSD2022 next month we will be highlighting resources, events and activities that will be happening across CNWL to promote WPSD and medication safety. If you would like more information about how you can get involved in WPSD activities then please feel free to contact the Patient Safety team at: datixsupport-cnwl@nhs.net
If you would like to explore medication safety ideas for an improvement project with a member or our team please do not hesitate to get in touch with Geetika Singh, our Head of Quality Improvement at geetika.singh@nhs.net and we will be more than happy to help you.
Additional ways of gaining support are at our QI Clinic by contacting us at cnw-tr.improvementsupport@nhs.net and other educational opportunities here.
In keeping with theme of medication safety, this month we also have an improvement story from HMP High Down and how they have improved the number of missed medications by 12% as part of this year’s CNWL improvement practicum. If you would like to read more than please click here.
References:
Bodenheimer, T. & Sinsky, C. (2014) ‘From Triple to Quadruple Aim: Care of the patient requires care of the provider’, Annals of Family Medicine, 12 (6), pp.573-576. doi: https://doi.org/10.1370/afm.1713
Institute of Medicine (U.S.). (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, D.C., National Academy Press.
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To Err is human: building a safer health system. Washington, D.C., National Academy Press.
Perlo, J. et al. (2017). IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. Available at: http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx
World Health Organisation (2022). World Patient Safety Day 2022. Available at: https://www.who.int/news-room/events/detail/2022/09/17/default-calendar/world-patient-safety-day-2022
Improvement Stories: Improving medication safety @ HMP High Down
Following on from the introduction of World Patient Safety Day and the theme for 2022 being medication safety, this month we have an improvement story from HMP High Down and how they have improved the number of missed medications by 12% as part of this year’s CNWL improvement practicum. If you would like to read more then please click here.
Improvement Stories: Reducing pressure ulcers @ Milton Keynes District Nursing Services
This improvement story focusses on the reduction of Category 3 pressure ulcers developed in the Milton Keynes District Nursing service. Kristina Thomson and her team, Milton Keynes District Nursing service, also produced a Quality Improvement (QI) poster about this project that won an Improvement Academy Award in May 2022. If you would like to read more about how the team improved pressure ulcer identification and intervention that resulted in a 25% reduction in category 3 Pressure Ulcers then please click here.
Meaningfully involving service users and carers in quality improvement work
Improvement Academy presents @ IHI/BMJ International forum on Quality & Safety in Healthcare in Sydney, Australia - Monday 25 July 2022
It has been a busy couple of months with CNWL teams presenting their improvement stories at different conferences across Europe and Australasia.
This month, members of our Improvement Academy faculty, Geetika Singh, Head of Quality Improvement, Sandra Jayacodi, Service User Advisor and Lucy Palmer, Head of Involvement presented their learning around how we are achieving meaningful involvement of service users and carers in our improvement work across the trust to the IHI/BMJ Conference in Sydney. There was also a contribution by Sarah McAllister, Former CNWL Improvement Coach.
Even though it was an early start to the day, 0400hrs GMT, to present virtually to the Australasian audience, this was an exciting opportunity for the team to share and learn by engaging in Q&A discussions that generated lots of interest and enquiries to understand how we have been able to achieve these successes. The team discussed how meaningful involvement can have a profoundly positive effect on services, experts by experience and staff alike.
The main focus of the presentation was on the establishment of our Expert by Experience (EbE) Improvement Forum at the international stage.
To ensure meaningful involvement of service users and carers within our quality improvement work, members of the QI team and Involvement team have established and co-produced a collaborative working group of service users and carers who have used CNWL services. Our group currently consists of 8-9 patients, service users, carers and community members, who are passionate about improving services and are involved in improvement activities. This group is called Expert by Experience (EbE) Improvement Forum that meets every 8 weeks.
The EbE forum offers practical tips for involvement, quality improvement training opportunities and a space for members to share their current experiences of working with quality improvement teams.
Furthermore, it provides advice, support and coaching to CNWL staff on EbE involvement on their improvement projects. CNWL staff can book a 20-minute time slot. In the allocated time slot, the project team gets the chance to share their improvement journey/idea and get live coaching from the forum members.
The forum will also ensure that EbE can maintain involvement in future quality improvement work. This will enable the identification of future quality improvement opportunities so that EbE will be part of the improvement conversation from inception of an idea to projects delivering outputs and outcomes.
If you would like a 20 minute slot to discuss or explore how to get more meaningful EbE involvement in your improvement work, then please do to get in touch with Geetika Singh, our Head of Quality Improvement at geetika.singh@nhs.net and she will be more than happy to help you.
Additional ways of gaining support are at our QI Clinic by contacting us at cnw-tr.improvementsupport@nhs.net and other educational opportunities here.
#WMTY event with CNWL Pharmacy
What Matters to You?
Like many other teams, responding to Covid-19 meant that the Pharmacy Operational Leads at St Charles Hospital have had a busy few years with limited time to stop and reflect. At their Team away day they decided to use Improvement tools to take a moment to pause, reflect and plan. Using a Lego Serious Play ® facilitated by Bridget Browne, Improvement Advisor the team built a series of models to reflect on "What Matters to you?" before coming together on a final build of “How do we build a team that matters to us?”
Deputy Chief Pharmacist Anshu Rayan said of the day "What a wonderful day. The team really appreciated having time to reflect and review and set the pace for the future…lots of innovation and enthusiasm. Utilising Lego to open up creative conversations and engaged us all"
If the idea of holding a WMTY event in your local area interest you and you would like to explore this further with a member or our team please do not hesitate to get in touch with Geetika Singh, our Head of Quality Improvement at geetika.singh@nhs.net and we will be more than happy to help you.
Additional ways of gaining support are at our QI Clinic by contacting us at cnw-tr.improvementsupport@nhs.net and other educational opportunities here.
Image Source : https://wmty.world/
Bronze QI Training – Bitesize – Now CPD accredited!
We are pleased to announce that the Continuing Professional Development (CPD) Service has now accredited the Improvement Academy’s level 1 Bronze QI training from July 2022. If learning more about quality improvement and how you could gain skills to commence your improvement journey to address your messy problems then please click here. We look forward to providing more CPD accredited courses for 2022 and beyond and will update you in future newsletters.
The QI Clinic is here to support your improvement ideas:
Book time with us today to discuss
We are excited to announce that we have listened to your feedback and have increased our QI Clinic time slots from 20 to 30 minutes. So take the opportunity today to book a QI Clinic slot while they are still available!
To book, send a request stating your preferred date and time to cnw-tr.improvementsupport@nhs.net and we shall confirm back to you with a diary invite and link to your QI clinic slot.
We look forward to speaking with you!
Useful Links
Contact information for Improvement Advisors:
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Diggory Division |
Peter Toohey |
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Goodall Division and Corporate |
Peter Smith |
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Jameson Division |
Bridget Browne |
CNWL Improvement Academy Microsite: https://www.cnwl.nhs.uk/ia
Life QI: www.lifeqisystem.com/
If you want to get in touch please contact us here:
cnw-tr.improvementsupport@nhs.net
and follow us on twitter by clicking @CNWLImprovement.