140 likes | 264 Views
‘Active Risk Management at Rotherham’ Rotherham NHS FT QUEST presentation 24th June 2011 Dr Trisha Bain. What is risk management?.
E N D
‘Active Risk Management at Rotherham’Rotherham NHS FTQUEST presentation24th June 2011Dr Trisha Bain
What is risk management? ‘Risk management is the identification, assessment, and prioritisation of risks followed by coordinated and economical application of resources to minimise, monitor, and control the probability and/or impact of negative events or to maximize the realisation of opportunities’
QUEST topics VTE Falls, Pressure Ulcers, UTIs Falls care pathway assessments Pressure ulcer assessment , including MUST UTIs – blood sampling method to accurately identify catheter related UTIs
Identification of risks • Web Datix Incident • Web Risk registers • Serious Incident process • Mortality reviews (Trust and CSU MDT) • Global Trigger • NICE/NCEPOD, National Audits • CHKS :national and peer benchmarking
Assessment and management of risk across pathways: Falls • A&E: Falls and Fracture pathway (50-75yrs) • Referral Osteoporosis and Bone Health Clinic • Referral to community: home safety assessment, falls management • FNOF pathway were appropriate • Ward Falls assessment and MDT Action Plan • Discharge forms to the community team
Community to BoardMonitoring and ImprovementProgrammes • SNAP electronic data collection tool • All wards, community sampling • Automated ‘real-time’ feedback reports • Linked to quality accounts programmes
Local level monitoring B3 Ward Quality Indicators B2 Ward Quality Indicators
Trust wide monitoring Falls from height: April 2009 – March 2011 Falls same level April 2009 – March 2011
National benchmarks of reported slips, trips and falls in acute (NPSA 2010) hospitals
Proxy measures VTE90% target metevidence ofactions
Linked to improvement programmes: Quality Accounts • 95% high risk prescriptions, opiates, anticoagulants, antibiotics prescribed as per protocol • Reduce number of communication incidents : handover/hand-off • Continue to have zero Never Events Patient Safety Patient Experience • Increasing responsiveness to our patients needs on composite indicator (PET) • Increasing compliance to 95% of key measures of End of Life care pathway Clinically Effective KPIs • Linked to Improvement programmes • On-going : • Mortality. Fluid balance and MUST tool • CQUINs, National Priorities • Reducing 30day re-admission rates for Falls, Diabetes, • COPD • Continue to achieve month on month 90% VTE risk assessment • Ensure 90% of VTE prophylaxis prescribed as per national guidance
Continuous improvement and management of risks