Our improvement journey - November 2016

Looking back, since we received our Requires Improvement rating in January, these are the improvements we're most proud of.


CQC icon - Staffing

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

Recruiting more permanent staff and achieving a strong skill mix is easier said than done, with a national shortage and experienced staff retiring or leaving, while others join us. 

Because of this it's a challenge which will not go away over the next few years. 

Over the last year we've invested a lot of time and effort into recruitment and will continue to do so. We now have 66 more nursing and midwifery staff on our wards than we had in January and 182 more than we did in April 2013 when our recruitment drive began. 

This includes five nursing staff in the Emergency Department since January and an additional senior matron to work alongside the medical lead. This new role will help to ensure the nursing and medical teams have strong and consistent leadership. 

Since January we have: 

1. A better oversight of staffing

Staffing is now monitored in 'real time' and any risks are escalated promptly.

We must continue to use experienced temporary staff to ensure we maintain safe staffing levels, but when extra staff are needed, an effort is now made to use the same temporary staff where possible. This means we are using staff who are familiar with the department and the processes they follow.

New members of staff are now given an induction pack.

2. Explored international recruitment

Earlier this year we began recruitment in India, however the complexities involved in foreign recruitment, means that nurses who had expressed an interest in working with us, are now unlikely to complete the recruitment process this year.

Although things are moving more slowly than initially expected, our Recruitment Team are doing all they can to ensure they can join us as soon as possible.

Our international recruitment drive, which has seen us welcome 17 nurses from abroad this year, will continue in Europe and we will also continue to explore opportunities elsewhere.

This summer we also 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. Since January ten nurses have joined us via this route.

3. Worked with local universities to attract the best graduates

Closer to home, 44 newly qualified nurses have joined our wards.

4. Invested in healthcare assistants

Around 40 of our healthcare assistants and nursing auxiliaries started training as assistant practitioners in September. Over the course of two years trainees develop the skills and experience to become qualified for this exciting new nursing role supporting clinical teams across the Trust.

5. Reached out to people looking to return to nursing

Our free Return to Practice and Return to Acute Care courses target people who might consider returning to a career in healthcare. Since January 13 nurses have joined us via this route.

6. Launched an apprenticeship scheme

Our new apprenticeship scheme offers the chance to earn and learn, while training towards a professional qualification. Since January 15 staff have joined us through our apprentice scheme.

We've also been working with schools, colleges and universities to raise awareness of routes into the NHS and the diverse range of career opportunities.

Patient flow and emergency care 

 CQC icon - patient flow

Making sure patients experience a smooth journey of care through the hospital and into the community or home

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.

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.  

Since January we have: 

1. Introduced electronic white boards

Electronic display boards are now being used in our unscheduled care wards and departments, including the Emergency Department. Having key patient information visible in this way is helping staff to plan the patient journey. Similar boards will be introduced to other wards and departments across the Trust by the end of the year.

2. Introduced a new safety check list in the Emergency Department

We are using a new patient safety check list in the Emergency Department to help standardise and improve nursing and medical care while patients are waiting for a decision to be made regarding either their admission into hospital, transfer to another healthcare provider or discharge home.

The checklist, endorsed by the West of England Academic Health Science Network, is a list of tasks to prompt busy staff. It includes actions such as basic observations and basic nursing and medical care which needs to be provided to each patient every hour.

3. Asked local people to support us where they can

Work is 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, preparing for leaving hospital, seeking medical help early on and choosing the most appropriate healthcare option.

4. Increased use of the Discharge Lounges

We are making better use of our Discharge Lounges, as waiting areas which help to free up beds, so other patients can begin treatment sooner.

The lounge for medical patients is open 8am until 6pm, Monday to Friday and the surgery lounge is open 7am until 7pm, Monday to Friday.

They are a great service that supports patients who are well enough to leave hospital.
For more information about leaving hospital which can support your conversations with patients, please visit the Leaving Hospital section of the website.

5. Improved initial nurse assessments in the Emergency Department

Made changes to the way the team works in the Emergency Department, to help ensure patients receive an initial assessment within 15 minutes of arrival.

This helps us to ensure that patients are seen in order of urgency and are as comfortable as possible while waiting.

Nurses who triage patients within the Emergency Department have also been given extra training.

A new electronic patient tracking system in the Emergency Department is also giving staff a clear overview of the department at a glance, helping to manage the flow of patients and staffing.

6. Expanded our ambulatory care service

We've extended the opening hours of our Ambulatory Care and Triage Unit which is now open 24/7, seven days a week and this month will be going one step further with Hot Clinics.

The team already assesses, diagnoses, and starts treating and then discharging patients within 72 hours.

Hot Clinics involve a dedicated consultant visiting patients in ambulatory care as part of a Hot Clinic, so that decisions can be made even sooner and fewer patients need to stay overnight.

Ambulatory care helps to reduce pressure on our Emergency Department and our ward staff, by providing a service for patients who have arrived via the Emergency Department or have been referred by their GP for urgent care, yet can be safely treated without being admitted to a ward. 

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 January we have:

1. Invested in training

Training has taken place to better equip staff to care for mental health patients on the Emergency Department Observation Unit.

New documentation in the Emergency Department Observation Unit has also made it easier for staff to record information in a more consistent way.

2. Started to improve the environment to better support patients with mental health needs

As part of a redesign of the Emergency Department Observation Unit we are planning to improve the environment and better accommodate patients with mental health needs.

Although building works will not begin until later next year, the redesigned Unit will include two dedicated private rooms for patients with mental health needs.

3. Invested in a specialist mental health nursing team in the Emergency Department Observation Unit

We've invested in a team of mental health nurses from Avon and Wiltshire Mental Health Partnership NHS Trust who are now based in the Emergency Department Observation Unit, providing 24 hour support.

This will ensure we can meet the specific needs of patients with mental health conditions. Having this expert advice to hand also means decisions will be made more quickly.

Learning and effective governance

 CQC -icon - Learning

Making sure we are open, learn, share and improve 

Since January we have:

1. Strengthened record keeping

Nursing documentation has now been reviewed and revised documentation will be introduced for 2017.

Recording information regularly and using consistent documentation is something we absolutely have to get right to ensure we identify patient needs early on and provide personalised care.

We've also made sure that the responsibilities for checking and monitoring patient documentation is specified within nursing job descriptions.

2. Trained our staff to use NEWS (National Early Warning Score)

More staff are using this vital tool confidently and accurately.

NEWS is a standardised NHS monitoring tool for adult patients in hospital, which is used to help identify patients whose condition is deteriorating, and to trigger a timely response.

3. Introduced a Quality Improvement Coaching and Peer Support Network

We're pleased that staff now have a dedicated network to build on our culture of openness and transparency and share ideas in relation to quality improvement. We've also developed special quality improvement toolkits to support staff with their own quality improvement work.

We're also using a special project database to record improvement work across the Trust in a consistent way, highlighting more opportunities for joined up working.

The above information is available in a downloadable PDF file: 

Our improvement journey - November 2016

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