Customer: Safer Salford
Challenge
The Safer Salford programme is a system-wide, quality improvement focused initiative that began in 2016 in the wake of the Francis and Berwick reports (2013), and Salford’s involvement in The Health Foundation’s Safety Measurement programmes (2014a, 2014b).
This learning provided the impetus for a partnership of health and social care system leaders¹ collaborating as partner organisations to inspire safe high-quality care across the city-region; strengthening links and sharing best practice between the converging health and care sectors.
At its inception, Safer Salford’s approach to work on safety at a system rather than organisational level was deemed progressive. The challenges of safety work across a system that is itself changing – for example with the incorporation of Salford’s Integrated Care Organisation into the programme in 2016 – cannot be understated.
The challenge for aqua was to collaborate with the partners to reduce unnecessary patient harm, improve treatment outcomes and reduce waste; in both clinician time and erroneous or superfluous medication prescription.
At the time the programme launched primary, secondary and community care records were disconnected, and a clear record of care did not move with patients between services. Salford’s care homes were performing very poorly, with the Care Quality Commission (CQC) ranking them at 150 out of 151 in the national standings.
Public health outcomes in the city-region were also below the national average. This was in part due to a lack of engagement with health and care services. There was also a failure to take undertake healthy behaviours which could have a positive impact.
In partnership with the Safer Salford pharmacy teams, aqua designed and implemented seven new programmes to improve medication safety. These included a Neighbourhood Integrated Practice Pharmacists (NIPPS) project team providing pharmacy capability to support medicines optimisation in Salford general practices following hospital admissions, specialist pharmacists; embedding pharmacists in GP practices; and establishing best practice around the prescription of medication in care homes.
As part of this, a digital tool was developed to help care homes manage medicines safely and an online referral platform signposted patient discharged from hospital to their nearest appropriate pharmacy.
A project to integrate patient records and encourage better communication between services was called the Safer Handover project. From 1,000 discharge summaries, aqua created a new training plan for junior doctors to improve these documents. This was also informed by 300 patient interviews and mapping 25 patient journeys, from admission to discharge home, in order to capture lived experience and the patient voice.
Safer Salford also brought together staff from the care sector, to establish the areas of failing, to shape change and build the internal capability required to improve them. Eight interactive events spanned topics including nutrition, dementia, medicine use, and the best way to analyse complex dashboards.
Another programme strand comprised the design and roll-out of engaging videos and interactive tools, which encouraged patients to take ownership of their own health, while signposting the most appropriate source of treatment.
The pharmacy initiatives have resulted in a marked decrease in: patients being prescribed the wrong medication; inappropriate prescription of antibiotics; the prescription of risky drug combinations; and care home residents being admitted to hospital due to problems with their medication.
Around 3,000 fewer patients in Salford are now at risk of taking inappropriate medication. The NHS England Chief Pharmacist, Dr Keith Ridge, has hailed Salford as having the most integrated pharmacy team in the country.
Through the Safer Handover project there was an increase from 5% to 19% of discharge summaries rated “great” overall and early signs of improvement in the follow up action, clinical information and functional assessment information. Plus the patient communication and video education programme has led to reductions in unnecessary onward referrals or admissions to hospital.
Four out of five GP practices reported improvement in patient care and all practices which took part in the programme have a member of staff trained in QI methodology and the frameworks to build continuous improvement for the future.
Better patient engagement has led to increased uptake of cervical screening; a reduction in blood glucose levels in at-risk patients; reduced use of prescribed opioids; and increased attendance of childhood asthma reviews.
The work done with care workers has led to Salford’s care homes rising 118 places in the CQC rankings in less than four years, to be cited in the top third nationally.
In early 2020 all care homes in Salford were rated “good” or “outstanding” in CQC Safe and Responsive domains. There has also been a reduction in A&E attendances from care homes, including a 66% reduction in admissions due to falls.
A new digital dashboard rolled out in care homes has enabled the quick and simple assessment of complex data to improve safety and inform decision making. These new digital systems have been vital to the COVID-19 response.
AQ: Improving Care for Patients with Sepsis in an Acute Trust
Southport and Ormskirk Hospital NHS Trust provides acute hospital services to 258,000 people across Southport, Formby and West Lancashire. Acute care is provided at Southport and Formby District General Hospital and Ormskirk and District General Hospital. Sepsis accounts for around 1,200 acute admissions to the trust each year.
AQ: Aintree Improvement Journey for Patients with Alcohol Related Liver Disease
Aintree University Hospital NHS Foundation Trust joined the Advancing Quality (AQ) programme at its launch in 2008 and is currently participating in eight clinical focus areas (CFA), this includes Alcohol Related Liver Disease (ARLD).
AQ: Reducing Avoidable Harm through Patient Assessment & Escalation
In patients who are, or become acutely unwell in hospital, there is evidence that deterioration is not always recognised or it is not acted on rapidly enough (NICE, 2007). The Walton Centre NHS Foundation Trust wanted to improve observation recording, recognition and response to deteriorating patients using the NEWS assessment tool.
AQ: Reducing Mortality in Community Acquired Pneumonia (Liverpool University Hospitals NHS Foundation Trust)
The NICE (2014) guidance publication ‘Pneumonia in Adult: Diagnosis & Management’ covers diagnosing and managing Community Acquired Pneumonia (CAP) in adults. Its aim is to improve the accurate assessment and diagnosis of pneumonia to help guide antibiotic prescription and ensure that people receive the right care. It estimates a mortality rate between 5% and 14% for patients admitted to hospital with CAP.
AQ: Serum Lactate in the Treatment of Sepsis
he Royal Liverpool & Broadgreen University Hospitals NHS Trust (RLBUHT) identified an opportunity to improve the early diagnosis of patients with sepsis. Evidence suggests that the sickest sepsis patients have high levels of serum lactate. Timely measurement of serum lactate levels in patient pathways can improve early diagnosis which will lead to improved outcomes.
AQ: Embedding Early Assessment In Out of Hours Primary Care
Sepsis and deterioration is a huge clinical problem and 70% of sepsis cases originate in Primary Care. In the last five years we have experienced a culture shift in primary care; from seeing sepsis as an acute condition that is difficult to detect, to recognising the need to actively assess patients where infection could be causing significant illness or deterioration.
AQ: Effective Management of Frailty in Hip & Knee Replacement (Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust)
NHS England defines frailty as ‘where someone is less able to cope with and recover from accidents, physical illness or other stressful events’1. As the population ages, so frailty rates increase, presenting challenges to care systems. Elective hip and knee replacement patients undergo pre-surgical checks to ensure they are able to cope with their procedure.
AQ: Improving the Management of Acute Kidney Injury (AKI)- Role of the AKI Pharmacist
The 2009 NCEPOD report, Adding Insult to Injury, reviewed outcomes for patients with acute kidney injury (AKI) in hospital. The report found that medication was the most common AKI risk factor not assessed and only 15% of patients had their medication altered to renal doses. The national AKI programme Think Kidneys advises that medicines optimisation is essential to reduce the risk of AKI and mitigate its severity if it occurs.
Sepsis is a life-threatening condition which has in recent years become a high priority for healthcare providers. Early recognition and prompt management of sepsis can improve outcomes for patients, reducing the risk of mortality and morbidity. This could potentially save 14,000 lives and result in 400,000 fewer days in hospital for patients every year, according to estimates by the Sepsis Trust.
AQ: A Collaborative Approach to the Management of Acute Kidney Injury (AKI)
Southport and Ormskirk Hospitals NHS Trust has established a steering group to improve care for patients with AKI. The group is using the care bundle data from the Advancing Quality Alliance (AQuA) Advancing Quality (AQ) AKI programme to monitor care delivery for patients with AKI and to provide a framework for improvement.
AQ: Improving the Ultrasound Scanning Process for Patients with Acute Kidney Injury
Acute kidney injury (AKI) may sometimes be caused by an obstruction in the urinary tract, which can require treatment with a nephrostomy. It is important that people with AKI who are suspected of having a urinary obstruction receive an ultrasound scan early in their management, as outlined in national guidance (NICE, 2019).
AQ Insight Reports: Case Study
More patients are admitted to hospital as a result of pneumonia in the north of England compared to the south. In the North West in 2019, the rate per 10,000 population was 58.5. To help reduce unwarranted clinical variation and health inequality, capture best practice and share evidence-based insights to AQ members across the North West, the AQ team created ‘Insight Reports’.
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