Human Rights in Healthcare Betsi Cadwaladr University Health Board

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Human Rights in Healthcare Betsi Cadwaladr
University Health Board

• Anne-Marie Rowlands Deputy Director of Nursing
• Sally Hughes-Jones Head of Equality and Human
  Rights
• Julie Smith Associate Chief of Staff Nursing

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About BCU Health Board

• Largest health organisation in Wales
• Primary, community, mental health acute
  hospital services for a population of around
  676,000
• Workforce around16,000 staff
• Budget around 1.2 billion

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Acute and Community services

• 3 district general hospitals
• 22 other acute and community hospitals
• 90 health centres, clinics, community health team
  bases and mental health units
• 121 GP practices and NHS services provided by
  North Wales dentists, opticians and pharmacies.

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Our Strategic Direction

• Anyone coming in contact with a public service
  should be treated with respect and dignity, have
  their health need assessed, be helped and not
  handed off to someone else, receive a responsive,
  safe and high quality service that continually
  improves, is easy to access and understand
  (Strategic Directions 2009)

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Our Positive Obligation

• Positive obligations on public authorities to
  take a proactive approach to human rights.
• FREDA principles (Fairness, Respect, Equality,
  Dignity, Autonomy) underpin Human Rights and
  public service ethos.
• Supports BCU Strategic Equality Plan our
  organisational values

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Human Rights Based Approach

• Empowers service users and staff
• Protects vulnerable people
• Improves experience
• Improves outcomes
• Bring human rights to life by applying the
  principles to a clinical pathway

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Leading Defining the Project

• Championed at Board level by the Director of
  Nursing, Midwifery and Patient Services
• Deputy Director of Nursing, whose portfolio
  includes nutrition
• Head of Equality and Human Rights
• Associate Chief of Staff Nursing, lead for
  transformational group

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Why Human Rights, Nutrition and Hydration?

• Patient Association, Care Quality Commission,
  Ombudsman, Age Concern
• No specific guidance direct link nutrition,
  hydration, human rights obligations of service
  providers
• Evidence, guidance and best practice
• BCU huge organisation different ways of
  working

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Quality Patient Care

• Ward staffing/ nurse patient ratio review
• Supernumerary ward sisters/charge nurses
• Introduction of matrons
• Strategic nutritional and catering group
• Saving 1000 Lives Intentional rounding
• Striving for excellence good is not good
  enough

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Project Aims

• Development of a practical toolkit
• Directly links nutrition, hydration, human rights
  obligations of service providers
• Increase knowledge and awareness of human rights,
  nutrition and hydration
• Embed dignity and human rights within everyday
  ward routine
• Place the patient at the centre of care.

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Achieving the Aims

• Multidisciplinary project steering group
• Redefined the role of nutritional sub group
• BIHR Human Rights training
• Brainstorming session - practical starting point
• Project plan driver diagram agreed
• Draft toolkit developed

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Engagement and Involvement

• Communication press briefing
• Stakeholder event - ward staff, dietetics, Speech
  and Language, education, catering, service users,
  specialist nurses
• BIHR training, questionnaire, workshop
• Draft toolkit questions posed positives and
  negatives? what would you change? barriers to
  implementation?

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Outcome of Stakeholder Event

• Event ideas and feedback discussed
• Changes to toolkit made
• 6 pilot wards identified (mix of acute medical,
  care of the elderly, acute surgical, acute
  orthopaedic)
• BIHR training for pilot wards, matrons and senior
  nursing team

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Transformational sub group

• Reporting to Human Rights steering group
• Monthly meetings
• Leads identified to support pilot wards
• Focus on establishing the baseline, identifying
  areas for change
• Testing (and changing) the toolkit

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Drivers to Succeed

• Over arching aim
• Primary Driver (Patients receive the required
  level of support with eating drinking)
• Secondary Drivers (Safety, Environment etc.)
• Interventions
• Cornerstone of the toolkit

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Drivers Key Components of Nutrition Hydration
in relation to Ward Routine
Environment Ensure appropriate environment of
care including access to equipment.
Safety Identify vulnerable patients and those at
risk at the beginning of every shift. Establish
an alert system.
Choice Enable and promote choice and ensure 24
hour access to food and drinks.
Meal times Ensure mealtimes are protected. Enable
and promote appropriate involvement of carers and
volunteers
Empower patients and their families. Ensure and
enable regular communication. Ensure patients
autonomy and dignity is respected.
Audit compliance and measure improvement MUST
audit and fundamentals of care audits. Identify,
monitor and learn from concerns.
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Principles of Improvement Methodology

• Initiative to improve patients nutrition and
  hydration in various areas of practice using PDSA
  cycle methodology with fast cycling
• Measure it gt change it gt re-measure it gt change
  it
• Until you get it right!
• Aims to introduce effective processes and systems
  for staff in ward environments
• Aims for culture change!

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Methodology
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Human Rights Strategic Group
In Patient Transformational Group
East Central West
Mealtimes Environment
Patient Choice
Patient Safety Empowerment
Measurements
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How did we do it ?

• East pilot areas
• Patient safety and empowerment work streams in
  line with improvement methodology
• Wards and teams identified
• Operational definitions for measurements
  developed
• Baseline measurements undertaken
• PSDA cycles - process redesign
• We stacked the odds in our favour!!

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Patient Safety

• 3 dimensions of patients safety
• Identification of patients at risk during safety
  briefing (measure 1)
• (Safety briefing measure 2)
• Delegation of Nursing orders (measure 3)

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Methodology

• Baseline measurement on pilot ward showed
  identification of patients at risk at safety
  briefing at 59
• Target compliance 95

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Methodology (2)

• Changes introduced
• Raise awareness of human rights approach and
  toolkit development matrons meeting/staff
  meetings
• All Wales e learning directive for all nurses to
  complete
• Posters for SBAR
• Symbols
• Letters to nurses in charge outlining roles and
  responsibilities
• Red jugs/lids
• At a glance board
• Roles and responsibilities e.g. For house keepers
  for data collection, Change ward routine in
  relation to undertaking distribution of red
  jugs/symbols

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Example of reliable design evolution

• Implement a system to ensure patients at risk are
  identified at safety briefs
• Who - All team leaders
• What ensure at risk patients are identified at
  safety briefing
• When during safety briefings (3x daily)
• Where - Pilot ward
• How -
• Design brief the nurses regarding
  responsibilities of identifying patients at risk
• Redesign re introduce safety briefing into ward
  3 times daily
• Redesign develop a poster to be clearly
  displayed at nurses station prompting safety
  brief times
• Redesign - change the pm SB time to accommodate
  shift patterns
• Redesign introduction of symbols relating to
  patients at risk

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Reliable Process Design
Dont forget
Dont Forget
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Results weekly data
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Results monthly data
Introduced symbols/posters
Re affirmed RR
No SB (nights)
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Delegation of need
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Empowerment
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Conclusion

• Through repeated testing and process redesign,
  reliability and sustainability achievable
• Lessons learnt
• At the beginning state who, what, where and when
  (prevents defects being the people you forgot to
  include!
• Keep it simple
• Spread only when processes reliable

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Next Steps

• Project steering group meeting Dec 12
• Agree implementation plan
• Development of ward resource file/website
• Communication within organisation
• Strategic Nursing and Midwifery Committee
• Improving Service User Experience Committee
• Evaluation of impact
• Sharing across Wales and wider

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Thank You

• Our contact details
• Anne-Marie.Rowlands_at_wales.nhs.uk
• Sally.HughesJones_at_wales.nhs.uk
• Julie.Smith_at_wales.nhs.uk