Quality Improvement Zone

To increase Standard Infection Control Precaution compliance with all cleaning episodes carried out between patient operations in the Vanguard theatre, Raigmore Hospital, from 60% to 90% or above by February 2018

The project aimed to reduce the rate of all PPH (blood loss greater than 1L) within the maternity unit in NHS Fife by 15% by January 2018.

Aim: By December 2017, 95% of patients will have an accurate Needs Assessment Summary and Careplan (NAS), reducing the need for ​Enhanced Engagement (EE) in Ward 10, BGH.​

The aim of medicines reconciliation when patients are admitted to hospital is to ensure that important medicines aren’t stopped and that new medicines are prescribed, with a complete knowledge of what a patient is already taking.(NPSA, Dec 2007)....

Project Aim: By December 2017, 100% of patients within Urquhart Ward, Biggart Hospital will have an accurate Early Warning Score and Frequency of observations carried out and patients with a NEWS ≥5 will be appropriately escalation to FY2/ANP.

AIM : By March 2018, all patients leaving Ward A will have a risk assessment and safety plan that has been developed to minimise harm incidents whilst promote recovery.

Aim: By February 2018, 90% of patients being discharged from Ward 23a, Ninewells Hospital, Dundee, will be provided a printed list of medicines on discharge. ​

By 30th September 2017 95% of patients who are admitted to Ward 102 are participating in the get up, get dressed, get moving programme.

Aim ​ Within Cardiology our aim is to go 300 days without an adverse event that includes​ deterioration as a causal factor. ​

Aim: By 1st April 2018, we will reduce the number of times an ‘at risk’ patient in Ward 4A (Fracture & Acute Orthopaedics) is incorrectly repositioned by 50%

Aim Aim is to achieve 30 days between incidence of acquired avoidable grade 2 and above tissue damage within Ward 53 Queen Elizabeth University Hospital Glasgow by May 2018

Aim: By May 2018, 90% of all adverse events reported will have the appropriate level of review and 100% of serious adverse events (graded major harm or death) will have a full review and improvement plan in place

Project Aim: By March 2018: Three nurses within NHS 24 Cardonald Centre would achieve the 90% KPI for the effective metric: 'Identify action already taken‘

Aim:To facilitate an organisational wide Safety Brief taking no more than 15 minutes which is multidisciplinary, focused on delivering safe patient care and effective Patient Flow by end of March 2018.

Aim: By July 2018 100% of patients will have a 4AT assessment completed if they are showing potential signs of delirium and if positive have elements of a delirium bundle completed​

Aim: 30% reduction in central line associated blood stream infections (CLABSI) in the Neonatal Unit of the Royal Hospital for Children by 31st March 2019.

AIM By August 2018 60% of clinical staff will have completed an on line module raising awareness of the duty of candour.

Increase the % of patient-days in which our patients receive adequate protein from 29% to > 80% by December 2018

By 30 November 2018, Ward 14 in the Vale of Leven Hospital will be able to demonstrate 50% reduction of reported medicine administration errors

Improve early detection and response to clinical deterioration and reduce the number of clinical emergency calls by 10% in ward 109 by December 2018.

A reduction in falls by 50% on ward 14 at BGH by November 2018

By 1st Nov 2018, Ward 3C at Gartnavel General Hospital will demonstrate 85% compliance with the recording of between meal snacks, on the Food and Drink Recording Chart for all nutritionally vulnerable patients who are eating and drinking.

To achieve 95% reliability in the delivery of a mealtime bundle in critical care at GRI by 1st December 2018.

Reduction in Falls Within Acute Neurology to no more than two per calendar Month by the end of November 2018

To improve accuracy of Single Question in Delirium answer for patients in Ward 2 East to 95 % by March 2019.

Aim – 85% of patients will have a diagnosis documented at the point of discharge from Intensive Home Treatment by November 2018.

To reduce the number of coagulation screen tests requested by Belfast City Hospital surgical pre-assessment team by 50% by the end of April 2018

To eliminate preventable falls on Neurology Ward by 20% by June 18 by identifying patients at most risk and to put in place triggers to reduce the likelihood and frequency.

To reduce average fracture patient active recovery time (from leaving theatre until fit for discharge) by 25 minutes by 1 May 2018

To eradicate CoNs sepsis within 72 hours of insertion of a PICC line by September 2018.

By March 2018, reduce of unnecessary attendances following orthopaedic trauma for Metacarpal or Radial head fractures by 50%

Project Aim: By March 2019 90% of the East Ayrshire Adult Speech and Language Therapy Team will experience quality supervision in line with regulatory standards and recognised good practice.

AIM: By December 2018 pilot ward 7C will achieve a 50% improvement in reliability of documented clinical escalation for all elevated NEWS scores that are out with documented, acceptable parameters.​

AIM: By January 2019 there will be a 15% reduction in patient falls with harm in Brandon Ward Udston

Aim: By Jan 2019 90% of parents within Nairn district identified with anxiety concerning parenting during their 6-8 week Health visitor check will receive additional advice and/or support. Sub Aim: To upskill early years staff by 50% to be...

Aim: By January 2019, reduction in waiting time from referral to diagnosis in patients with food and complex allergies from average of 18.5 weeks to average of less than 12 weeks and also reduction in number of appointments per patient.

AIM: Anticipatory Care Planning conversations will happen reliably in 75% of patients in the respiratory ward at the Western General Hospital, Edinburgh by March 2019.

Aim: By January 2019, 95% of women receiving high risk medicines identified on the local high risk medicines list in Ashgrove and Summerfield wards at Aberdeen Maternity Hospital (AMH) will have the appropriate specialist prescription and...

AIM: By January 2019 the Emergency Department will achieve a 20% improvement in reliability of medical assessment for Sepsis within 15 minutes of arriving into the Emergency Department at Raigmore Hospital.

Aim: Reduce the number of yellow calls waiting over 60 minutes on one ACC shift in the Lothian area by 100% by February 2019. - 10 patients a day on average are waiting excessive times for an ambulance to this category of emergency call.

Aim: by the end of December 2019 clinical staff will reach a target of greater than 90% compliance with hand hygiene.

AIM: To reduce time to theatre for patients who require medical optimisation, to reduce “medical delays” by 25% by February 28th 2019 *Delay = >36 hours from admission to surgery

Aim 100% of patients at Tranent Medical Practice who had a blood test done receive their results within four weeks by June 2019.

Aim: 95% Care Home residents admitted to Ward 54 QEUH will return home with key documents form the Red Bag by December 2019.

AIM: To improve the therapeutic environment and culture in Ward 10 Woodland View Hospital reducing incidents of Violence/Self Harm and Restraint by 10% by April 2019.

Aim: By June 2019, a minimum of 30 patients with Chronic Obstructive Pulmonary Disease (COPD) in the NHS Forth Valley area will have up to-date observations recorded into their Key Information Summary (KIS). This will allow Health Care...

Aim: To reduce the drug prescription errors in the Medicine on Discharge Process in a Community Hospital by 50% within three months.

Aim: 95% of people with physiological deterioration in ward 51 of the acute medical receiving unit (AMRU) have a structured response and plan by June 2019.

AIM: To reduce the number of falls in Brucklay Ward by 10% by the end of May 2019.

Aim: By 31st July 2019, to have reduced the percentage of A&E letters being work-flowed to the Senior Administrative Officer by 30%.

AIM: 90% of patients will have accurate completion of fluid balance charts by April 2019 to improve fluid balance monitoring in Ward 18, University Hospital Wishaw.

AIM: By May 2019, 75% of patients admitted to Isla Ward, Whitehills Health & Community Care Centre, Angus, will have a person centred Treatment Escalation Plan in place.

AIM: To reduce the incidence of Acquired Pressure Ulcers in Castle Douglas Hospital by 50% by April 2019.

Aim: 90% of patients open to a Community Psychiatric Nurse (CPN) in the Community Mental Health Team (CMHT) will have a care plan recorded by March 2019.

Aim: By June 2019 there will be an 70% reduction in unintended drug omissions in an elective orthopaedic ward in Golden Jubilee National Hospital.

AIM: To achieve 80% compliance with Pressure Risk Assessment completion within ward 11 University Hospital Wishaw by June 2019.

AIM: Patients in ward 10 at University Hospital Wishaw, with a newly inserted urinary catheter, will have a 50% reduction in the number of days that the urinary catheter remains insitu.

AIM: By 30th August 2019 40% of patients in an adult in -patient respiratory ward with a Do Not Attempt Cardio Pulmonary Resuscitation order will have a Hospital Anticipatory Care Plan.

AIM: By March 2019 ,Over 90% of patients in A11 will have a completed admission risk assessment ‘Prevention of Pressure Injury’ on the day of admission to the ward.

AIM: > than 85% of patients admitted or transferred into ward 9 University Hospital Hairmyres will have a Person Centred Care Plan by June 2019

Aim: The electronic Safe care staffing and patient dependency tool will be completed 95% of the time in Ward 120 by May 2019.

AIM: To reduce the Additional Duty Hours requested on E roster by 50% by May 2019 in Ward 109, RIE

Aim: By May 2019, 95% of patients in B23 Forth Valley Royal Hospital, presenting with a fractured neck of femur will have an accurately completed preoperative Fluid Balance Chart.

Aim: By June 2019, in 1 team identified at Clyde Contact Centre (CCC), all clinical call takers in NHS 24 111 service, will score at least 95% in their monthly call reviews, for the section on appropriate and effective triage, relevant to...

Aim: By June 2019 increase capacity within GP Practice service to support GP manageable workload by 30% by introducing the role of Advanced Nurse Practitioner.

AIM: By August 2019 80% of staff in Skye Ward of the State Hospital will have access to their workforce tool outputs

AIM: By June 2019, 80% of patients admitted to Coatbridge Community Nursing Team caseloads will have clinical observations taken and mapped on a NEWS Chart

Aim: 95% of patients in a general adult psychiatry acute admission in-patient unit will have care plans that are person centred by May 2019.

By December 2019, the aim is to reduce the occurrence of low level incidents in the Home by 30%.

To reduce violent and aggressive incidents in a psychiatric inpatient unit (Ward 5, AMHIC) by 30% by 31 December 2019.

To reduce the incidences of aggression ad violence in two inpatient psychiatric wards by 20% by January 2020.

By December 2019 80% of Assessed Year in Employment (AYE) Social Workers in Children's Services within South Eastern Trust will report an increase in their perceived self -efficacy and confidence in role.

To increase the safety of victims of high risk domestic abuse current to Family Intervention Service, by accessing multi-agency safety plans through increased referrals to MARAC from an average of 0 per month to 2 per month by December 2019

To increase compliance with the Paediatric IV Fluid Audit Improvement Tool (PIVFAIT) from 71% to 100% by May 2020

90% of Band 5 Registered Nurses (RN) will be compliant with 50% of statutory/mandatory/essential skills listed in the learning log by November 2019

By December 2019 95% of all GP Practice Pharmacists will submit the monthly PDQIP (Prescribing Data-driven Quality Improvement in Primary Care) Tool data entry.

To reduce the use of face down restraint in a General Admission Psychiatric ward by 40% by the end of 2019.

Use of the SSKIN tool will result in a 50% reduction in the incidence of avoidable community acquired pressure ulcers (grade 2 or above) by February 2020 in housebound patients admitted to the District Nursing Caseload registered at Rubislaw and...

85% of all PPH’s will have appropriate medical escalation byendofDecember2019

Reduce the number of acute prescriptions requested in Wallace Medical Centre by 20% by March 2020

For Health Visitors in Clackmannanshire to achieve 96% completion of My Word Triangle (MWT) Assessments for all children with an allocated additional Health Plan Indicator (HPI) by January 2020.

The aim of this project is to increase the number of babies born at <32 weeks who are discharged from the RHC neonatal unit on their mother’s breastmilk by 20% by January 2020.

By March 2020 50% of patients who have been diagnosed with incurable lung, upper Gi or HPB cancer have been offered and 30% received multidisciplinary support (ESC), 25 % will have had ACP documentation.

To reduce the duration of the shift handover at Rachel House Children’s Hospice by 25% (from 23 minutes to 17 minutes) by January 2020.

To reduce the volume of documents being sent (workflowed) to the GPs by 50% by March 2020.

Reducing Medication Omissions in an Acute Orthopaedic Ward in University Hospital Wishaw

Reduce falls within an acute ‘Care of the Older Person Ward’ in NHS Ayrshire & Arran by 25% by May 2020.

By January 2020 95% of Cardiotocography (CTG’s) interpretations at the Western Isles hospital that are more than one hour should have an hourly fresh eyes review.

By January 2020, 90% of the self-referrals to the mental health service in will be seen for a screening appointment by a mental health professional within 3 calendar days of receipt of self-referral.

6 adult mental health wards show 90% compliance with key features of the Greater Glasgow and Clyde ward patient care Clozapine bundle by April 2020.

By March 2020, 100 new cancer patient Clinical Nurse Specialist speciality notes will be uploaded onto clinical portal each month within NHS Ayrshire and Arran.

By March 2020 > 90% of critical care nurses that are moved to the general wards of University Crosshouse Hospital to fill staffing gaps will report a good ward experience upon return to intensive care. (A good experience will be defined as a safe...

By October 2020, the time taken for genetic testing for ataxia from the sample being taken to the result being fed back to the patients is no greater than 273 days in 90% of the patient samples submitted at WOSCGM

By May 2020, achieve a 10% increase (target = 71.5%) in the number of PWE with good adherence who attend the weekly clinic, QEUH.

By November 2020, 95% of women in Labour Ward at the RAH will have appropriate Recognition and Response to Fetal distress by the Midwife.

To improve the frequency of pain & comfort relief measures in neonates used during minor painful procedures (heel prick, venepuncture, cannulation) in the Neonatal unit at Ayrshire Maternity Unit (AMU) up to atleast 80% by start of March 2020.

Recognition and timely escalation of abnormal antenatal cardiotocograph (CTG) Improving Midwives knowledge and confidence . Improving the outcome for mothers and babies.

By April 2020 95% of patients in Ward 8, Royal Victoria Hospital will have person centred care plans in relation to stress and distress.

By Feb 2021, 90% of patients will be prescribed weight based Intravenous maintenance fluids in the four ward areas within the Golden Jubilee

Increase to 95%, the reliability of cardiotography (CTG) data in BadgerNet, for women receiving intrapartum care in the Labour Ward, QEUH, by May 2020, to support the Maternity and Children Quality Improvement Collaborative (MCQIC) aim of...

By November 2020 we will reduce the number of overnight deteriorating patient referrals from the Surgical High Dependency Unit to the Intensive Care Unit at Glasgow Royal Infirmary by 25%.

By June 2020 the amount of IBD Nurse time taken to co-ordinate the biologic patient journey to the point of booking first infusion will reduce by 20%.

By June 2020 the number of Falls in the ward will decrease by 35% from 9 to 6 falls per month.

The NMP / Nurse Led Trastuzumab telephone review clinic was established to provide a safe, effective and patient centred prescribing service

Reducing the prevalence of pressure damage in a palliative care setting –Evidencing the need for change

To Develop a clearer understanding of the needs of people with multiple sclerosis in relation to bladder management.

Improving the Quality of Public Protection Referral forms

Reviewing and amending the weekly multi-disciplinary team meetings to focus patient discussion and care planning.

Falls Prevention: A Time for Movement

IMPROVING PERSON CENTRED NUTRITIONAL CARE PLANNING IN A CARE OF THE ELDERLY WARD

To allow the pharmacy team to deliver a service to multiple practices producing a more sustainable model to account for annual leave, sickness etc.

Focusing on and understanding pressure ulcer prevention for patients with a lower limb fracture in an acute hospital setting

Improved use of National Early Warning Score (NEWS2) and documentation to manage deteriorating patients

Timely person centred discharges (Mental Health)

Improving the uptake of Annual Health Checks

Title: Hydration improvement in Trauma and Orthopaedic care

Reducing the time between TIA symptom onset and specialist assessment

Recording plaque and bleeding scores for adults with ACORN RED/ AMBER risk for PERIODONTAL disease

Reducing variation in QA tests of Automatic Exposure Control Systems in X-ray equipment

What we learned along the way

Increase oral intake in 80% patients in frail elderly ward by June 2022 using traffic light jug system.

Ensuring patients with dementia experience meaningful activities that take account their ‘Getting to Know Me’ information

Flush the line! Are you under dosing intravenous medications?

Improving the Medicines Reconciliation Process in a Hospital at Home service

Stamping out falls in Medical Assessment Unit (MAU)

PrAMS: Pregnancy Anaemia Management Scotland in Greater Glasgow and Clyde (GGC) Health Board

By October 2022, 50% of patients known to Auchinlea CMHT Depot Clinic will have improved identification and treatment of physical health needs through reliable baseline physical health screening, improving outcomes and safety’ as per guidance from...

Improve documentation of post-operative plan on time to restart pre-existing anticoagulants and anti-platelet therapy in patients admitted to the Orthopaedic wards at the Golden Jubilee National Hospital for hip or knee arthroplasty

To increase the number of staff within NHS Greater Glasgow & Clyde accessing Clinical Guidelines by 50% by 30th September 2022; we know that being able to access safe, up-to-date guidelines will support staff in their decision making

Maximising wellbeing for the Back Pain Specialist Physiotherapy team in Greater Glasgow and Clyde.

Using quality improvement methodology to increase the provision of venepuncture and cannulation training

PREPARING PATIENTS FOR RECOVERY BEFORE SURGERY

Improving blood glucose monitoring for patients with cancer who are undergoing systemic therapies.

Early Intervention & Prevention in Fife’s Children & Young People’s occupational Therapy Service

Increasing availability of nutrition and frailty information

The importance of nutrition in frail older adults

Improving the Use and Completion of Treatment Escalation Plans (TEPs)

A look at how person-centred care rounding which incorporates falls safety checks, can improve falls rates.

Reducing Food Waste on Morlich Ward at New Craigs Hospital

By September 2022 , 95% patients in 2 key wards of Aberdeen Royal Infirmary who require a hard collar for spinal fractures will get daily, routine pad changes by ward staff

Reduce the number of telephone calls to the maternity Triage phone line in Aberdeen Maternity Hospital, from a baseline of 542 per week to <487 (10%) per week by June 2022.

Improving Compliance with Standard Infection Control Precautions

By January 2023, all 14 health boards will engage with national work to improve and standardise access to diabetes education and support across Scotland, an increase from 6

Improve and reduce the variation within the manual card process in call handling operations by 35%, and investigate novel ways to redesign supervisor and team leader summoning, in line with existing NHS 24 Clinical Governance guidelines, within a...

Seamless Care in the Stroke Unit at UHW

Reducing cancelled and attempted home visits

Improving Attitudes Towards Adverse Incidents in the Periop Department

Reducing the number of medicines management-related incidents within Coatbridge Health Centre through process improvement

Improving omissions of questions during Donor Selection Health Check within Edinburgh and South-East Donor Collection team, Scottish National Blood Transfusion Service (SNBTS)