Our improvement journey - July 2016

We've come a long way since we began our improvement journey in January, and since the last update in April the improvements we're making are really starting to take shape.

Staffing remains one of our biggest challenges. Over the last few months we have made some progress with our recruitment drive. Since last autumn, the number of nursing staff in the Emergency Department (ED) has increased by 20 per cent.

Managing the high demand for our services will be a priority for years to come and much of our improvement work aims to support our team in the ED who all too often bear the brunt of the pressure.

Making decisions swiftly, working efficiently and being tightly coordinated with our health and social care partners, all helps to maintain a steady flow of patients through the hospital.

A critical part of this is ensuring patients experience a smooth, timely and well planned discharge from hospital, so we free up space for those who are most in need of our care.

The Care Quality Commission returned to the Trust in April as part of an unannounced visit to view the progress we have made since their inspection last autumn. The findings of this visit are published in a new report which states that "The Emergency Department had experienced an extremely challenging winter, with unprecedented demand. In this context, the improvements achieved to date were commendable".

This is something to be proud of and although it says there is still much to do, our progress and continued efforts have not gone unnoticed.


CQC icon - Staffing

Making sure we have the right number and mix of staff across all services at all times 

Maintaining a strong staffing level is an on-going challenge, as while more staff join us, others retire or leave. We currently have 166 more nursing and midwifery staff on our wards than we did in April 2013. 

A high number of vacancies can make it difficult to maintain the right skill mix on each of our wards and departments; which is why we continue to use experienced temporary staff to ensure we have safe staffing levels. 

Since April we have: 

  • Made 157 offers to nurses in India who should be with us by the end of 2016.
  • Made 20 offers to nurses in Spain and Portugal.
  • Recruited 56 newly qualified nurses from local universities, who will be joining us this summer. 
  • Following a successful apprenticeship event, with 75 per cent of attendees expressing an interest in apprentice opportunities, we have continued to promote our apprenticeship opportunities.
  • Introduced an Overseas Nursing Training Programme which offers overseas nurses based in the UK the chance to gain their NMC Registration and join us as a registered nurse.
  • Recruited five newly qualified midwives who will join us in September and two maternity support workers who are already working in our delivery suite. This follows an investment of £650,000 for around 14 additional midwives and two maternity support workers over the next two years. 

Over the next couple of months we will be:

  • Working with schools, colleges and universities to raise awareness of routes into the NHS and the diverse range of career opportunities.
  • Recruiting around 40 of our healthcare assistants and nursing auxiliaries to train as assistant practitioners from September 2016. Over the course of two years trainees will develop the skills and experience to become qualified for this exciting new nursing role supporting clinical teams across the Trust. Around 30, who began their training in 2015, are completing their first year of training.
  • Targeting people looking for a career change or those who might consider returning to a career in healthcare by promoting our free Return to Practice and Return to Acute Care courses.
  • Attending a range of recruitment events targeted at local people who may be interested in joining us as healthcare assistants, apprentices, allied healthcare professionals or nurses.
  • Continuing to recruit additional midwives and maternity support workers.

Patient flow and emergency care 

 CQC icon - patient flow

Making sure patients experience a smooth journey of care through our services and beyond remains a challenge for the whole local health and social care system

Demand for all of our services is high all year and one of our biggest challenges is discharging patients who no longer need care in a large acute hospital, so we can make space for those who do. Around one in three people attending the emergency department need to be admitted onto a hospital ward, in addition to the many who are admitted straight onto a ward via their GP.

Since April we have: 

  • Recruited nine nurses to the Emergency Department and continue to source support from temporary nursing staff, while recruitment for permanent nursing staff continues.
  • Recruited an additional senior matron in the Emergency Department. Working alongside the medical lead, this new role will help to ensure the nursing and medical teams have strong and consistent leadership.
  • Been able to admit, discharge or transfer more patients within four hours of arrival to the Emergency Department at the Great Western Hospital, despite being extremely busy.

    The team saw over 7,050 patients in June, that's 250 more than in April and around eight extra patients each day. On average 235 patients attend our Emergency Department each day, with around one in three needing to be admitted into hospital for further treatment.

    Despite this pressure, 86 per cent of patients were admitted, discharged or transferred within four hours of arrival to the Emergency Department in June. This is an improvement of eight per cent since April, although still below the national target of 95 per cent.
  • We continue to work on improving patient flow and the speed of our discharges, so that emergency patients needing admission can experience a smooth and timely transfer.
  • Work is also on-going with our health and social care partners, as well as our colleagues in the local media, to remind local people of actions they can take to support their local hospital, such as looking out for elderly friends and relatives, seeking medical help early on and choosing the most appropriate healthcare option.
  • As some patients are waiting in the Emergency Department for longer than we would like, we have strengthened the care plan we develop for each patient. This is to ensure that each patient receives the essential on-going care and nursing assessments that would usually take place in a ward environment.
  • Extended the electronic security system, already in the Emergency Department, to the Observation area.
  • We are embedding new patient safety check lists for more critically ill patients attending the Emergency Department. These are supported by the Academic Health Science Network and will provide staff with a simple time-based framework of nursing and medical tasks.

Over the next couple of months we will be:

  • Investing in additional equipment within the Emergency Department to ensure staff have all the equipment they need to hand, to provide essential care.
  • Continuing to recruitment more permanent nursing staff to join our team in the Emergency Department, so we are less reliant on temporary staff.
  • Continuing to audit and review safety and quality improvement within the department to support staff with further developments and to embed and build upon positive changes.

Caring for patients with mental health needs

 CQC - icon - mental health

Making sure we adapt our care to meet the individual needs of patients

Since April we have: 

  • Been reviewing the environment in the Emergency Department Observation Unit to evaluate how it meets the needs of patients with mental health needs, with a view to creating a dedicated area. This work is taking place in partnership with Avon and Wiltshire Mental Health Partnership NHS Trust and NHS Improvement.
  • Continued to work with Avon and Wiltshire Mental Health Partnership NHS Trust to ensure we have the right level of specialist mental health staff within our Emergency Department Observation Unit.
  • Continued to ensure all staff are using essential mental health risk assessment documentation.   

Over the next couple of months we will be:

  • Continuing to ensure all staff within the Emergency Department have completed mental health training.
  • Working with Avon and Wiltshire Mental Health Partnership NHS Trust to agree contracts for substantive mental health nurses to work in Emergency Department Observation Unit.
  • Working with our commissioners to agree the level of specialist mental health services needed in an acute hospital.
  • Exploring potential areas for the relocation of the Emergency Department Observation Unit to ensure the environment is adapted to the needs of our patients with mental health needs. 

Learning and effective governance

 CQC -icon - Learning

Making sure we are open, learn, share and improve 

Since April we have: 

  • Further strengthened our focus on the National Early Warning Score (NEWS), with simulation training and a video, to improve awareness and ensure staff can use the tool confidently and accurately. NEWS is a standardised NHS monitoring tool for all patients in hospitals, which can be used to help identify patients whose condition is deteriorating, and to trigger a timely response. 
  • Continued to involve staff in the Quality Improvement Coaching and Peer Support Network, to build on our culture of openness and transparency and encourage staff to share ideas in relation to quality improvement.
  • Shared quality improvement toolkits with staff to support their own quality improvement work.
  • Specified within nursing job descriptions the responsibilities for checking and monitoring patient documentation, to ensure staff recognise the importance of good record keeping.
  • Further strengthened governance arrangements within divisions by introducing more standardised documentation and the structure of local governance meetings, such as consistent management of the risk register, agendas and performance dashboards.

Over the next couple of months we will be: 

  • Reviewing the internal incident reporting system to ensure staff are reporting near misses and risks, as well as incidents. 
  • Launching a new safety newsletter for all staff to share the themes and learning from reported incidents, near misses and risks.

The above information is available in a downloadable PDF file:

Our improvement journey - July 2016

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