Agenda
A meeting of the Aneurin Bevan University Health Board Quality and Patient Safety Committee will be held on Wednesday 13th September 2017, commencing at 9:30am in Conference Room 2, Conference Centre, Headquarters, St Cadoc’s Hospital, Caerleon
AGENDA
Preliminary Matters Attachment 9:30
1.1 Welcome and Introductions Chair 5 mins 1.2 Apologies for Absence Chair
1.3 Declarations of Interest Chair
Presentations 9:35
2.1 Stroke Redesign Programme Presentation Dr Yaqoob Bhat/ 30 Performance Richard Griffiths mins 2.2 Improving Ambulatory Care Presentation Jeremy Griffith 20 and Discharge in Nevill Hall mins Hospital
For Consideration 10.25
3.1 Quality, Safety and Attachment Dr Paul Buss 20 Performance Overview mins
Risk Assessment Overview Risk Register – issues arising Chair for action Attachments Alison Shakeshaft QPSOG Assurance Report from Meeting held on 18th August 2017 Break 10.45 3.2 C-Difficile - progress against Attachment Moira Bevan 10 the action plan mins 3.3 Putting Things Right Annual Attachment Martine Price/ 15 Report Jane Dale mins 3.4 Health and Safety Annual Attachment Alison Shakeshaft 15 Report mins 3.5 Developing Our Approach to Attachment Kate Hooton 15 Clinical Audit mins
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Final Matters 11.50
4.1 Draft Minutes of the Committee Attachment Chair 10 – Monday 12th June 2017 mins 4.2 Action Sheet Attachment Chair 4.3 Items for Board Consideration Chair To agree agenda items for Board consideration and decision
12.00 Date of Next Meeting Wednesday 1st November 2017, 9:30am Conference Room 2, Conference Chair Centre, Headquarters, St Cadoc’s Hospital, Caerleon
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
3.1 Quality and Patient Safety Report
September 2017
Purpose of the Report:
The Quality and Patient Safety Report for the Quality and Patient Safety Committee provides information on the ABUHB main priorities in this area, as set out in the Integrated Medium Term Plan, the Annual Quality Statement and the Patient Safety Improvement Plan.
Recommendation:
The Quality and Patient Safety Committee is asked to review the report, note the progress being made in many areas and highlight any issues where further information is required for assurance.
The Quality and Patient Safety Committee is asked to: (please tick as appropriate) Approve the Report Discuss and Provide Views Receive the Report for Assurance/Compliance X Note the Report for Information Only Executive Sponsor: Dr Paul Buss, Medical Director Report Author: Kate Hooton, Assistant Director Report Received consideration and supported by : Executive Committee of the Board Quality and Team [Committee Name] Patient Safety Operational Group Date of the Report: 11.08.17. Supplementary Papers Attached:
Summary of Key Points
The mortality run charts have been produced in excel so they are easier to read. Some charts contain more data, which aids comparison, but means they are quite “busy”. Feedback on whether they need to be separated out to improve clarity would be helpful.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 A lower RAMI in comparison to other health boards in Wales has generally been maintained for ABUHB through 2016 to date. RAMI has decreased since the winter and settled at an expected level for the months with 3.1 reasonable coding levels. (p3).
Coding completeness is reliable through to October 2016 and for April 17 (p5). Data is given for RAMI for November 16-March 17, but the values shown should reduce as coding completeness increases. Coding completeness does not affect the number of deaths (crude mortality) or the mortality rate.
Results from the National Diabetes In-patient Audit Report are reported. The prevalence of diabetes in the population has increased. In summary, the staffing levels for specialist diabetes staff are low, particularly at RGH. NHH has changed its model of care, using its specialist staff to see all diabetic patients on admission. RGH has been unable to adopt this model of care because of the staffing levels. NHH performs well, with lower numbers of insulin related incidents, whereas RGH has some areas where it can improve. Patients also report a good experience at NHH, whereas the patient experience is rated less well at RGH. (p9).
ABC Sepsis has rolled out the sepsis screening tool to all wards, and is now working with the wards to improve the early identification of deterioration, supported by the Divisional Nurses and using data from the Outreach Databases. The A and E department performance is being generally maintained at RGH and NHH. MAU at RGH have increased the number of cases identified and the percentage treated with the sepsis 6 in 1 hour. The data reported is limited because a new spread sheet for recording and reporting the data is being introduced. (p17).
ABUHB was successful in meeting the Welsh Government target set for reduction of C diff. to March 17. The numbers of C. diff. cases increased from February to April 17. However, actions to reverse this were put in place and the number of hospital acquired cases has now reduced, in all probability due to the programme of deep cleans for wards. (p21).
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 1. High Level Outcomes 1.1 Risk Adjusted Mortality Index 3.1 Our aim in the IMTP is to reduce RAMI to 90 (2013 rebase) by March 2017 and to sustain this reduction through subsequent rebasing and to reduce/eliminate variation across our hospital sites.
RAMI (2016) ABUHB and Welsh Peer and Top Peer July 15-July 17
Risk Adjusted Mortality Index 2016 - ABUHB v Peer Groups ABUHB Welsh Peer Top Peer 250 225 200 175 150 125 100 75 50 25 0
RAMI (2016) ABUHB Hospitals against ABUHB July 15-July 17
Risk Adjusted Mortality Index 2016 - ABUHB Hospitals ABUHB RGH NHH YYF 250 225 200 175 150 125 100 75 50 25 0
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
1.2 Crude Mortality and Mortality Rate 3.1 ABUHB and Hospital Crude Mortality July 15 – July 17
Number of Deaths ABUHB RGH 400 NHH YYF 350 300 250 200 150 100 50
0
Jul-15 Jul-16 Jul-17
Jan-16 Jan-17
Jun-16 Jun-17
Oct-15 Oct-16
Apr-16 Apr-17
Sep-15 Feb-16 Sep-16 Feb-17
Dec-15 Dec-16
Aug-15 Aug-16
Nov-15 Nov-16
Mar-16 Mar-17 May-17 May-16 ABUHB Mortality Rate against Welsh Peer and Top Peer July 15- July 17
Mortality Rates
% ABUHB % Welsh Peer % Top Peer
3.0
2.5
2.0
1.5
Percentages 1.0
0.5
0.0
Hospital Mortality Rates with Welsh Peer and Top Peer July 15- July 17
Mortality Rates - ABUHB Hospitals v Peer Groups
% RGH % NHH % YYF % Welsh Peer % Top Peer
3.5 3.0 2.5 2.0
1.5 Percentages 1.0 0.5 0.0
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 1.3. Narrative on Mortality Data
CHKS is using the RAMI rebased in 2016, and the charts shown therefore 3.1 use RAMI 2016. The line in the run charts, which is ABUHB or an ABUHB hospital, shows more variation than the line for Welsh Peer or Top Peer. This is to be expected as the Peers include much greater numbers of patients and therefore the overall variation is reduced.
Current coding completeness means the RAMI is reliable through to October 2016, and April 17 is also reliable. The RAMI levels for November 16 onwards should decrease, but are shown to give an indication of the value. Since January 2017, when the RAMI, number of deaths and mortality rate were high, the levels of these indicators have all decreased and remained at the levels that are normal for the time of year.
The Palmer Review says that the RAMI can be used over time for the same hospital and we are therefore continuing to report RAMI. The RAMI for Welsh Hospitals and for the Top Peer is also shown, even though it is not a meaningful measure of quality when comparing with other hospitals. This is done because it is not a comparison with a single health board or hospital, but in both cases the average for a group of health boards or hospitals, and it gives general picture of what is happening over time for those hospitals. In ABUHB, the RAMI is generally lower than the Welsh average. The RAMI for the Top Peer is therefore shown in order to provide a goal to aim for, even though the top peer contains hospitals in England, where the coding is different because of Payment by Results and some differences in the coding guidance.
2. Completeness of Coding 2.1 ABUHB Coding Completeness:
Oct 16 95.3% Nov 16 91.4% Dec 16 86.9% Jan 17 89.0% Feb 17 86.2% March 17 82.8% April 17 96.3% May 17 90.7%
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 2.2 Uncoded Finished Consultant Episodes
3.1
3. Surveillance and Review
In June 2014, the Palmer Report was published, which considered the extent to which risk adjusted mortality data for Welsh Hospitals provides valid information. Professor Palmer concluded that the summary RAMI for Wales is not a meaningful measure of hospital quality; it could be misleading and could distract attention away from more meaningful approaches to measuring and improving hospital care.
The Welsh Government considered how to respond to the Palmer Review, and has moved away from RAMI as a single number to measure the quality of a hospital. However, the Palmer Review does say that the RAMI can be used over time for the same hospital and we are therefore continuing to report RAMI. As a Health Board we are developing how we use clinical data for quality improvement, in line with Professor Palmer’s recommendations. The data we are using includes:
National Clinical Audits, with full participation and use of the results to drive improvement year on year. Condition specific mortality statistics at an organisational level, such as the MI, Stroke and Fractured Neck of Femur data presented in this report (see section 4.5, 4.6 and 4.7). Review of clinical records of patients that die in our hospitals, following national protocols – the mortality review process.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 3.1 Mortality Review
Percentage Completion of Mortality Reviews –The Welsh 3.1 Government plan is that, when, as a recommendation of the Shipman review, the Medical Examiner role is introduced, the Medical Examiner will undertake the first level of the mortality review. This is a part of their role, as they agree the cause of death with the responsible medical team and high light any concerns they have about care from their review of the clinical record. They also talk to the relatives of the deceased person to ensure that they agree the cause of death and were happy with the care provided. The Health Board will undertake a more in depth, second level review into any deaths that the Medical Examiner highlights. It is currently planned by Welsh Government that the new role will be introduced in April 2019. Confirmation of the arrangements for implementation are currently awaited, as they are being developed with a once for Wales approach.
The Welsh Government are leading work to standardise the second level review process in advance of the Mortality Examiner role. They are looking at how learning is disseminated from other processes. ABUHB has proposed that there should not be a separate process for serious issues identified through the Medical Examiner, but that they should be investigated through each Organisation’s Putting Things Right processes. A mechanism for sharing the learning and good practice across Wales would be welcomed.
The Welsh Government has set the standard that 100% of the notes of patients that die in our hospitals are reviewed. In ABUHB, the mortality reviews are undertaken by senior, independent clinicians. There are now 4 funded sessions of senior reviewers, with 3 sessions in place – medical and nursing. The 4th session is in the process of being filled. The original estimate of the average time for a senior clinician to complete a mortality review was 15 minutes. This would mean that 4 reviewers would complete 200 reviews per month. The estimate for the Medical Examiner to review a set of case notes is 25 minutes. This now seems to be a better estimate of the time to complete a mortality review. The 3 reviewers are therefore completing 100 reviews per month. Higher numbers are achieved for key months through the input of the Deputy/Assistant Medical Directors.
One Consultant has a lead for appraisal and learning, and is working to ensure that learning from appraisals is used within the consultant appraisal process. The Assistant Medical Directors on each site will
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 continue to undertake their lead role, to promote continuity. Our target, once the 4th session is in place, will be to complete the mortality review for more than 90% of deaths. 3.1
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May Total 16 16 16 16 16 16 16 16 16 17 17 17 17 17 No. 73 78 19 37 27 91 98 135 92 220 141 119 137 138 1405 Review ed 2nd 19 17 1 8 2 14 17 11 7 34 6 6 7 5 154 Stage Review Total 259 220 169 202 215 209 234 260 260 371 227 241 247 225 3339 Deaths % 28 35% 11 19 13% 44% 42 52% 35% 59% 62 49% 56% 61% 42% Review % % % % % ed
Health Boards are reporting to the Welsh Government the percentage of deaths reviewed each month and the time taken to complete the review from the death of the patient.
Learning from Mortality Reviews – The Learning highlighted at the last Mortality Review Group focussed around End of Life Care. The reviewers had seen patients admitted for Palliative Care at the end of their life, when they could have been cared for in a Hospice or possibly at home. It is unclear from the notes whether they are in the most appropriate place, or whether they had expressed a wish to die in hospital. Dr Paul Edwards, who undertakes Mortality Reviews for RGH, has a strong interest in the Anticipatory Care Planning/Ceilings of Care, and is leading this work for the Deteriorating Patient Group. He has now been invited to be a member of the End of Life Care Board, so that there is good 2 way communication between the Morality reviewers and the End of Life Care Board. He is also a member of the Advance Care Planning sub-group of the End of Life Care Board, which was agreed as a priority for 2018-19. Dr Paul Edwards, with other representatives from the acute sector, will work with the End of Life Care Board to ensure the work that the Advance Care Planning work in the community is also taken forward in the Acute Hospitals. We will then have the same training and system and processes across the whole health community. Advance Care Planning with the patient and their family for the end of life can then be initiated in all sectors, and the plan available to all professionals involved with the patient.
The mortality reviews are also highlighting the importance of accurate coding of the clinical notes. The Medical Director will meet with the Head
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 of Coding and raise the issue with the Clinical Directors to encourage the Specialties to work with the clinical coders to improve mutual understanding of the clinical and coding processes. 3.1
It is encouraging that the cause of death is now recorded in most notes for patients who die at NHH. There has been an improvement at RGH, but this still requires further improvement.
3.2 National Clinical Audit (NCA)
National Audits enable healthcare organisations in Wales to measure the quality of their services against consistently improving standards, and to confirm how they compare with the best performing services in the UK. National Audits also have great potential to provide information to the public about the quality of clinical care provided by NHS Health Boards.
As a Health Board we aim to participate in all the NCAs on the Welsh National Clinical Audit and Outcome Review Programme 2016-17. The programme for 2017-18 will be published soon by the Welsh Government.
The National Diabetes Inpatient Audit (NaDIA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and delivered by NHS Digital, working with Diabetes UK.
The National Diabetes Inpatient Audit is a snapshot audit of diabetes inpatient care. Between 26-30 September 2016, the National Diabetes Inpatient Audit was conducted in hospitals across England and Wales, collecting data on characteristics of the hospital including staffing structures, patient clinical data and patient experience information.
The audit looks at the following areas:
• Did diabetes management minimize the risk of avoidable complications?
• Did harm result from the inpatient stay?
• Was patient experience of the inpatient stay favorable?
• Has the quality of care and patient feedback changed?
The Annual Report provides a summary of the 2016 audit findings for England and Wales, and where possible compares to the 2011, 2012, 2013 and 2015 audit findings. There was no audit collection or report
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 in 2014, so 2014 data is not available. The audit is supported by the Hospital Level Analysis, which provides results at individual site level. 3.1 ABUHB Results
Quartile 1 means that the result is in the lowest 25% of participating hospitals. Quartile 4 means that the result is in the highest 25% of participating hospitals. A result in quartile 1 can be positive (eg the percentage of patient with hypo glycaemic episodes) or negative (eg visits by specialist teams).
Nevill Hall Hospital
The prevalence of diabetes has risen over the last 5 years from 16.6% to 19.1% in 2017.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
3.1
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
3.1
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
3.1
Royal Gwent Hospital
The prevalence of diabetes has risen over the last 5 years from 16.6% to 19.1% in 2017.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
3.1
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
3.1
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
3.1
The key issues from the health board are:
The increasing workload due to the increase in prevalence of the disease and therefore the proportion of people in ABUHB hospitals is high and increasing. Staffing levels for specialist diabetes care are low, particularly at RGH The percentage of people experiencing a mild hypoglycaemic incident is higher than average at RGH The percentage of people reporting they are satisfied or very satisfied with care at RGH is low.
In summary, the staffing levels for specialist diabetes staff are low, particularly at RGH. NHH has changed its model of care, using its specialist staff to see all diabetic patients on admission. RGH has been unable to adopt this model of care because of the staffing levels. NHH performs well, with lower numbers of insulin related incidents, whereas RGH has some areas where it can improve. Patients also report a good experience at NHH, whereas the patient experience is rated less well at RGH.
To address these issues, the diabetes team are presenting a business case to the Executive Team in October or November 2017. If this is successful and there are additional specialist staff at RGH, then the Diabetes Inpatient Team model will be implemented at RGH. In addition, it is planned to introduce the “Think Glucose” programme across the 3 hospitals in ABUHB in March 2018.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 4. Optimising Care Delivery
4.1. Deteriorating Patient/Sepsis – ABC Sepsis 3.1 The Aneurin Bevan Collaborative on Sepsis (ABC Sepsis) was launched on 7th January 2015. The Collaborative is working in defined clinical areas, to improve the recognition and response to sepsis and therefore eliminate avoidable deaths and harm from sepsis. Key to this is the understanding that sepsis is a time sensitive condition – every extra hour of delay in treating sepsis means a 7.6% risk of mortality – and therefore it has to be treated as a medical emergency, like a stroke or MI. The focus has been on the front door to the Hospitals, as the report “Just Say Sepsis” identifies that 70% of sepsis cases are in the community.
The Collaborative’s outcome measures are:
the % of patients triggering with sepsis that die within 30 days of recognition, and the number of patients triggering with sepsis that die within 30 days of recognition.
The process measure for the collaborative is:
Sepsis 6 compliance, which means that all 6 elements of the sepsis bundle are completed within 1 hour of recognition.
4.1.1. Review of Results from ABC Sepsis
ABC Sepsis has been collecting data from the sepsis screening tools completed for patients triggering with sepsis. The data is fed back to the wards and departments at the weekly DRIPS (Data, Review, Improvement, Plot the dots, Share) meetings and by e-mail after the meetings. This crucial role has been undertaken by the Medical Director’s Support Team. At the moment, a new excel spread sheet for capturing the data is being developed, so only limited data is available for this report. Data is still being fed back to the wards and departments every week so that they know in real time their performance.
A and E Departments:
Nevill Hall Hospital: The data shows that NHH has maintained the number of forms completed into the summer period. Compliance with the bundle has sometimes dropped below 50%, but it is usually documentation of the process that lets them down. For those cases not
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 given the sepsis 6 within 1 hour, the bundle is often completed within 1-2 hrs, which is still good care. The factors that are barriers to the completion of the bundle vary at NHH. The new database will be able to 3.1 show the % sepsis 6 bundles completed in 1 hour and the time taken for antibiotics to be both prescribed and given. This will allow a better focus on the aspects of the process that are causing the delay.
EAU at NHH needs to engage more, and the lead nurse for sepsis is working with them to train more staff.
The table below is the data reported to Welsh Government and shows the number of forms completed for people who are found to have sepsis. There are additional forms started for people who subsequently do not trigger for sepsis and are not thought clinically to have sepsis, as well as forms started for people who do trigger for sepsis but are not thought clinically to have sepsis. The data reported previously was for all forms started, and so the numbers below are now lower.
Table 1: NHH A and E and EAU
Emergency April May June July 2017 2017 2017 2017 The number of patients identified as positive to sepsis 143 69 121 119 screening requiring a new response in a 24 hour period Number who received all six elements of the sepsis bundle 73 32 67 63 within 1 hour % compliance 51.05 46.38 55.37 52.94
Royal Gwent Hospital: RGH A and E has increased the number of forms completed. The department has shown full participation in the sepsis meetings, with good medical support. When appropriate, the Consultant feeds back not compliant cases to the junior doctor involved to discuss the care given. For the cases identified, the compliance with the bundle is consistently 50% or more.
MAU at RGH is now fully engaged with ABC Sepsis. The number of forms completed has increased and the compliance, and is the main reason for the increase in cases below.
Table 2: RGH A and E and MAU
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 Emergency April May June July 2017 2017 2017 2017 The number of patients identified as positive to sepsis 121 153 168 201 3.1 screening requiring a new response in a 24 hour period Number who received all six elements of the sepsis bundle 79 109 120 131 within 1 hour % compliance 65.29 71.24 71.43 65.17
Ysbyty Ystrad Fawr: ABC Sepsis covers the whole of YYF, wards and Emergency Department. There is good engagement with the meetings. The System C Pilot is due to start at YYF in September, and the ABC Sepsis Team have worked closely with the IT Staff to make sure that the system can identify and notify clinicians of deteriorating patients. The Lead Nurse for sepsis has completed an audit which demonstrated how well patients are monitored, identified, escalated and treated on all the wards at YYF. This will be used as baseline data to understand whether System C improves the recognition and response to the deteriorating patient.
Table 3: YYF Emergency Department
Emergency April May June July 2017 2017 2017 2017 The number of patients identified as positive to sepsis 19 22 15 22 screening requiring a new response in a 24 hour period Number who received all six elements of the sepsis bundle 9 11 11 14 within 1 hour % compliance 47.37 50 73.33 63.64
Community: Previously, the call handlers have audited the percentage of admissions from GPS where they are given the patient parameters that make up the NEWS score by the GP. The re-introduction of this audit has been delayed by a change in management. This is now being picked up. Once this data is available, there will be another campaign to raise the profile of the NEWS score in primary and community care, and a review of how the data is used in EAU/MAU when the patient is admitted to support the recognition of the deteriorating patient.
Wards at NHH and RGH:
On the wards, the number of patients identified as triggering per ward with sepsis has been low – 1 or 2 per week. ABC Sepsis is therefore now focussing on the deteriorating patient. The deteriorating patient audit tool developed for YYF is being used to audit the wards in NHH and RGH to understand how well they recognise and respond to deterioration.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 The sepsis screening tool, developed by ABC sepsis with the Emergency Departments, has been rolled out to all the wards in acute hospitals from April 2017. Data taken from the Outreach databases for NHH and RGH 3.1 showed that the wards were not using the screening tool, which would support them to initiate the treatment for sepsis rapidly on the ward. The Lead Nurse for sepsis, with support from the Divisional Nurses, is now meeting regularly with the wards to review the Outreach database against the forms the sepsis screening tools completed by the wards.
The Lead Nurse for Sepsis has organised a Sepsis Awareness Day on 22 September, to support the wards in embedding this work. Four people with personal experience of sepsis are giving their stories at the event, to demonstrate the impact of sepsis on individuals and their family. Teams that have made great improvements in their recognition and response to sepsis are also presenting to the event, to describe their journey, and the benefits to staff and patients of the timely recognition and response to sepsis.
4.1.2. ABC Sepsis Steering Group
The next steps for 2017 are:
To move the YYF DRIPS meeting on to have local leadership To work with the vital pack pilot at YYF to ensure that the recording of patient parameters supports the recognition of the deteriorating patient To profile the presumed source of infections from the ABC sepsis data To link with Infection Control in relation to e-coli reduction target, as UTIs are often e-coli related in the elderly To work with primary care and community services to establish NEWS as the common language for deterioration To pursue the deteriorating patient agenda on the wards, including the roll out of the trigger tool, acute response and regular audit in acute hospitals To agree the PGD for community hospitals
The ABC Sepsis Team are working with the Infection Prevention and Control Team and other Teams, as well as through the Deteriorating Patient Group to achieve these aims.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 4.2 Reducing C Diff and MRSA
Aim: For C. Difficile, the Health Board is to ensure a rate of no more 3.1 than 25.2/100 000 population is delivered in the final 6 months of the reductions period 1 April 2017 – 31 March 2018. Welsh Government has agreed an individual rate for the Health Board for S. Aureus bacteraemias (MRSA and MSSA) which is to ensure a rate of no more than 15/100 000 is delivered in the final 6 months of the period.
Total C diff. Cases
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
3.1
Total MRSA and MSSA Cases
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
Hospital Actions 3.1 Whilst appreciating that the Welsh Government target for C. difficile was met in March 2017, it should be noted that the Health Board saw a sustained increase in cases from February to April 2017. We are now seeing a welcome downward trend particularly on hospital sites, with only four identified new C. difficile cases in July 2017. This, in all probability, is due to sustained deep clean programme, particularly on the Royal Gwent site.
Whilst the “hospital acquired” position has improved, it is disappointing to note 10 C. difficile cases acquired in Primary Care. All ten cases have undergone intense analysis and five of the ten cases were found to be unavoidable based on appropriate antibiotic prescribing and no recent admissions to hospital. Nevertheless five cases identified were considered avoidable because of inappropriate prescribing or inappropriate sampling. Further C. difficile guidance for GPs is being prepared for dissemination.
Relapses remain an issue with four cases identified in July 2017. The Infection Prevention Team will shortly undertake a piece of work with the antibiotic pharmacist to establish compliance with treatment regimes.
C. difficile Cases in ABUHB
Area April May June July
Unscheduled Care 10 13 7 3
Scheduled Care 4 3 2 0
Primary Care 7 2 5 10
Family & Therapies 0 0 0 1
Relapses 6 4 1 4
Community 2 1 5 0 Hospitals
Acquired in another 1 HB Hospital
Total 29 23 20 19
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 The Executive Team were alerted to the recent increase and, following an extraordinary meeting of the Champions Steering Group, key messages have been disseminated with particular emphasis on ownership. Indeed, 3.1 divisional management teams were asked to reiterate the UHB’s commitment to “infection control being everyone’s responsibility”. This is a key message that has been emphasised at all levels of the organisation.
A number of key actions have continued including:
The dissemination of key messages around hand hygiene, cleanliness and prudent antibiotic prescribing from the Executive Nurse Director, Director of Therapies and Health Sciences and Medical Director. A deep clean of wards affected by outbreaks, utilising hydrogen peroxide vapour. An inspection of mattresses, with appropriate replacement if found to be contaminated. A proactive programme of deep cleans has been drawn up with plans to utilize D4W as a decant ward. Close communication with Patient Flow Teams to ensure patient movement is appropriate and restricted and symptomatic patients are rapidly isolated.
Medium term actions include:
A refreshed hand hygiene campaign in conjunction with the Communications Team A review of medical engagement in relation to antibiotic compliance. The development of a prudent antibiotic prescribing model to ensure antibiotics are prescribed to policy. A review of the number of cleaning hours across all hospital sites to provide an equitable service. Dissemination of further guidance to GPs
Community Acquired Clostridium difficile cases - Primary Care Data and Actions
The GP’s appropriate choice of antibiotics is a key component of any C. difficile strategy and Root Cause Analysis is undertaken routinely to determine risk factors and potential interventions. A Primary Care Clinical Director is a member of the ABUHB C. difficile Champions Group and drives improvement in the C. difficile rates for both hospital and community acquired infections. Antibiotic maps are discussed and reviewed within NCNs
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 Antibiotic prescribing and Patient Performance Indicators (PPI) trends are in line with ABUHB messages Educational and audit work with GPs has been undertaken, with a 3.1 particular focus on prudent antibiotic prescribing. This has resulted in a significant reduction in prescribing of high risk antibiotics. C. diff acquisitions in the community are treated as a significant event, and reported on datix. An analysis of antibiotic prescribing for each case is undertaken by the GP. The Community Pharmacist is undertaking education on management of Urinary Tract Infections (UTIs) in Care Homes, as they have a key population that are at risk of C. diff and often have multiple courses of antibiotics. Guidance has been produced for GPs about other risk factors for C. diff. PPIs can increase the risk of CD associated diarrhoea by approximately 65% and H2antagonists by approximately 40%.
4.3 Hospital Acquired Thrombosis
A Hospital Acquired Thrombosis (HAT) is defined as:
“Any venous thromboembolism arising during a hospital admission and up to 90 days post discharge". There is no target HAT rate, as the rate in a hospital will vary according to the casemix of patients. Even if the patient is correctly risk assessed and given all the correct thromboprophylaxis, they can still develop a HAT. In these cases it is recognised that the HAT was unavoidable. The aim is that all cases of HAT will have been correctly risk assessed and given the correct thromboprophylaxis and therefore were unavoidable.
The data below shows the number of cases of HAT in ABUHB in 2016/7 and early 2017/8. The data is derived from combining RADIS data with discharge data. The process has been improved from November 16 onwards, and the slight increase in cases is likely to be due to the process being more effective.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
April May June July Aug Sept Oct Nov Dec Jan Feb Mar Total 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 3.1 13 14 10 15 1 15 18 12 10 12 15 28 163
Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total 37 Total 31 Total 40 Total 55
April May June July Aug Sept Oct Nov Dec Jan Feb Mar Total 2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018
19 16 18 53
Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total 53 Total 0 Total 0 Total 0
All cases of HAT that identified are sent to the Consultant for review. Improvements have been made to the timeliness of the administration of this process and this is improving the number of reviews returned by Consultants. We will therefore have more robust data in the future showing whether there have been any potentially preventable cases of HAT – cases that were not given the correct thromboprophylaxis. These cases will all be taken to the Thrombosis Group, to ensure that learning is happens at all levels from the individual, to the team, to the organisation.
The introduction of the new All Wales Prescription chart in September 2016 was a key element in ensuring that a thromboprophylaxis risk assessment is completed, and so the right thromboprophylaxis is prescribed. The pharmacists have worked with the ward nurses to ensure that all the wards have only the new prescription chart available from August 17, as the new doctors in training started in August. The audit of the prescription chart has also been restarted at RGH, and will be brought in at NHH and YYF in September 2017.
4.4 Pressure Damage
Aim: Zero Tolerance, with interim targets of a 50% reduction in Hospital Acquired Pressure Damage over the next 18 months and a 30% reduction in level 3 or 4 Community Acquired Pressure Damage. Divisional Reduction Targets are now being set.
The data collection for pressure damage has been reviewed and streamlined and is now based on Datix collection alone. Following the introduction of this new reporting mechanism, there is confidence that
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 the data is more robust and comprehensive. Whilst the rise in significant pressure damage is of concern, it is most likely to be due to better reporting. The data is now being cleansed, as some pressure 3.1 ulcers are reported on each ward, when a patient is transferred between wards.
The following actions continue in order to reduce pressure damage in the hospital and the community:
The pressure damage review model continues on hospital and community sites. Real time pressure damage data means that rapid learning is returning to the ward/service.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 In order to support the pressure ulcer agenda further, the Health Board has made a significant investment in pressure relieving mattresses the use of which are being closely monitored to ensure at 3.1 risk patients receive the most appropriate mattress at the right time.
Good progress has been made in extending the pressure damage review model to nursing homes. Nursing homes are now reporting pressure damage via Health Board Governance Leads who in turn are reporting the damage on Datix.
Health Board Governance leads for Nursing Homes are developing the skills to review significant cases for onward reporting to Welsh Government.
A transformational approach to reducing pressure damage across hospital and community sites will be shortly implemented across the Health Board. The work will be in collaboration with ABCi utilising Improvement Methodology. The first collaborative meeting will be held on the 11th September 2017
Numerical targets have been set based on April 2016 – March 2017 baseline data. A 50% reduction of pressure damage in hospital has been set stretching to 75 and a 30% reduction for significant ulcers has been set for the community.
4.5 Stroke Care
Stroke 30 day mortality against Top Peer
Stroke - Mortality Rates % ABUHB % Welsh Peer % Top Peer 30
25
20
15
10 Percentages 5
0
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 Welsh Peer
3.1
Top Peer
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 The Stroke Consultants have reviewed the deaths from stroke included in this CHKS data as the mortality rate showed some spikes. The deaths included in the data above are deaths that have been coded as stroke and 3.1 include some that were cared for on wards other than the stroke wards. For example, one patient had a CVA, but also an exacerbation of COPD. As Non-Invasive Ventilation was needed, the patient had to be on a respiratory ward. Other patients were coded as stroke, but there was not a confirmed stroke. This will be discussed with the coding staff. The review did not identify any concerns about the stroke care of the people reviewed.
4.6 Myocardial Infarction 30 Day Mortality Ages 35-74 against Top Peer
MI aged 35 to 74 - Mortality Rates
% ABUHB % Welsh Peer % Top Peer
18 16 14 12 10 8
6 Percentages 4 2 0
Welsh Peer
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 Top Peer
3.1
In April- September 16, there were either 1 or 2 deaths each month. In November 16 there were 2 deaths and in December 16 and January 17 there were 3 deaths. The Cardiologists have audited the 20 deaths within this data from January 2016 to March 2017. It was concluded that most of the deaths were from Type 2 MIs, which are MI’s where other conditions have been a part of the death, such as heart failure or multi- organ failure. An MI is therefore possibly not the main cause of death. This was discussed with the coding staff, who highlighted that there are no codes available to distinguish between Type 1 and Type 2 MI’s in the ICD-10 index. One of the cardiologists offered to review the notes of these patients in order to ensure that they are coded appropriately. The process for this will be agreed between him and the Coding Staff.
There were no concerns about the care given to the people that had died. The Clinical Director is not aware of any wider issues and does not have any concerns about practice on the RGH site and they provide 24/7 cardiology cover.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 4.7 Fractured Neck of Femur 30 Day Mortality against Top Peer
#NOF aged 65 & over - Mortality Rates 3.1
% ABUHB % Welsh Peer % Top Peer
18 16 14 12 10 8
6 Percentages 4 2 0
Welsh Peer
Top Peer
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1
The National Hip Fracture Data Base (NHFD) has raised with the University Health Board, ahead of the publication of their annual report, 3.1 that the RGH appears to be an outlier for the adjusted mortality rate. This has therefore been scrutinised. It has been found that there has been an issue with the RGH data entered into a key area of the database by a new Nurse Practitioner. This was picked up by the Clinical Director following a discussion with the clinical lead for the NHFD and is referenced in the letter highlighting the outlier status. There is a plan to retrospectively adjust the data in the database to ensure it accurately captures the complexity and comorbidity of the patients at RGH. We expect this to be completed in the next month. This will provide a much more accurate reflection of our mortality rate in RGH.
However, outside of the mortality data issues, there has been a programme of work on Fractured Neck of Femur within the HB since May 2016 to address the other issues that have been highlighted in the NHFD. Considerable progress has been made, and by the end of September 2017 all of the staff appointments will have been completed and staff will have commenced in their roles.
The progress made in the last year is given below along with the ongoing work plan.
Key actions taken to date:
In September 2016 there was a presentation to Executive Board which resulted in full agreement and support to develop the case. There is a nominated Executive Director lead attached to this programme of work – the Director of Therapies and Health Scientists.
In November 2016 the University Health Board was successful in securing funding for investment into the Fractured Neck of Femur programme of work. The increase in resources are outlined below:
2 consultant ortho-geriatricians – 1 in NHH and 1 in RGH 1 specialty doctor for RGH 2 specialist ANP’s for Fractured Neck of Femur patients for team support and coordination Additional trauma list at NHH on Sunday – commenced in February 2017 Configuration of junior doctors to support Orthogeriatric team Patient Flow Co-ordinators (PFCs) to help support complex discharge planning Therapy support (7 days) with the introduction of generic rehab assistants
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 We have used slippage money from the delays in recruitment to secure volunteer time on both sites to help with feeding and general wellbeing of patients. This has been done in conjunction with Age Cymru. 3.1
In addition to this, we have reorganised wards to ensure we have designated fractured neck of femur wards on each site, so there are the relevant staff and expertise on the wards. A ring fenced bed is kept for admission on to the wards to fast track patients with a fractured neck of femur on to the ward.
Bundles of care have been agreed and implemented for all stages of the pathway.
A traffic light system has been agreed for a consistent anaesthetic approach to assessing patient’s fitness for surgery.
The “Discharge Ticket Home” has been introduced in order start to plan discharge within 48hrs of admission. This plan includes ensuring that patients have a clearer involvement in and understanding of their goals and the part they play in recovering from a fractured neck of femur as quickly as they are able. With the ortho-geriatricians in post (September 2017) there will be multidisciplinary daily ward rounds on the Fractured Neck of Femur wards.
4.8. Falls
4.8.1. In-patient Falls Data ABUHB Total Number of Falls
Inpatient Falls - April 2016 to June 2017 500 400 300 200 100 0
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 Number of Patient Falls by Division
3.1
Total Number of Inpatient Falls Incidents by Division Division Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 TOTALS Community 98 97 103 298 Family & Therapies 8 2 2 12 MH & LD 33 52 41 126 Scheduled 52 42 52 146 Unscheduled 194 169 161 524 Total 385 362 359 0 0 0 0 0 0 0 0 0 1106
Number of People who Fell - by Division (ie each person could have fallen more than once to give total number of falls above)
Division Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 TOTALS Community 69 61 65 195 Family & Therapies 7 1 2 10 MH & LD 24 26 29 79 Scheduled 42 39 40 121 Unscheduled 141 132 116 389 Total 283 259 252 0 0 0 0 0 0 0 0 0 794
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 Falls per 1000 OBD - by Division Annual Division Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Average 3.1 Community 9.2 8.9 9.9 9.3 Family & Therapies 8.6 2.1 2.1 4.3 MH & LD 5.2 7.4 6.2 6.3 Scheduled 7.6 6.0 7.7 7.1 Unscheduled 12.8 11.3 11.3 11.8 Overall Average 8.7 7.1 7.4 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 7.8
The Falls Steering Group will agree a regular Falls Dataset at its next meeting. The data for the number of falls by Division, the number of people who fell and the falls per 1000 bed days are shown above.
The data for the number of inpatient falls with fractures has been compared with the data from the NHFD, where the patient with the fractured neck of femur is identified to have fallen and sustained the fracture as an inpatient. This has highlighted that some falls with fractures have not been identified at NHH, as the fracture was confirmed some days after the fall, and the datix incident report has not been updated to reflect the fracture. This exercise is now being undertaken for RGH. The Divisions are also putting in place a mechanism to ensure that datix is updated when fractures are identified. Corporately, we will also compare datix data for fractures from inpatient falls with the data entered into the NHFD on a monthly basis.
5 Recommendation
The Quality and Patient Safety Committee is asked to review the report, note the progress being made in many areas and highlight any issues where further information is required for assurance.
Assessment of the Impact of the Report: Financial Some issues highlighted within the report Assessment will require additional resources to support further improvement. These will be subject to individual business cases which will contain the full financial assessment. In many cases, improving the quality will reduce harm to patients and/or waste, but this will also be highlighted in the business cases.
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Quality and Patient Safety Report Quality and Patient Safety Committee Agenda Item: 3.1 Link to Three Year Quality and Safety is a section of the IMTP Plan and the quality improvements highlighted here are within the Plan. 3.1 Risk Assessment The initial section of the report reviews high level data in order to highlight clinical risks in the system. The quality improvement initiatives in this report are being undertaken to improve patient safety and therefore reduce the risk of harm to our Patients. Improved patient safety also reduced the risk of litigation
Quality, Safety and The report is focussed on improving quality Patient Experience and safety and therefore the overall patient Assessment experience.
Health and Care Health and Care Standards form the quality Standards for framework for healthcare services in Wales. Wales The issues focussed on in the report are therefore all within the Health and Care Standards themes, particularly safe care, effective care and dignified care. Equality and Advice will be obtained from the Workforce Diversity Impact and OD Directorate about how the Impact Assessment Assessment is carried out for this report. (including child impact assessment)
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Quality & Patient Safety Committee Corporate Risk Dashboard
IMTP STRATEGIC OBJECTIVE: Enabler Risks Associated with Delivery of IMTP
KEY THEME ACTIONS: No specific SCPs – these areas overarch and underpin the IMTP
Quality & Patient Safety Committee - 13th September 2017-13/09/17 September - 13th Committee Safety Patient & Quality These areas are not directly associated with SCPs, but will if mitigated, facilitate the delivery of the plan.
RISK PROFILE REPORT Description of Risk and Action and if Risk Mitigated, 5 1 2 Unchanged or Worsened Since Last Assessment RISK: Failure to meet the expectations of population in relation to 20 4 2 4 patient experience and dignity of care
Since ACTION: Monitoring of quality measures are in place via Quality 3 May and Patient Safety Committee, patient experience is being 2014
Impact captured and specific spot checks are being undertaken. 2 OWNER: Director of Nursing OVERSIGHT: Quality and Patient Safety Committee 1 RISK: Potential failure to maximise infection control performance 15 1 2 3 4 5 ACTION: Action plans provide assurance that a positive impact on Likelihood current performance is being noted. Infection control targets will Since be included in the quality metrics dashboard to provide assurance Key: Sept 2013 and triangulation of data where there are quality issues.
= Risk Worsened OWNER: Director of Nursing
OVERSIGHT: Quality and Patient Safety Committee
= Risk Unchanged
= Risk Mitigated
3.1 Tab 3.1.1.1 Risk Register
Quality & Patient Safety Committee Corporate Risk Dashboard
12 RISK: Compliance rates of statutory and mandatory training of staff and potential impact on patient care Since ACTION: Upgraded ESR to enable better monitoring May arrangements of compliance levels 2013 OWNER: Director of Therapies and Health Science OVERSIGHT: Quality and Patient Safety Committee Quality & Patient Safety Committee - 13th September 2017-13/09/17 September - 13th Committee Safety Patient & Quality
41 of 175 41 3.1 42 of 175 42 Tab 3.1.1.1 Risk Register
Quality & Patient Safety Committee Corporate Risk Dashboard
IMTP STRATEGIC OBJECTIVE: Supporting a further shift of services closer to home through building a NCN foundation for delivery of care (SCPs 2, 3 and 4) KEY THEME ACTIONS: SCP 2 – Care Closer to Home SCP 3 – Management of Major Health Conditions SCP 4 – Mental Health and Learning Disabilities
Quality & Patient Safety Committee - 13th September 2017-13/09/17 September - 13th Committee Safety Patient & Quality The overall aim of these Service Change Plans (SCP) is to facilitate the development and sustainability of service improvement models that support the delivery of care closer to home. It also aims to deliver more systemic and proactive management of chronic disease to improve health outcomes, reduce inappropriate use of hospital services and have a significant impact on reducing health inequalities. The Mental Health and Learning Disabilities SCP seeks to provide an integrated, whole system model of care that improves the mental health and well being of our population. RISK PROFILE REPORT Description of Risk and Action and if Risk Mitigated, 5 2 1 Unchanged or Worsened Since Last Assessment
4 RISK: Inability to recruit to junior and middle grade doctors within 2 25
the Mental Health and Learning Disabilities Division means a 3 reduced medical workforce to ensure cover of all sites. Since
Impact March ACTION: Redesign of the service options are being explored 2 2017 alongside a medical workforce paper presented to the Executive Team which was considered and agreed. 1 OWNER: Chief Operating Officer and Medical Director OVERSIGHT: Quality and Patient Safety Committee and Mental 1 2 3 4 5 Health and Learning Disabilities Services Board Likelihood
RISK: Risk to patient safety if the re-modelling of crisis services is 20
not staffed and resourced appropriately within Mental Health and
Learning Disabilities Division. Since
May ACTION: Re-modelling and development work is underway in 2017 relation to crisis services in Mental Health however it is recognised that urgent action is required to ensure safe delivery of services 3.1 Tab 3.1.1.1 Risk Register
Quality & Patient Safety Committee Corporate Risk Dashboard
whilst development work is undertaken. OWNER: Chief Operating Officer OVERSIGHT: Quality and Patient Safety Committee and Mental Health and Learning Disabilities Services Board.
RISK: Failure to implement adequate falls prevention on in- Quality & Patient Safety Committee - 13th September 2017-13/09/17 September - 13th Committee Safety Patient & Quality 20 patient wards ACTION: Appropriate training plans in place to improve Since July understanding of in-patient falls. Monthly review and learning 2016 from all in-patient falls that result in a fracture.
OWNER: Director of Therapies and Health Science OVERSIGHT: Quality and Patient Safety Committee
43 of 175 43 3.1 44 of 175 44 Tab 3.1.1.1 Risk Register
Quality & Patient Safety Committee Corporate Risk Dashboard
IMTP STRATEGIC OBJECTIVE: Improving access and flow and reducing waits (SCP 5 & 6)
KEY THEME ACTIONS: SCP 5 – Urgent and Emergency Care SCP 6 – Planned Care
Quality & Patient Safety Committee - 13th September 2017-13/09/17 September - 13th Committee Safety Patient & Quality To develop coherent, co-ordinated, high quality urgent and emergency care that works seven days a week, and where possible 24 hours a day. In accordance with patient expectations whilst delivering the best clinical outcomes. To secure improvements in efficiency and productivity that in combination woth prudent healthcare, will improve access and deliver high quality, affordable and sustainable services. RISK PROFILE REPORT Description of Risk and Action and if Risk Mitigated, 5 2 4 Unchanged or Worsened Since Last Assessment
4 RISK: Unsustainable model of care in Primary Care services 20
ACTION: Welsh Government sustainability framework has been 3 Since implemented and is in use. A range of policies and procedures are
Impact Sept in place and in some instances, the Health Board directly manages
2 2015 some Practices.
OWNER: Chief Operating Officer 1 OVERSIGHT: Quality and Patient Safety Committee
1 2 3 4 5
3.1 Tab 3.1.1.1 Risk Register
Quality & Patient Safety Committee Corporate Risk Dashboard
IMTP STRATEGIC OBJECTIVE: Service Sustainability (SCP 7)
KEY THEME ACTIONS: SCP 7 – Service Sustainability
Quality & Patient Safety Committee - 13th September 2017-13/09/17 September - 13th Committee Safety Patient & Quality To ensure that the Health Board focuses on the transition of services that are fragile and present sustainability issues over the next three years and in particular in advance of the SCCC. RISK PROFILE REPORT Description of Risk and Action and if Risk Mitigated, 5 1 5 Unchanged or Worsened Since Last Assessment
4 2 3 20 RISK: Failure to appropriately recruit levels of medical staffing in
Primary and Secondary care services a particular area of concern 3 Since is neonatal and paediatrics. May
Impact ACTION: The Deanery has been requested to reflect on the 2013 2 implications of the requirements regarding the decommissioning of the neonatal trainees from March 2017. Feedback is currently 1 awaited. OWNER: Medical Director 1 2 3 4 5 OVERSIGHT: Quality and Patient Safety Committee and Finance and Performance Committee Likelihood
16 RISK: Failure to deliver the appropriate care for patients in local care homes
Since ACTION: Monitoring arrangements in place through the Complex March Care Team and ongoing active engagement with care homes to 2016 reinforce key requirements to mitigate risks.
OWNER: Chief Operating Officer
OVERSIGHT: Quality and Patient Safety Committee
45 of 175 45 3.1 Tab 3.1.1.2 QPSOG Assurance Report from Meeting Held on 18th August 2017
Aneurin Bevan University Health Board Health Board Committee Update Report 3.1 Name of Group: Quality and Patient Safety Operational Group (QPSOG) Chair of Group: Alison Shakeshaft Reporting to: Quality and Patient Safety Committee Reporting Period: 18 August 2017 Key Decisions and Matters Considered by QPSOG: Quality, Safety and Performance Report The draft report for QPSC 13 September 2017 meeting was discussed in depth allowing additions to be considered ahead of the QPSC meeting. There was particular discussion regarding the ABUHB results from the National Bowel Cancer Audit and the difference across the two sites. The improved 90 day mortality rate between 2015 and 2016 was welcomed as was the 2 year mortality improvements at Royal Gwent Hospital. Concern was raised with regards to the 2 year mortality rates for Nevill Hall Hospital and the link between these rates and the increased rates of emergency surgery was discussed. The group was informed that the Directorate was considering the results in detail.
The changes in reporting mechanism related to ABC sepsis were noted which had impacted on the level of data contained in the draft report. Suggestions were made regarding strengthening this element of the report prior to QPSC.
There was discussion regarding the recent increase in C Difficile cases and the range of actions being progressed to reverse this position. The group was satisfied with the level of focus on this area and the progress made against the key actions.
It was noted that a number of fractures from inpatient falls had been subsequently identified sometime after the event and a discussion was held around DATIX reporting where a fall do not immediately show a resulting fracture at the time the fall is recorded on the system, but identified later, often after transfer to another hospital site and the DATIX incident is not updated. This is being considered by the Falls Steering Group and the wider issue regarding updating of DATIX by the Health and Safety Committee.
Health and Safety Annual Report The report was discussed at length and the group noted the significant work and the number of positive areas contained within it, including the reduction in RIDDOR incidents (noting the changes in reporting), and no formal HSE enforcement notices for the Health board over the past 6 years. However the group also noted the areas for improvement including mandatory and statutory training rates (noting the start of an improvement trend) and the challenges around divisional ownership of updating and closing down DATIX incidents. The report is an agenda item for the QPSC on 13 September 2017.
46 of 175 Quality & Patient Safety Committee - 13th September 2017-13/09/17 Tab 3.1.1.2 QPSOG Assurance Report from Meeting Held on 18th August 2017
Putting Things Right Annual Report The report was discussed in depth. The plans to implement close monitoring of complaints performance by Divisional level was welcomed. The reduction 3.1 in cases referred to the ombudsman was noted. The report is an agenda item of the QPSC on 13 September 2017
National Clinical Audit Outcome Review and Plan for Wales The report was discussed with detailed discussion regarding expectations on the Health Board with regards to National Clinical Audit. It was noted that there are 2 national audits that the health Board is not currently participating in and that actions are in place to achieve 100% participation and to ensure that we act on the reports and report progress to Welsh Government.
SBAR Pathology Accreditation An SBAR was received regarding the accreditation for Cellular Pathology. It was noted that the Executive Team had also discussed this issue and is content with the approach being taken regarding accreditation.
Change in Practice in Blood Transfusion The group was alerted to a potential change in practice in blood transfusion services, whereby a second sample being received by the laboratory would automatically render any previous sample invalid and as a result any blood products already issued but not yet administered being withdrawn. This change is currently being discussed at a national level and that the Chair agreed to contact the Health Board’s lead.
Infection Prevention and Pressure Ulcers The update report was discussed and is an agenda item for QPSC on 13 September 2017.
SBAR Pregnancy Testing An SBAR was received and considered related to proposed changes to pregnancy testing within the Health Board. The group considered that further work was required including consideration of the impact on Primary Care and the potential cost of the suggested change to the Health Board. The department was requested to undertake further work and to bring back to the Operational Group.
Risk Registers/Concerns The group received the Divisional reports and Divisional leads were given the opportunity to flag any significant areas of concern. These included: nurse vacancies, vandalism at the Llanfrechfa Grange Hospital site, security issues at Ysbyty Ystrad Fawr – all having been escalated to relevant executive directors. One new risk was shared regarding the baby tagging system in RGH being at the end of its life. Details were not available but this has been flagged to the Director of Nursing.
Matters Requiring QPSC Level Consideration: Quality, Safety and Performance Report Health and Safety Annual Report
Quality & Patient Safety Committee - 13th September 2017-13/09/17 47 of 175 Tab 3.1.1.2 QPSOG Assurance Report from Meeting Held on 18th August 2017
Putting Things Right Annual Report National Clinical Audit – Developing our approach to Clinical Audit 3.1 Key Risks and Issues/Matters of Concern: There were no key risks or matters of concern to note. Planned Business for the Next Reporting Period:
Date of Next Meeting: 13 October 2017
48 of 175 Quality & Patient Safety Committee - 13th September 2017-13/09/17 Tab 3.2 C-Difficile - Progress Against the Action Plan
Aneurin Bevan University Health Board 13th September 2017 Agenda Item: 3.2
Aneurin Bevan University Health Board 3.2
Update Clostridium difficile Infection ABUHB July/August 2017
Purpose of the Report:
The purpose of the paper is to updated the Executive Team on the current situation on C difficile for July and August
Recommendation:
This report is presented to the Quality and Patient Safety Committee for information and discussion
The Board is asked to: (please tick as appropriate) Approve the Report Discuss and Provide Views Receive the Report for Assurance/Compliance √ Note the Report for Information Only Executive Sponsor: Bronagh Scott – Director of Nursing Report Author: Moira Bevan/Liz Waters Report Received consideration and supported by :Infection prevention Committee Executive Committee of the Board Quality & Team [Committee Name] Patient Safety Committee Date of the Report: August 2017 Supplementary Papers Attached: A concise “C.difficile Management” guidance document has been sourced from Kirklees
2 Background
The HB experienced a sharp rise in hospital-acquired cases, originating mainly in the Royal Gwent Hospital, in February and March 2017. Following assessment and targeted interventions, the number of cases stabilised in April and May and showed a decrease in June and July. The current rate of C difficile is 39 per 100,000 population and the HB target for 2017/18 is a rate of 26 per 100,000
1
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Aneurin Bevan University Health Board 13th September 2017 Agenda Item: 3.2
3 Issues 3.2
Despite the good progress on hospital sites the number of cases of C difficile has been slow to fall because of identified cases in Primary Care. Following in-depth review 15% of these cases have had little or no contact with hospitals and antibiotic prescribing has been appropriate meaning the case was “unavoidable”. Nevertheless inappropriate antibiotic prescribing was identified in one case in Primary Care.
A further issue relates to patients who have previously isolated C.difficile and relapsed. In response the Infection Prevention Team in conjunction with the antibiotic pharmacist will be undertaking a “deep dive” analysis of each relapse case to ensure treatment has been prescribed to national guidelines.
As discussed above a total of 21 cases identified across the HB of which ten were deemed “hospital acquired”. It is recognised that nine of the cases were attributed on wards which haven’t undergone the deep clean process with HPV
4 Recommendation
The Board is being requested to support the recommendations highlighted within the report to further aid the reduction of C difficile to patients.
Assessment of the Impact of the Report: Financial Healthcare associated infection has Assessment significant risk to patient safety, thus resulting in not only a cost to the patient but the Health Board. Each C.difficile case estimated at £10K Link to Three Year The HB has a Welsh Government Plan performance monitoring around C difficile and its unlikely that this will be achieved within 2017/18 Risk Assessment Healthcare associated infection has a patient risk in relation to mortality and morbidity. Risk to the organisation includes reputation, financial risk due to increased length of stay. This has been identified on the Divisional and corporate Risk Registers.
2
50 of 175 Quality & Patient Safety Committee - 13th September 2017-13/09/17 Tab 3.2 C-Difficile - Progress Against the Action Plan
Aneurin Bevan University Health Board 13th September 2017 Agenda Item: 3.2
Quality, Safety and Healthcare associated infection has an Patient Experience impact on patient experience and this is 3.2 Assessment discussed via Divisional Quality and Patient Safety forums. Learning is shared within the infection prevention committee. Standards for Infection prevention is linked to standard 2.1 Health Services and 2.4 by managing risk and promoting Wales health and safety, promoting infection prevention must be everyone business and part of everyday holistic healthcare Equality and Equality impact assessments are considered Diversity Impact in all assessment and local action plan Assessment developed accordingly. Strategy action plan (including child monitored via the Infection prevention impact Committee assessment)
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3.2
Increase incidents of Clostridium difficile Infection ABUHB July and August 2017 Introduction
The purpose of this paper is to update the Quality & Patient Safety Committee with regard to C. difficile acquisition across the Health Board (HB). Although good progress has been made in reducing the number of hospital acquired cases it must be noted that the rate for ABUHB is above the Welsh Government (WG) target. In light of this an in-depth review of July/August cases can be found below.
Situation
Clostridium difficile infection is spread by bacterial spores found within feces. Surfaces may become contaminated with the spores with further spread occurring via the hands of healthcare workers. Risk factors for infection include antibiotic or proton pump inhibitors use, hospitalisation, other health problems, and older age. Complications may include pseudomembranous colitis, toxic megacolon, perforation of the colon, and sepsis which can be associated to high mortality rates, therefore a performance indicator for the HB and WG.
The current rate of infection is 39 per 100,000 per population but a Welsh Government target has stipulated a rate of no more than 26 per 100,000 population over the last three months of the target period – up to March 2018.
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3.2
The table below compares rates with other Welsh Health Boards to the end of July - but as discussed above the rate has reduced to 39 per 100,000 when taking August numbers into account.
Health Board Number Rate per 100,000 pop ABM UHB 102 58.07 AB UHB 91 46.80 BC UHB 88 37.91 C&V UHB 44 27.16 CT UHB 23 23.19 HD UHB 55 42.94 P THB 7 15.79 V NHST 6 N/A All Wales 416 40.16
Background
The HB experienced a sharp rise in hospital-acquired cases, originating mainly in the Royal Gwent Hospital, in February and March 2017. Following assessment and targeted interventions, the number of cases stabilised in April and May and showed a decrease in June to 20 cases. July and August have identified similar numbers, 19 and 21 respectively.
Assessment
The Executive Team was updated at the end of July. Each case identified in July was reviewed in-depth:
Out of 19 cases 4 were deemed “hospital acquired”. This is excellent progress when compared to recent acquisitions, particularly on the
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Royal Gwent site where deep cleans are eradicating C.difficile spores in the environment. 3.2 Clinician engagement had also increased around prudent antibiotic prescribing.
Ten cases were identified in Primary Care – four of which were considered avoidable either because of inappropriate samples or non-compliance with antibiotic prescribing policies.
A further four relapse cases were identified two of which were avoidable.
One case was attributable to a hospital in another Health Board – unfortunately it was attributed to ABUHB.
The table below displays a summary of the cases August outlining where the patient acquired the infection, the likely root cause and learning to be taken forward across the HB.
Key Yellow = Community acquired Blue = Hospital acquired Green = Other Health Boards Pink = Relapse
AUGUST DATA
398727 Hospital Root cause – concerns noted re nursing and Avoidable acquired domestic cleaning and hand hygiene No 96 USC 6085290 Hospital Root cause - concerns re hospital cleaning Avoidable acquired - & inappropriate sample No 99 Community 396450 Hospital Root cause – Inappropriate prescribing Avoidable acquired - No 101 USC 565870 Hospital Root cause, inappropriate sample Avoidable acquired – No 104 Mental Health 3062303 Hospital Root cause – inappropriate sample Avoidable acquired - No 106 USC 5000914 Hospital Root cause - C4C indicated concerns from Avoidable acquired - a domestic and nursing cleaning prospective No 109 USC 355520 Hospital Root cause – inappropriate antibiotics and Avoidable acquired – near patient equipment cleaning and hand No 110 F&T hygiene
409712 Hospital Root cause Awaiting review on ward acquired - No 111 SC
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6960706 Hospital Root cause – Nursing cleaning not 95% and Avoidable acquired - multiply antibiotics for abdominal sepsis No 112 SC 5180895 Hospital Root cause Awaiting review 3.2 No 114 acquired - Community 231763 Community Root cause no previous admissions within Unavoidable acquired GP ABUHB, no previous antibiotics No 95 sample 6969681 Community Root cause – no previous admission within Unavoidable acquired GP HB, nursing home patient. No 100 sample 868599 Community Root cause – last admission 2015. Last Avoidable acquired – specimen resistant to trimethoprim not in HB No 102 sample guidelines collected on admission 417514 Community Root cause – appropriate antibiotic Unavoidable acquired GP prescribing No 103 sample 6066308 Community Root cause – inappropriate sample Avoidable acquired – No 105 sample collected on admission 054196 Community Root cause – appropriate antibiotic Unavoidable No 115 acquired GP prescribing sample 182522 Hospital Root cause – ongoing treatment at Velindre Unavoidable acquired in hospital. Likely attributable to No 98 another Velindre Health Board 6902869 Hospital Root cause – recent admission with AMBU Unavoidable acquired in No 108 another Likely attributable to Health Board ABMU – Burns unit
187593 Hospital Root cause – recent admission with Velindre Unavoidable acquired in No113 another Likely attributable to Health Board Velindre
5196282 Relapse – Root cause - appropriate antibiotic Unavoidable No 97 USC management 5152142 Relapse Root cause - appropriate antibiotic Unavoidable No 107 management
August analysis
Out of the 21 cases 10 were assessed as hospital acquired with the majority being attributed to Unscheduled Care. Nine of the cases were attributable to wards that have not undergone a hydrogen peroxide deep clean process within the last 12 months.
Six cases have arisen in Primary care four of which are classed as unavoidable, as there was no evidence of recent hospital admissions or inappropriate prescribing. Two cases were associated with inappropriate antibiotic prescribing.
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Two cases are attributed as relapses. C.difficile treatment was appropriate, but despite evidence based antibiotics the patients became symptomatic 3.2 again. Evidence suggests that 25% of C.difficile cases relapse.
Three cases are attributable to a hospital in another Health Board – unfortunately this will be attributed to ABUHB as samples were processed within our laboratories. Unsuccessful attempts have been made to remove cases attributable to other Health Boards via Public Health Wales.
Recommendations
It is clear that the hospital HPV deep cleans are having a positive effect – all hospital acquired cases identified in August - bar one - have been identified on wards who have not benefited from a deep clean. To that end there is a need to rapidly increase the number of cleans particularly on the Royal Gwent site.
Four patients were identified as C.difficile positive but in fact were not symptomatic for the disease - stool samples were inappropriate. In response the Infection Prevention Team will repeat the appropriate stool collection campaign (To Pot or Not).
Recognising that good progress has been achieved in the reduction of number of cases, due to the inventions indicated above further consideration must be given to the following themes:-
Primary Care Support the business case to expand the antibiotic pharmacist role across the HB.This will also support the Ecoli bloodstream reduction strategy as this is an issue for Primary Care in particular. Promote HB guidelines for Urinary Tract Infection management within Primary Care. This will prevent the prescribing of inappropriate antibiotics.
Secondary Care
Continue to progress with the HPV cleans across the HB and review any further options to increase the scope of the provision to allow for more ward areas to undergo the process. Currently the RGH hospital has a decant facility however at NHH a rolling programme of cubicle clean has been approved however this is proving very difficult to sustain due to capacity demands and little progress has been achieved Review roles and responsibilities for cleaning of patient equipment, dialogue is in earlier stages with Facilities colleagues Continue to support the Capital schemes for ward upgrades
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Primary and Secondary Care
Antibiotic stewardship audits in Secondary and Primary Care need to 3.2 progress. Review HB policy with regard to collecting repeat samples, provisional conversations with Microbiology colleagues have commenced, this would be introducing a similar process like other HB”s in Wales and England Review treatment pathway for C difficile in line with all Wales recommendations Implement faecal transplant for relapsed patients who don’t respond to antibiotic therapy Promote education for staff re specimen collection
Conclusion
Whilst good progress has been made to reduce cases on hospital sites – further work is needed to refine the management of diarrhoea and antibiotics in Primary Care.
A concise “C.difficile Management” guidance document has been sourced from Kirklees which will be localised to Aneurin Bevan. The guidance will be sent to all GP’s (appendix 1).
In terms of cases acquired in hospital – the deep cleans are a key component of a C.difficile reduction strategy and must continue on both the Royal Gwent and Nevill Hall sites. Currently there is no decant facility at Nevill Hall but once the ward upgrade of 4/2 has been completed, a limited number of deep cleans will be undertaken as agreed by the Executive Team.
The table below indicates the current rate of C difficile compared to the WG target. However it must be noted that the overall target will be measured within the last three months of the reporting period between January and March 2018 and therefore if the HB implement the above recommendations there is a possibility that the target could be achieved.
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3.2
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58 of 175 Quality & Patient Safety Committee - 13th September 2017-13/09/17 Tab 3.2 C-Difficile - Progress Against the Action Plan GUIDANCE AT A GLANCE - CLOSTRIDIUM DIFFICILE
These guidelines support the control and prevention of C.difficile in community and primary care settings. Key Ref: PHE (2013) Updated guidance on the management and treatment of Clostridium difficile infection
Early diagnosis prevents complications and saves lives
These affect the balance of Prudent prescribing of antibiotics may prevent infection bacteria in the bowel Communication of infection risk helps prevent cross infection 3.2 providing an opportunity for Alcohol hand rub is ineffective at killing C.difficile spores. C.difficile to multiply, Review Risk factors for infection = over 65’s, recent produce toxin and inflame hospitalisation, recent antibiotics, GI procedures and gastric KEY POINTS KEY the bowel ulcer medications ANTIBIOTICS
My patient has diarrhoea
A useful mnemonic protocol for potentially infective diarrhoea is : Watery or mucoid Suspect that a cause may be infective where there is no clear alternative diarrhoea with or cause of diarrhoea or the patient has recently received antibiotics without blood (typical Isolate the patient if appropriate – i.e. care home residents smell and green Gloves and aprons must be worn to reduce cross contamination appearance), Hand washing with soap & water before and after each patient contact abdominal pain, loss of and the patient’s environment appetite, fever. Test the stool for toxin, by sending a specimen immediately CDI Symptoms
My patient has confirmed CDifficile Infection
CDI can lead to: No repeat specimens are required once diagnosed. For toxin gene dehydration, detected results, only treat as C.difficile infection (CDI) if symptomatic. electrolyte imbalance Review the need for any current antibiotics and stop the course if possible – if unable to stop, change to a narrow spectrum antibiotic. low blood albumin pseudomembranous Review other drugs that may potentially cause diarrhoea. colitis, Proton pump inhibitors (PPI) should be reviewed/reduced where possible toxic megacolon, For treatment options refer to the algorithm over the page and also the sepsis , death. local antimicrobial guidelines for primary care.
Maintain hydration, monitor diarrhoea (for care homes residents, advice Complication care plan, fluid balance chart and Bristol Stool Chart to support this) s Where patients/carers are unable to manage due to the symptoms of C.difficile consider referral to social services. Communicating. infection risk: If admitting a patient with symptoms, notify the receiving area so appropriate isolation can be instigated. The IPC team will write to your patient supplying a leaflet and card with Resources information – copied to the practice. Record the infection risk on the patient record as guided by the IPC team. Antimicrobial guidelines Patient held card
My patient has a history of CDifficile and needs antibiotics CDifficile patient information leaflet There is an increased risk of CDI if someone has had it before or has had the PHE guidelines ‘13 gene detected. Consider narrow spectrum antibiotics if treating other infections
Infection Prevention and Control Team for resources and advice on Tele: 01484 225598 or [email protected] Microbiologist for prescribing and treatment advice (SWITCHBOARD) CHFT – 01484 342000, MYHT – 08448 118110 Thanks to Calderdale IPC team for allowing adaptation of this guidance
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Treatment Algorithm for CDI
Diarrhoea AND one of the following: Positive C.difficile toxin test OR results of C.difficile toxin test 3.2 pending/Gene detected AND clinical suspicion of CDI
Discontinue non C.difficile antibiotics if possible to allow normal intestinal flora to be re- established. Confirmed and suspected cases must be isolated if living in communal areas, where practicable. For recurrent infection, review or stop PPIs unless required acutely.
Symptoms/signs of non-severe CDI Symptoms/signs of severe CDI Oral Metronidazole 400 or 500mg WCC >15, acute rising creatinine TDS for 10-14 days and/or signs/symptoms of colitis
Daily assessment
Symptoms Symptoms not improving improving or worsening (treatment Contact microbiologists OR refer should not patient to hospital. Inform the Diarrhoea should be deemed admitting unit and complete resolve in 1-2 weeks a failure infection risk transfer assessment. until day 7 Recurrence occurs in of ~ 20% of cases after treatment) first episode Anti-motility agents should not be Recurrence occurs in Recurrence – within 30 days of ~ 50-60% of cases prescribed in acute previous case AND positive after second episode CDI CDI toxin test, discuss with the
microbiologist.
Severity Mild CDI is not associated with a raised WCC; it is typically associated with <3 stools of types 5-7 on the Bristol Stool Chart per day. Moderate CDI is associated with a raised WCC that is <15x109/L; it is typically associated with 3-5 stools per day. Severe CDI is associated with a WCC >15x109/L, or an acute rising serum creatinine (i.e. >50% increase above baseline), or a temperature >38.5˚C, or evidence of colitis (abdominal or radiological signs). The number of stools may be a less reliable indicator of severity. Life-threatening CDI includes hypotension, partial or complete ileus or toxic megacolon, or CT evidence of severe disease. N.B. Mild/moderate CDI – treat as non-severe.
Infection Prevention and Control Team for resources and advice on Tele: 01484 225598 or [email protected] Microbiologist for prescribing and treatment advice (SWITCHBOARD) CHFT – 01484 342000, MYHT – 08448 118110 Thanks to Calderdale IPC team for allowing adaptation of this guidance
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Quality & Patient Safety Committee 13th September 2017 Agenda Item: 3.3
Aneurin Bevan University Health Board 3.3
Putting Things Right Annual Report
Purpose of the Report:
This report provides the Committee with an update in respect of the requirements set out in the National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (Putting Things Right).
Recommendation:
The Committee is asked to consider this report and the assurance it provides on progress made with the implementation of Putting Things Right.
The Board is asked to: (please tick as appropriate) Approve the Report Discuss and Provide Views Receive the Report for Assurance/Compliance Note the Report for Information Only Executive Sponsor: Bronagh Scott, Executive Director of Nursing Report Author: Penny Gordon, Corporate Lead Incidents and Complaints Report Received consideration and supported by : Executive Committee of the Board Team Quality and Patient Safety Committee Date of the Report: August 2017 Supplementary Papers Attached: Appendix 1 PTR Progress against Evans report Appendix 2 Learning Bulletin Appendix 3 Rule 28 Reports Appendix 4 Public Service Ombudsman Wales upheld cases
2 Background The underlying principle of Putting Things Right is that whenever concerns are raised about treatment and care, whether through a complaint, claim or clinical incident, those involved can expect to be dealt with openly and honestly, receive a thorough and appropriate investigation, and a prompt acknowledgement and a response about how the matter will be taken forward.
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Quality & Patient Safety Committee 13th September 2017 Agenda Item: 3.3
The need to ensure that these principles are implemented has been highlighted in the Evans Report 2014. 3.3
3 Implementation of the Regulations within ABUHB
Aneurin Bevan University Health Board has a well established corporate team which manages complaints, clinical incidents, and claims, both personal injury and clinical negligence, together with Ombudsman cases and Inquests. The establishment of such a team is in line with the regulations and in addition fits with the model of management as directed by the Evans review 2014.
Training in the management of concerns is provided as part of junior doctor and Consultant induction and on the Core Skills Programme.
A Putting Things Right Investigating Officer Training Programme is available for Band 6/7 staff and is linked to the Electronic Staff Record. The aim of the programme is to develop key skills required to undertake investigations, whether under the PTR process, disciplinary or POVA process. Each participant requires a sponsor and nominated mentor who will support the investigation officer through their first investigation. A toolkit is available to support staff in carrying out an investigation
Pages on the intranet and the internet have been established and provide staff and patients with information about how to raise a concern and how to manage patient concerns with links to the Putting Things Right Team. Patients can now raise an issue through email as well as by post, by telephone and in person.
The Learning Committee has been reviewed and revised. Following each meeting a learning bulletin is produced which is circulated across the Health Board. A thematic approach has been adopted over the last year to focus on key areas of concerns. A Deep Dive into the deteriorating patient has been carried out and a task and finish group established to ensure improvements occur across the whole of the Health Board.
Members of the team have worked with the Welsh Government (WG) following the Evans Review to ensure that the recommendations are implemented. Progress with this All
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Quality & Patient Safety Committee 13th September 2017 Agenda Item: 3.3
Wales work can be seen at appendix 1. The All Wales Listening and Learning from Feedback group has been 3.3 established with attendance from the Assistant Director of Organisational Learning (Putting Things Right) who is the Vice Chair and represents ABUHB.
Following a homicide review, work has been ongoing in Mental Health in relation to supporting families who have suffered a bereavement following a traumatic death. A leaflet has been developed in conjunction with the Third Sector and an engagement pathway has been developed. This has been shared nationally as an example of good practice. A task and finish group has developed a Support Pathway for staff who have been involved in complaints, claims, incidents and inquests to ensure that staff can access the support they need at any stage of the investigation.
A Governance Review has been undertaken by HIW. The work of Putting Things Right was reviewed positively with acknowledgement of the work undertaken by the Assistant Director of Organisational Learning (Putting Things Right).
Focus for Next Year
Transfer of the team to the Director of Nursing to better align with the wider patient experience portfolio.
Review the form and function of the Concerns Team to consider capacity, cross cover, accountability and links with the Divisions.
Workshop with Divisional leads to clarify roles and responsibilities in the management of concerns.
Review the Investigating Officers training programme and develop programmes for specific teams as required.
Consider how the team links with bereaved families and review responses to ensure they offer signposting to bereavement services.
Focus on complaints performance by linking with the Chief Operating Officer and Divisional performance reviews.
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Quality & Patient Safety Committee 13th September 2017 Agenda Item: 3.3
4 Recommendation 3.3 The Committee is asked to consider this report and the further progress made with the implementation of Putting Things Right.
Assessment of the Impact of the Report: Financial The financial implication of the new Assessment regulations have to date been positive as more cases are being considered under Redress and thus these cases do not continue to a civil litigation case Link to Integrated There is a requirement for an annual report Medium Term Plan for assurance. Risk Assessment Concerns raised under these Regulations may pose a financial risk. There are also risks to the reputation of the Health Board. If a risk relating to a particular case or trend is found and assessed to be high this will need to be included in the appropriate risk register and escalated as necessary. Quality, Safety and This report provides a summary of patient Patient Experience concerns raised during the last financial year Assessment and actions taken to improve patient experience. Health and Care The regulations relate to the Health and Care Standards Standards 2015 (Individual Care) Equality and The Health Board is required to make all Diversity Impact reasonable adjustment to allow a patient or Assessment relative to raise a concern. An individual (including child assessment is required to ensure that in all impact cases, all reasonable adjustments have been assessment) taken to allow all patients to raise a concern in the most appropriate format.
rows
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3.3
Aneurin Bevan University Health Board
PUTTING THINGS RIGHT ANNUAL REPORT 2016/2017
COMPLAINTS
In 2016/2017 the Health Board received 992 formal complaints and 920 informal complaints, which is a slight reduction from 2015/2016.
No of Formal and Informal Complaints Received 2016/2017 120
100
80
60 Formal Complaints
No Received No 40 Informal Complaints
20
0
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Complaints Performance 3.3 For formal complaints, complaints performance for 2016/2017 against the 30 day target was 54%. This is fall from 59% in 2015/2016. Monthly performances are shown below:
Monthly complaints performance during 2016/2017 and number of formal complaints received 100 80 60 No of Responses sent out 40 20 Complaints Performance
0 against 30 day target (%)
Jul-16
Jan-17
Jun-16
Oct-16
Apr-16
Sep-16 Feb-17
Dec-16
Aug-16
Nov-16
Mar-17 May-16
Complaints performance is a priority for improvement for 2017/18. Going forward complaints performance will be more closely aligned to Divisional performance reviews and form part of the assurance review meetings led by the Chief Operating Officer and the Executive Team. Closer working with Divisional leads to identify training needs and support plans for complex complaints.
Specialties receiving the highest number of complaints
The following shows the top 10 specialties which have received the highest number of complaints during 2016/2017, together with the subject of those complaints. There has been little change in the top 5, with a slight reduction in the number of complaints received in Care of the Elderly and a slight increase in Adult Mental Health.
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Specialities receiving the highest number of formal complaints 2016/2017 (Top 10) 3.3
120 Waiting Times/Delays/ Cancellations 100 Transport 80 Medical Records 60 Discharge Arrangements 40
20 Communication
0 Clinical Care
Car Parking
Attitude
Clinical care is the most reported complaint subject for 2016/2017, as it was in 2015/2016. The trend in the subjects of complaints during the year is shown below
Trend in the Subject of Formal Complaints during 2016/2017 60 Clinical care
50 Waiting times/delays/cancellations 40 Attitude
30 Communication/information No Received No 20 Discharge arrangements
Physical environment 10
Car Parking 0 Hotel services
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Grading of Concerns 3.3 Complaints are graded on receipt, and concerns received in 2016/2017 were graded as shown below. This does not include concerns that have been considered by the Redress Panel.
Grading of Complaints on Receipt 2016/2017 450 400 350 300 250 No Harm 200 150 Low Harm 100 Moderate Harm 50 0 Serious Harm Catastrophic/Death
Key Learning from Complaints
During this period there were a total of 1912 informal and formal complaints received. As identified previously these covered a number of themes. Key learning from this time included: Staff have been reminded of the importance of considering cultural issues in relation to patient care following a complaint in relation to the physical care provided to a male patient. The family were distressed because the patient had been shaved and this is against his beliefs. Further work is now being done to ensure staff are aware of religious and cultural considerations.
The use of pain assessment tools, analgesia and the use of other methods of controlling pain in child health.
Clinical assessment of patients presenting with potential Deep Vein Thrombus (DVT), their diagnosis and prescription of Fragmin.
Complaints Management
Importance of early contact with a complainant by telephone on receipt of concern. The importance of open, transparent conversations with families following a complaint in order for them to understand the problem and the personal involvement of key staff in ensuring best treatment is accessed.
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PATIENT SAFETY INCIDENTS
These are reported through an electronic database (Datix). Any 3.3 member of staff can raise an incident through Datix. Any incident which has caused serious or catastrophic harm to a patient is reported to WG and managed through the Serious Incident process. Also any incident where a patient has developed a Grade 3 or above hospital acquired pressure ulcer (HAPU), has fallen whilst an inpatient and sustained a long bone fracture or been identified as Clostridium difficile contributing to death, alongside any other WG reportable incidents.
Where incidents are reported to WG a 60 working day timescale for completion of the investigation is given. WG expects a closure assurance form to be provided by the deadline outlining findings, learning and actions taken. WG measure the Health Board’s compliance with this reporting and assurance process.
Total number of incidents reported to WG Serious Incidents reported to WG 1.4.16 - 31.3.17 250 211 200 150 100 50 20 19 15 12 17 14 13 14 17 26 25 19 0
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Description of Incidents reported to WG 3.3 1.4.16 – 31.3.17
Description Number In-patient falls - fractures 55 Absconsion whilst detained 5 infection control 17 CAMHS (adolescent admitted to adult MH ward) 4 In-patient fall - head Injury 5 Information Governance 3 HAPU 46 PRUDiC 9 Never Events 2 Mental Health unexpected deaths 12 Suicides including suspected suicides 30 Suicide - in-patient 1 Others Referral to GMC 1 Anaesthetic awareness 1 Arterial line complication 1 Arrest in department 1 Assault on staff 1 Patient assault by staff 1 Delayed appointment (ophthalmology) 1 Delay in receiving treatment 1 Medical devices 2 Ionising Radiation (Medical Exposure) Regulations 2000 3 Intrauterine death 1 Neonatal death 1 Missed chest x-ray result 1 PCI transfer issue from A&E to UHW 1 Ophthalmology 1 WAST delay in offloading/ responding 2 Retained trial femoral head 1 Wrong site surgery/cut to toe 1 TOTAL 211
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Number of ‘No Surprise’ incidents reported to WG 1.4.16 – 31.3.17 3.3
No Surprises 29
Overview of all patient related incidents reported 2016-2017
Total number of patient related incidents reported via Datix 17,514 Top 5 incident categories Slips, trips, falls and collapse (incl patient found on floor) 4575 Pressure Ulcer (non healthcare acquired) 1766 Pressure Ulcer (healthcare acquired) 1560 Pressure Ulcer (transferred with) 1086 Discharge issues including absconding/missing patients 682 Total 9669
Incidents broken down by level of patient harm reported to NRLS Catastrophic harm (e.g. concern leading to unexpected 14 death, multiple harm or irreversible health effects) Severe harm (e.g. clinical process issues that have resulted 74 in avoidable, semi permanent harm, or impairment of health or damage leading to incapacity or disability) Moderate harm (e.g. clinical/process issues that have 2003 resulted in avoidable, semi permanent injury or impairment of health or damage that requires intervention) Near misses 1379
Other Incidents Unexpected deaths (incl suspected suicides) 43 Never Events 2
Number of serious incidents reported to Welsh 211 Government
Never Events
Never Events are a subset of serious incidents and are defined as serious largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. The list provided by the Department of Health lists 14 such events. If a Never Event occurs the Health Board must notify Welsh Government and it is the Delivery Unit who oversee the investigation process of all Never Events to ensure that remedial actions are taken and lessons are learned.
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On completion of the Serious Incident investigation process the Delivery Unit provide assurance to Welsh Government that the investigation and learning generated are robust and complete. 3.3
Overview of Never Events
Retained Needle Post Operation A patient was undergoing elective complex hip revision surgery. Towards the end of the operation, at the point of skin closure, the Registrar assisting the Consultant Surgeon noted that the suture needle was missing.
The needle could not be located and the Consultant Surgeon decided to X-ray the patient post operatively. It appears that the missing needle was not flagged for further investigation post operatively in the notes. The missing needle was identified in the patient on review of the plain X-ray.
The needle was successfully removed under local anaesthetic in theatre. The patient has made a full recovery with no complications.
Wrong Route Administration of Medication The epidural was sited by an anaesthetic core trainee. The nurse noticed that the epidural line was connected to the intravenous line. The mistake was rectified. The patient was informed of the error. The patient came to no harm.
Key learning from Serious Incidents
As stated 211 incidents were reported to WG, in addition to this WG were also alerted to 29 ‘No Surprises’.
Implementation of Deteriorating Patient Policy – this key learning was identified and shared as a theme for Learning Committee (see appendix 2 Learning Bulletin).
Use of risk assessments in patients who fall and fracture, including awareness of changes in policy.
The importance of lying and standing blood pressure monitoring to identify patients with postural hypotension, as part of the assessment process.
The importance of risk assessment of patients with tinnitus, as it is associated with a higher occurrence of depression than in the general population and when combined with other factors may increase the risk of suicide.
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Use of integrated inpatient notes in acute inpatient wards to improve communication between multi-disciplinary teams. 3.3
The importance of clear, concise information given to patients, especially in relation to consent, to ensure that potential complications are clearly understood.
REDRESS CASES
The underlying principle of Putting Things Right is that whenever concerns are raised about treatment and care, whether through a complaint, claim or clinical incident, those involved can expect to be dealt with openly and honestly, receive a thorough and appropriate investigation and a prompt acknowledgement and a response about how the matter will be taken forward. The Health Board is also required to consider whether there has been a breach in our duty of care. The judgement of a breach of duty is based on the Bolam principles. That is would a reasonably competent person trained in the procedure have behaved in that way.
If a breach of duty is agreed consideration then needs to be given as to whether that breach of duty caused the patient harm. Where it is judged that the breach of duty caused harm there is a qualifying liability in tort and Redress needs to be considered.
Redress can mean:
. An apology . Remedial Action . Explanation of the care given . Compensation
Number of cases heard by Panel in 2016/2017 70
Of these : A qualifying liability was established 53 A qualifying liability was not found 5 The potential of a qualifying liability was found but due to 1 potential value exceeding 25K taken out Further investigation on causation is being undertaken 10 Further investigation on breach of duty being carried out 1
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Outcome of Panel Decision 3.3
Directorate Liability Liability Not Further Breach of Total proven Established Investigation Duty Required established but value > £25k Acute medicine 2 2 Anaesthetics 2 2 Blaenau Gwent 7 1 6 14 Caerphilly 2 1 1 4 Cardiology 1 1 Care of the 4 4 Elderly Child health 1 1 Diabetiology 1 1 2 Emergency care 12 1 1 14 Gynaecology 3 3 Maternity 2 1 3 Medical 3 3 admissions Mental health 1 1 Monmouthshire 1 1 Ophthalmology 1 1 Out of Hours 1 1 Physiotherapy 2 2 Radiology 1 1 2 Respiratory 3 3 Torfaen 1 1 T & O 4 1 5 Total 53 5 11 1 70
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Themes from Redress Cases
Whilst many of the breaches of duty were specific events there were 3.3 several themes that emerged during the year.
Number of
admissions of Theme Issue breach of
duty of care Pain Failure to investigate pain and 1 Management cause of pain Inadequate pain assessment 2 Inaccurate wound charts 1 Failure to administer pain relief. 1 Pressure Ulcers Failure to follow protocols 1 Lack of documentation 1 Total number of Failure to consider deep tissue 1 cases 5 (each damage case may have a Lack of risk assessment 2 number of Lack of/incorrect Waterlow 3 breaches) score 1 Failure to take account of co- morbidities 1 Failure to provide right 1 equipment 1 Failure to implement skin bundle Wound chart not completed/updated Incorrect 6 Vaccine Administered Patient falls Failure to hand over known risk 1 Lack of risk assessment 7 Total number of Lack of care plan 6 cases - 12 Failure to review 4 plans/assessment in light of change to patient’s condition Care plan/risk assessment not 4 updated Missing nursing notes 1 Failure to consider preventative 3 measures Clinical error Substandard surgery 2 Failure to refer to surgical team 2 Failure to assess patient post op 1 Failure to check equipment 1 Failure to change patient’s 1
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programme in light of change in symptoms In appropriate assessment 1 3.3 Failure to seek consultant 1 advice 1 Incorrect measurement 1 Inappropriate discharge Medication Incorrect dose of medication 1 given 1 Failure to prescribe 1 Discharged with wrong medication Test results Failure to undertake tests 1 Failure to recheck test results – prior to discharge, prior to 2 surgery 1 Failure to act on results 1 Under-reporting of x ray Delay in reporting Delay/Failure to Fracture 6 diagnose Anterior Cruciate Ligament 1 injury 2 Tendon injury 1 Ectopic pregnancy Documentation Lack to document clear rationale Missing notes Failure to document x ray had been requested Incomplete examination, history, investigations requested
Lessons Learned from Redress Cases
Part of the Redress Panel’s function is to also ensure that lessons are learned. Due to the membership of the Panel opportunities arise to identify themes on a number of different levels e.g. cluster of similar incidents at one hospital, health board wide trends.
In the cases of pressure ulcers and patient falls, incidents will have been taken previously to the review group for these injuries where the focus is on the learning and the action taken to address the events in question.
Often learning is at a more local level where the consultant and/or team involved are asked to reflect on the incident that occurred.
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Cases are often discussed in directorate/audit meetings and/or are taken to “Grand Round” for junior doctors to learn. 3.3 However some additional actions to note
Training given in Ysbty Ystrad Fawr by tissue viability to increase awareness of the potential risk of developing pressure ulcers based on clinical judgement and not to be reliant on Waterlow scoring system Falls audits are now undertaken, auditing risk assessments and relevant documentation on a regular basis. Single referral form to Deep Vein Thrombosis (DVT) clinic with signs and symptoms identified to trigger referral is being considered. Patient Safety At A Glance Boards now indentify patients who are at high risk of falls. Risk register of equipment being compiled in clinical ophthalmology. New Multifactorial Risk Assessment regarding falls now rolled out throughout the Health Board. Pressure ulcers now added routinely to safety briefings and ward hand overs. Letter sent to all junior doctors in acute care at RGH informing them of correct VIP processes to follow. Review of reporting arrangements and practices within emergency admissions units has been undertaken.
Rule 28 reports The Legal Services Managers are involved and support the Health Board in the matter of Inquests held by the Coroner. When the Coroner hears, receives evidence and believes that actions can be taken to prevent future deaths he must issue a Rule 28 report asking the appropriate body to respond within 56 days. The Health Board received four such reports. The reports have also involved other external agencies including other health bodies. A description of the reports and actions which relate to the Health Board is found in Appendix 3.
PUBLIC SERVICE OMBUDSMAN FOR WALES (PSOW) INVESTIGATIONS
The data illustrates that there has been a 28% decrease in the number of upheld Formal Section 21 Reports (reported to the organisation and the Ombudsman has determined there is no wider Public interest) compared to last financial year - from 25 to 18. There
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has also been a slight decrease in the number of cases referred to the Ombudsman compared to last year from 103 to 97. 3.3 The Ombudsman’s Office has been very positive about the Health Board’s management of concerns at an early stage, this financial year there has been a slight increase in the number of cases settled. There are close links with the Ombudsman and the Health Board, the Concerns Review Manager who regularly attends the Ombudsman Sounding Board Meeting and meets with the Ombudsman Improvement Officer. The Manager also attends the All Wales Ombudsman Health Board Network Group to share good practice.
This section of the ABUHB Annual Report includes Primary Care & Network Ombudsman cases. A total of 97 cases were referred to the PSOW for 2016/2017, below is a bar chart comparing the number of concerns referred to the PSOW over a five year period.
Concerns referred to PSOW
120
100
80
60
40
Numberofconcerns raised 20
0 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 5 year period
Of the cases referred, set out below is the data for new, upheld and not upheld investigations over a five year period. The graph shows a slight decrease in the cases not upheld from 57 cases last financial year to 55 this financial year.
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PSOW New, Upheld, Not Upheld and Settled cases 3.3 2016/2017
2015/2016 5 years 5 - 2014/2015
2013/2014
2012/2013 Financial Financial period
0 20 40 60 80 100 120 Number of investigations
New Upheld Not Upheld Settled
The Health Board has received 18 Upheld Section 21 Cases and one public report from the Ombudsman in November 2016, the details are as follows:-
The Section 16 Report (public report with wider public interest) was critical of the Scheduled Care Division, General Surgery Directorate, predominately the nursing care provided on Ward C5 West at the Royal Gwent Hospital.
Public PSOW ref 201503082 HB ref SH/OMB/2015061 Summary
Mrs X complained to the Ombudsman about the care her father Mr Y received at RGH between Friday 5 December 2014 and over the weekend after his admission suffering with constipation. Mr Y died on Monday 8 December. Mrs X complained her father’s raised blood glucose levels were not managed and he was not seen by a doctor for several hours. Mrs X said that despite her father having a full care package in place at home, he remained on an unsuitable ward and had an undignified end of life. Mrs X also complained that the HB’s investigation of her complaint had been unhelpful.
The Ombudsman upheld Mrs X’s complaints. He found that no action was taken in relation to Mr Y’s elevated blood glucose levels over the weekend. Further, nursing staff had not informed the medical team of Mr Y’s aspiration or fluctuating swallowing ability (dysphagia). He was
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not referred to a Speech and Language Therapist (“SALT”) and he had not been kept nil by mouth (“NBM”) in the interim. 3.3 The Ombudsman found that on Sunday, Mr Y’s condition deteriorated and he was not reviewed by a doctor for over six hours. Nursing staff had not escalated the failure of a doctor to attend to Mr Y. Consequently, antibiotics were not administered in a timely manner. The Ombudsman could not be certain whether earlier intervention might have led to a different outcome for Mr Y.
The Health Board had not recognised that Mr Y had a full care package in place at home, and he had been placed on an inappropriate ward.
The Ombudsman did not uphold Mrs X’s complaint about her father’s end of life on an open ward. Side rooms were in use by patients with priority need.
The Ombudsman found that the HB’s own investigation of Mrs X’s complaint did not identify the failings in Mr Y’s care.
The action taken by the Division and the Health Board in response to the Ombudsman’s recommendations are:-
the HB has provided an apology to Mrs X for the identified failings and, in recognition of the distress and uncertainty associated with her father’s care, the Division made a financial redress payment of £2000. The Senior Divisional Nursing staff have reminded all nursing staff that patients with dysphagia should be referred without delay to SALT and kept NBM until formally assessed. The Division with the Educational Diabetic Nurse are reviewing the training issues for nursing staff on C5 West Ward in relation to the identification and management of hyperglycaemia The Division has established why the escalation procedures were not followed and has undertaken a review of the escalation process, in light of the outcome, to ensure it will be more effective in the future. A copy of the corporate action plan has been included.
The Divisions and the Concerns Review Team actively resolve/settle the concerns at Ombudsman stage. This action rebuilds relationships with the person raising the concerns, diminishes the number of cases formally investigated and thereby reduces the possibility of a public report. There has been a significant increase in settled cases which has risen to 11 this financial year.
Below is the annual breakdown of Ombudsman cases by Division:
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PUBLIC SERVICE OMBUDSMAN INVESTIGATIONS 2016/17
Category Total Division 3.3 Unscheduled Care Division 25 Scheduled Care Division 20 Mental Health & LD Division 17 Concerns Referred 97 Family & Therapy Division 11 to PSOW Community Division 2 PC & Networks Division 15 Corporate Services 3 Anon 4
Upheld 1 Section 16 Scheduled Care Division 1 Reports
Unscheduled Care Division 8 Upheld Scheduled Care Division 6 Section 21 18 Family & Therapy Division 2 Reports Community Division 1 PC & Networks Division 1
Unscheduled Care Division 17 Scheduled Care Division 11 Not Upheld Mental Health & LD Division 6 Concerns 55 Family & Therapy Division 5 Community Division 3 PC & Networks Division 9 Anon 4
Unscheduled Care Division & 3 Settled Corporate (concerns Scheduled Care Division 1 resolved by the HB 11 Mental Health & LD Division 1 at PSOW stage) PC & Networks Division 1 Family & Therapy Division 2 Corporate Division 3
A Divisional snapshot of activity is provided below to illustrate a four year breakdown of data:-
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Unscheduled Division - PSOW Concerns 35 3.3
30
25 2016/2017 20 2015/2016 15 2014/2015
Number of cases of Number 10 2013/2014
5
0 New Upheld Not upheld Settled
Scheduled Division - PSOW Concerns 35
30
25
2016/2017 20 2015/2016 15 2014/2015
Number of cases of Number 2013/2014 10
5
0 New Upheld Not upheld Settled
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MH & LD Division - PSOW Concerns 18 3.3 16 14 12 2016/2017 10 2015/2016 8 2014/2015
Number of cases of Number 6 2013/2014 4 2 0 New Upheld Not upheld Settled
F&T Division - PSOW Concerns 18
16
14
12 2016/2017 10 2015/2016 8 2014/2015
Number of cases of Number 6 2013/2014 4
2
0 New Upheld Not upheld Settled
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Community Division - PSOW Concerns 14 3.3
12
10 2016/2017 8 2015/2016 6 2014/2015
Number of cases of Number 4 2013/2014
2
0 New Upheld Not upheld Settled
PC&N Division - PSOW Concerns 16
14
12
10 2016/2017
8 2015/2016 2014/2015 6
Number of cases of Number 2013/2014 4
2
0 New Upheld Not upheld Settled
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Corporate Division - PSOW Concerns
7 3.3
6
5 2016/2017 4 2015/2016 3 2014/2015
Numberofcases 2 2013/2014
1
0 New Upheld Not upheld Settled
From the data provided, Primary Care & Networks and Mental Health & Learning Disabilities Divisions have seen an increase in the number of Ombudsman cases this financial year. The remaining Divisions have seen a decrease in the number of cases received.
A review of upheld cases has identified that the lack of communication with the family is a core reason why a case proceeds to the Ombudsman. The bar graph below sets out the key elements of the upheld Section 21 Reports.
Key Elements of Ombudsman Upheld Cases 20 18 16 14 12 10 8 6 4 Number of cases of Number 2 0
Key elements
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Changes/Improvements in practice from concerns
Reflections on poor management of complaints have taken place 3.3 by senior Directorate staff and also by clinicians.
Clinical staff have been reminded to monitor and escalate deteriorating patients appropriately.
Reflection by clinicians to improve communication when discussing the DNACR process with families.
Clinicians were reminded to carry out further radiology investigations after repeat admissions, an appropriate radiological investigation would probably have identified that Mrs X had a brain tumour.
Radiology now have a bank holiday CT scan logging process which enables requests to be actioned quicker.
Radiology have reviewed missed diagnosed images at a radiological discrepancy meeting to learn lessons.
Nursing staff at EAU & ED have undergone further training on record keeping for fluid monitoring, pain assessment, patient transfer, and communication with families.
ABUHB introduced a new colour coded early warning chart. New staff on ED now receive additional training to use the chart.
County Hospital staff are now trained in toe nail cutting for patients who do not require a referral to podiatry.
County nursing staff have been reminded to ensure patients have access to the necessary equipment which supports posture when seated.
Clinicians were reminded of the importance of ensuring that the discussions around consent and possible risks and complications are fully and accurately recorded in the clinical notes.
The F&T Division are to ensure that the guidelines issued by the Royal College of Obstetricians and Gynaecologists (on ruptured membranes and pain management) are brought to the attention of its midwifery and medical staff.
Clinical staff have reviewed the Caesarean section technique used for a specific case to learn from the shortcomings identified.
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Wards have been reminded to record and to accurately assess, record and monitor the mental state/mental capacity of patients and, where appropriate, to make referrals to mental health 3.3 teams, link nurses and psychiatric liaison nurses.
Acute wards at RGH have undertaken audits on cannula care and compliance with hygiene standards
Acute wards have improved the communication with people with sensory loss, to ensure there is a plan in place to seek consent from patients with sensory loss.
The documentation when using a password system for communicating with relatives has been improved.
ABUHB Upheld Case Summaries can be found in Appendix 4.
ASSURANCE, LEARNING AND CLOSING THE LOOP
A review by the Welsh Risk Pool into the implementation of the regulations has identified that progress has been made year on year and that the Health board has a strong framework for learning from concerns.
A key focus of the Legislation is the importance of learning from concerns and ensuring that actions are taken to prevent the issue arising again. Over the last twelve months there has been increased scrutiny around patient safety from the Welsh Risk Pool, the Ombudsman and Welsh Assembly. The release of the Francis, Andrews and recently the Evans reports has heightened this scrutiny and the Board is now required to provide clear evidence of actions taken to improve patient safety. This includes providing evidence of actions taken from bodies which we contract with such as independent contractors and Care homes.
The corporate team has linked with Divisional Leads to ensure that there is a framework for feedback and learning and more importantly a mechanism for monitoring agreed actions. The Learning Committee aims to link the learning from concerns across the Health Board and ensure that any lessons are spread across ABUHB. Following each meeting a Learning Bulletin is produced which is circulated to all divisions. Primary Care has also developed their own bulletin for dissemination across the division.
The Executive Team receive a monthly summary of concerns and claims. Areas for consideration and escalation are highlighted with an expectation that the Divisions will take the appropriate remedial actions.
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The Chief Operating Officer is including complaints performance within the Divisional performance reviews with an expectation that complaints performance will improve over the next year. 3.3
A bi-monthly Concerns Report is provided to the Quality and Patient Safety Committee. This report, as well as providing information about the number and nature of serious concerns, also provides a summary of the lessons learnt and the action taken to assure the Board that concerns are being appropriately managed.
An annual PTR report and an annual Claims report are presented to the Quality and Patient Safety Committee for scrutiny and then to the Main Board.
Audit reviews
Internal audit review the management of concerns annually and this report is presented to the audit Committee.
External reviews are undertaken by the Welsh Risk Pool and the next review will be in May 2018.
Following both the internal and external audit reviews, action plans are developed to meet the recommendations and ensure that improvements are made.
HIW have recently undertaken a governance review and the findings of which will be included in next year’s annual report.
Welsh Government
The Executive Team meet with the Delivery Unit quarterly to review progress against key patient safety targets. This includes progress with the closure of serious incidents. To support this a new post was appointed in June 2016 and the new post holder has made a significant impact with regard to compliance in respect of closure forms.
Actions Taken
Below are some examples of the actions taken:
Where learning can be shared Health Board wide, this is often disseminated by highlighting in the Learning Bulletin which is cascaded to staff and is available on the intranet.
Where claims have arisen and breaches of duty are identified, these cases are at reviewed at the Directorate clinical governance meetings which are held monthly.
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A framework for the support of families following a homicide has been developed. A second framework for the support of families following a serious incident has also been developed. 3.3
The arrangements for Redress within ABUHB have been highlighted as an area of good practice.
Upheld Ombudsman reports are now regularly presented at the Directorate Quality meetings and at the Grand Rounds, which are learning sessions held at Nevill Hall where doctors of all grades attend to discuss case studies.
These are just a few examples of the actions taken following the investigation of a concern but help to demonstrate the commitment of the staff to use concerns as a tool to improve the service they deliver.
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Appendix 1
PTR Progress against the Evans report 3.3
Learning from Evans Progress made by PTR Report Points of contact for Customer contact centre 9-4pm health board Email Letter Direct calls Direct contact –aim to resolve quickly where possible. Records of informal complaints is made to track trends Redress Arrangements Established Redress Panel (1st in Wales) Clear process Used as a model across Wales
Training Awareness raising Investigating officer training now focused on clinical team requirements linked with staff record/ competencies Sage and Thyme Customer care Values framework
Reporting arrangements Monthly performance reports to the Executive team /Divisional teams Bi monthly reports to Quality and Patient safety Annual reports –PTR /Claims Data sent to Welsh Government Internal Audit review HIW Governance review WRP
All Wales Work Senior staff are part of the Part of quality forum Representative on the All Wales Listening and Learning forum Representative on the All Wales concerns Network
Team focus Learning lessons Taking action Closing the loop Mechanism for Learning Learning committee Learning Bulletin
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Learning strategy All Wales work Divisional Quality meetings 3.3 Links with action learning sets in ABCi
Support for complainants CHC Advocates Independent advice Expert advice
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Appendix 2
3.3
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3.3
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3.3
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3.3
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Appendix 3
Rule 28 Reports
The Legal Services Managers are involved and support the Health Board in the matter of Inquests held by the Coroner. When the Coroner hears, receives 3.3 evidence and believes that actions can be taken to prevent future deaths he must issue a Rule 28 report asking the appropriate body to respond within 56 days. The Health Board received four such reports during the year 2016 – 2017. The reports have also involved other external agencies including other health bodies but below is a description of the reports and actions which relate to the Health Board.
Case 1 Conclusion of accidental death was given to patient who had sustained a fall whilst transferring to a commode. The commode moved backwards despite the brakes having been applied. Patient, who was large, fell to floor striking her head and suffered a subdural haemorrhage.
Coroner’s concerns a) That braking mechanism of commode showed that it was possible for it to move despite brakes being applied. That braking mechanism of all commodes be reviewed and that a risk assessment of their future use be undertaken.
Action Taken Confirmation given that the brakes on the commode had been correctly applied at the time of the incident and that there was no fault shown with the equipment.
Health and Safety Information Notice issued to staff to reinforce the need to check all equipment (commode, wheelchair bed or hoist) for stability prior to use.
Confirmation given that contract for procurement of commodes will commence in 2017. Further a member of the Health Board will be part of the Panel for the evaluation process and the issue of the braking system will be brought to the Panel’s attention.
Case 2 Conclusion was one of suicide in a patient who was known to mental health services and had been recently discharged from an in patient admission
Coroner’s concerns a) Liaising with family members in respect to discharge b) Plans of action for discharge of in-patients. c) Lack of communication to primary care team when patients are discharged from mental health services.
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Appendix 3
Action taken The Senior Psychiatry team and adult psychiatrists informed of the expectation to fully liaise appropriately with family members once patients have been discharged from inpatient admissions. 3.3
Community Care Co-ordinator to be present at the ward round or the Community Link Nurse to act as mechanism for ensuring link with primary care and community team on discharge of patients.
Case 3 Coroner’s Conclusion was a narrative one in which the deceased died from the effects of Venlafaxine Toxicity but the circumstances in which she came to be affected by it remains unclear.
Coroner’s concerns a) That the ambulance being despatched to the home of the deceased who was clearly experiencing seizures/fits was delayed. The main reason for the delay was the significant hand over delays being experienced at RGH and NHH. Further that there had been guidance issued on the agreed hand over time and that since this had been issued, the position had worsened.
Action Taken Confirmation given that the Health Board has implemented and reviewed a number of key processes including:
Establishment of Urgent Care Board which looks at urgent and emergency care services pathway. It agrees, sets and monitors shared clinical and management action.
Implementation of Standard Operating Procedure which supports bed management and site management teams in utilising all bed capacity.
Utilisation of escalation protocols to guide ED staff in operation procedures for receiving and off-loading ambulances.
Introduction of Red Release Protocol for response to Welsh Ambulance Services NHS Trust when an ambulance crew is required to attend a “red” call in the community.
Introduction of “Breaking the Cycle” initiative looking at processes to support flow within the acute hospitals i.e. timely discharge, appropriate placement and timely transfer of patients from ED and MAU.
Case 4 Coroner’s conclusion was that the deceased was admitted to Royal Gwent Hospital following a fall in which she sustained a fractured neck of femur. A decision was made to treat her by a total hip replacement. The patient was given a general anaesthetic in preparation for surgery. Shortly after
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Appendix 3
anaesthesia was induced she suffered an adverse reaction to the anaesthetic agent that caused cardiac failure and her death.
Coroner’s Concerns 3.3 Patient was listed for surgery but due to insufficient theatre staff operation was cancelled and rescheduled for the following day which was then cancelled due to resource availability. Next available opportunity for surgery with a specialist surgeon was seven days after the fall. NICE guidelines state treatment for fracture neck of femur should occur within 48 hours but recognises that in certain circumstances, it may be appropriate to delay for the correct operation by the correct specialist. It was acknowledged that there were competing priorities on resources and surgery was arranged for the first available list with an appropriate specialist. It is also acknowledged that the delay in surgery did not have an impact on the patient’s cause of death; however it is recognised that serious complications leading to potentially life threatening conditions can arise where prompt surgery is not undertaken.
Coroner’s recommendation A review of the procedures in respect of the provision of emergency surgery for trauma patients where specialist skills are needed. The review should consider rescheduling elective cases and redeploying specialist staff if necessary.
Action taken Introduction of a system whereby trauma patients who are otherwise medically fit can be transferred to St Woolos Hospital, if need arises, where surgery can be performed on elective list. To facilitate prompt transfer, investment has been undertaken in a new MRSA screening device which provides fast track MRSA swabbing process including test result.
Plans to create specialist neck of femur fracture ward including recruitment of consultant orthogeriatrician with responsibility for medical management of elderly patients with particular refer to neck of femur patients. In addition plans to appoint a junior doctor and fracture neck of femur specialist nurse. The service would help to medically optimise patients pre and post operatively.
Employment of a Trauma fellow to co-ordinate trauma lists and to ensure flow of patients through the trauma list.
Proposed extension of trauma working day to provide greater capacity for trauma patients attending Royal Gwent Hospital site which would allow for prioritisation of neck of femur cases.
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Appendix 4
PSOW ref 201505689 HB ref SH/OMB/2015081 Summary 3.3
Mrs X complained about the care and treatment her late husband, Mr X, received during an admission to hospital. Mrs X complained that Mr X was prescribed medication despite informing clinicians that he had an adverse reaction to it; that there was a failure to administer treatment to remove fluid from Mr X’s lungs; there was a failure to monitor Mr X; that Mr X had been unnecessarily catheterised; and that there was a failure to complete medical records. Mrs X also complained that the HB failed to adequately respond to her complaint.
The investigation found that there was no evidence that the medication prescribed had an adverse affect on Mr X’s condition and, unfortunately, despite medical intervention, Mr X deteriorated quickly and sadly died. The investigation found no evidence to suggest that Mr X had been unnecessarily catheterised and the medical records were of a reasonable standard.
Finally, the investigation found that the HB had failed to provide Mrs X with a full response to her complaint. Instead, it provided a chronology of events.
PSOW ref 201503518 HB ref SH/OMB/2015048 Summary
Mr Y complained that there were failings in the care and treatment that his late wife, Mrs Y, received at Nevill Hall Hospital from July 2014. The complaint raised an important theme about the timeliness and adequacy of communication with patients and their relatives when they are dealing with very distressing and difficult events. Sadly, Mrs Y died later in 2014.
Taking account of clinical advice, the Ombudsman found nothing to suggest that any of the medical reviews had been inadequate and there was nothing to suggest that any of the discharges had been inappropriate or unsafe. The Ombudsman was also of the view that a CT scan had been conducted in a reasonable timeframe. He did not uphold these clinical areas of the complaint.
Mr Y also complained about the quality of the clinical recording and the general communication with Mrs Y and her family. He specifically referred to communication in respect of a Do Not Attempt Resuscitation order. To the extent of the shortcomings identified, the Ombudsman partly upheld these elements of the complaint.
The Ombudsman recommended that the HB apologises for the shortcomings identified and provides financial redress of £250 in light of the time and trouble incurred by Mr Y in pursuing the complaint.
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Appendix 4
The Ombudsman recommended that the HB reviews the process for the logging of requests to the Radiography Department and provides evidence of improvement to the Ombudsman of staff training event to ensure that nursing staff at ED and EAU are aware of record keeping requirements in respect of key 3.3 areas such as fluid monitoring, pain assessment, patient transfer, and communication with families.
PSOW ref 201505934 HB ref SH/OMB/2015091 Summary
Mrs X complained on behalf of her late aunt, Miss Y, about the care and treatment Miss Y received at Pontypool County Hospital, specifically, that there was a failure to maintain Miss Y’s podiatry and hair care. Mrs X also complained that there was a failure to provide adequate physiotherapy and ensure Miss Y was seated correctly. Finally, Mrs X complained that there had been a failure to adequately prepare Miss Y for discharge.
The investigation found that despite references in the records, Miss Y’s toenails were overgrown and painful. Additionally, Miss Y was discharged from hospital with head lice, which had a detrimental effect on her settling into her new home.
The investigation found that whilst Miss Y received regular physiotherapy, the treatment was not continued by ward staff which had affected her recovery. The investigation also found that there was a failure to assess Miss Y’s posture when seated which resulted in the compression of her trachea.
Finally the investigation found that whilst there was no communication with Mrs X regarding Miss Y’s discharge planning, Miss Y’s discharge was regularly discussed during multi-disciplinary team meetings.
The Ombudsman recommended that the HB apologises to Mrs X for the failings identified in the report and that the HB ensures that the ward has staff trained in toe nail cutting for patients who do not require a referral to podiatry.
He also recommended that the HB remind the relevant staff of the need to follow up any treatment administered for head lice and that the HB reminds staff of the need to ensure patients have access to the necessary equipment which supports posture when seated.
PSOW ref 201504364 HB ref SH/OMB/2015065 Summary
Ms A complained about the Welsh Ambulance Services NHS Trust (“WAST”), Aneurin Bevan University Health Board (“the Health Board”), and a GP (“the GP”) which she said, together, led to her brother, Mr B’s death from a bowel obstruction. In brief, she said that WAST should have sent an ambulance for her
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Appendix 4
brother, the GP should have examined him rather than prescribing antibiotics without seeing him, the out of hours GP (“OOHGP”) should not have advised Mr B to see his GP the following day and the Health Board should have carried out a CT scan sand subsequent surgery sooner than it did. Sadly, Mr B died of a 3.3 cardiac arrest while being anaesthetised.
The Ombudsman partly upheld the complaint against the GP and the Health Board. It had not been appropriate for the GP to prescribe antibiotics without examining Mr B, although the GP might not have identified the bowel obstruction and thus Mr B might not have been admitted to hospital sooner. The OOHGP should not have considered sending Mr B home, although the outcome of the consultation- that Mr B was admitted to hospital – was appropriate. The Ombudsman did not uphold the complaint against WAST, or against the Health Board in respect of inpatient treatment.
The Ombudsman recommended that the Practice apologises to Ms A on behalf of the family for the failings identified and provides evidence to the Ombudsman that the action points identified in Dr X’s discussion with the Appraiser have been carried out.
The Ombudsman recommended that the HB apologises to Ms A on behalf of the family for the failings identified on the part of the OOHGP and uses its best endeavours to draw this report to the attention of the OOHGP and provides evidence to the Ombudsman of the steps it has taken to do so.
PSOW ref 201503249 HB ref SH/OMB/2015044 Summary
Mr X complained about the inadequate standard of medical care provided to his late mother, Mrs X, from the time of her first admission to the Royal Gwent Hospital on 7 April 2014 until July 2014 when a brain tumour was diagnosed. Mr X was aggrieved that the HB initially wrongly diagnosed that his mother had suffered a stroke and treated her for that condition. Mr X was concerned that the HB failed to diagnose the brain tumour during that period. Mr X was also concerned that a prescription error led to his late mother taking inappropriate medication which led to her requiring urgent medical attention.
The investigation found that while the initial working diagnosis of a stroke after her first admission was reasonable, the HB should have investigated an alternative explanation for her condition after her second admission on 23 April. The appropriate radiological investigations would probably have identified that Mrs X had a brain tumour. The failure to investigate Mrs X at this stage was found to amount to service failure. This failure meant that there was a delay in properly treating her condition. While it was unlikely that the failure affected the sad outcome, the delay in treating Mrs X amounted to an injustice. The complaint was upheld.
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The Ombudsman recommended that the HB provides a fulsome apology to Mr X and the family for failing to properly consider and investigate Mrs X’s condition and for the distress this failing has caused. 3.3 He also recommended that the findings of the report are formally shared with the clinicians involved in this case and discussed at an appropriate forum so that lessons can be learned regarding the management of similar cases and that the radiological images are reviewed at a radiological discrepancy meeting so that lessons can be learned from this case.
PSOW Ref 201502943 HB Ref SH/OMB/2015053 Summary
Mrs X complained that she was not informed of the risks involved with the minor operation she had to remove a cyst from her left arm. She said that after the operation she developed keloid scarring (an overgrowth of scar tissue that develops around a wound - from which she was at an increased risk due to her dark skin) which was more painful and itchy than the cyst had been. She said that she had been told that the procedure was simple and that she would have minimal scarring, but instead the scarring was raised, itchy, painful and ugly.
Mrs X said that steroid injection treatment for the scar led to it subsiding but also left her with an unsightly scar with the skin thinned around it, so that it looked like it was constantly bruised. She said that she was self-conscious and embarrassed about the scar, which was also painful to the touch. She said that her left arm was very weak, which she suspected was because of nerve damage. She said that had she known that these would have happened, she would not have gone ahead with the surgery.
The investigation found that the HB could not demonstrate, because of inadequate record keeping, that informed consent had been obtained, which is maladministration. That caused Mrs X to suffer an injustice, in that she was denied the opportunity to make an informed decision about whether or not she should undergo the procedure which led to her having an unsightly and painful scar. The complaint was upheld. It was recommended that the Health Board apologise to Mrs X, pay her £2,000 as redress and share the findings of the report with the clinician who undertook the procedure so that lessons could be learned.
The Ombudsman recommended that the HB apologises to Mrs X for failing to obtain her informed consent for the procedure in question.
That the HB makes a payment of £2,000 to Mrs X as redress for the distress caused by denying her the right to make an informed decision regarding her treatment and for the detrimental impact on Mrs X of the resulting keloid scar.
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That the HB shares the findings of this report with the clinician who undertook the procedure so that lessons can be learned about what should be recorded in the notes when consent is being obtained for a patient to undergo a surgical procedure. 3.3
PSOW ref 201503030 HB ref SH/OMB/2015043 Summary
Ms B complained about the delay in providing restorative dentistry treatment to her father.
The Ombudsman found that Mr D had been receiving treatment from a restorative dental consultant up until 2013. However, the consultant then left and the HB could not recruit a replacement. It was therefore unable to provide restorative dental services to patients within its area. In 2015, it managed to offer a limited service following an agreement with the University Dental Hospital in Cardiff. Mr D was offered an appointment at the end of 2015 and has since undergone treatment.
The Ombudsman acknowledged that there were problems nationally in recruiting suitably qualified restorative dentists. However, there were two and a half years during which Mr D did not receive a service from the HB. In addition, the HB’s response to Ms B’s complaint and communication with Mr D was poor. The Ombudsman upheld the complaint and recommended that the HB should apologise. He was also critical of how the HB had responded to Ms B’s complaint. The Ombudsman made no further recommendations as the HB confirmed that it had now recruited a restorative dental consultant.
The Ombudsman recommended that the HB should give a written apology to Mr D for the delay in his treatment and to Ms B for its poor responses to her complaint.
PSOW ref 201600421 HB ref SH/OMB/2016005 Summary
Mrs X complained about the maternity care that she received at the Royal Gwent Hospital in July 2015. She said that the Surgeon failed to explain all the risks during the process of consenting and continued to proceed with the operation despite the medication not being sufficiently effective. Mrs X said that she suffered with wound dehiscence (wound breaking open) due to poor technique which resulted in the need for further surgery. Mrs X also said that the Health Board’s complaint response was unsatisfactory.
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The Ombudsman taking account of advice from his clinical adviser concluded that the consenting process and the management of Mrs X’s expression of feeling sensation/pain during the operation were not unreasonable and he did not uphold these elements. 3.3
The Ombudsman did however identify that an inappropriate technique may very well have contributed to the negative outcome for Mrs X. Although shortcomings were not apparent from the first operation (caesarean section) notes, the findings recorded at the second operation were highly suggestive that this was the case.
The Ombudsman noted the uncertainty remaining for Mrs X and to that extent he upheld this element of the complaint. He also upheld the concern about the HB’s complaint response.
The Ombudsman recommended that the HB apologises to Mrs X and provide financial redress of £1,000 in recognition of the uncertainty which remains in respect of the possibility of a poor technique being employed.
That the HB advises the agency that provided the Surgeon so that the practitioner can reflect on his practice.
That the HB reviews this case at the relevant risk meeting to ensure that learning takes place for relevant staff
PSOW ref 201504212 HB ref SH/OMB/2015057 Summary
Mrs L complained about her late son Mr B’s care and treatment. Mr B, who had chronic health problems, had a hernia operation in 2013. He was subsequently transferred to a rehabilitation centre in respect of his mobility. Mrs L complained that the hernia operation had caused changes in her son’s personality. She was concerned he had been prescribed to high dosages of magnesium leading to seizures. In 2014, Mr B had a further hospital admission. Mrs L was dissatisfied with the nursing care that her son received with regards to dressings for his badly ulcerated legs, his nutrition and pressure sore care. She was also concerned that there had been a delay in her son having an operation for a perforated ulcer. He later died in the intensive care unit.
The Ombudsman’s investigation found no evidence that Mr B had been given excess magnesium during his hospital admission in 2013 and there were no concerns about the hernia operation. The Ombudsman noted that a medical adviser appointed by the Coroner had concluded that appropriate investigations had been carried out on Mr B and that even if he had been operated on sooner for his perforated ulcer the outcome would not have changed. This aspect of Mrs L’s complaint was not upheld.
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The Ombudsman recommended that the HB’s Chief Executive should apologise for the failings identified in this report.
That the HB should remind staff of their professional obligation and accountability 3.3 when it comes to record keeping.
PSOW ref 201504742 HB ref SH/OMB/2015064 Summary
Mr X complained that a procedure undertaken to treat his haemorrhoids, by injection sclerotherapy (where a chemical solution is injected into the haemorrhoids to reduce pain and the size of the haemorrhoids) in August 2015, resulted in him suffering painful complications and side-effects. Mr X said that he suffered from prostatitis (inflammation of the prostate gland); he experienced severe pain and he had other problems associated with his urinary system. He considered that the procedure might also have caused cancer of the bladder. He said he was unaware of the risks of injection sclerotherapy.
The investigation found that there was insufficient evidence to prove that Mr X was informed of the risks associated with the procedure and therefore insufficient evidence to conclude that informed consent for the procedure was properly obtained. The failure to obtain informed consent for the procedure amounted to maladministration on the part of the HB. Mr X was denied the right to make an informed decision regarding his treatment and he suffered from unpleasant symptoms which he might otherwise have avoided.
The Ombudsman recommended that the HB apologises to Mr X for failing to obtain his informed consent for the procedure in question.
That the HB makes a payment to Mr X of £2000 as redress for the distress caused by denying him the right to make an informed decision regarding his treatment and for the detrimental impact on Mr X of the resulting condition.
That the HB shares the findings of the report with the clinician who undertook the procedure so that lessons can be learned about what should be recorded in the notes when consent is being obtained for a patient to undergo such a procedure.
That the HB shares the findings of this report with clinicians who undertake procedures of this kind so that they are aware of the importance of ensuring that the discussions around consent and possible risks and complications are properly recorded in the clinical notes.
PSOW ref 201505608 HB ref SH/OMB/2015092 Summary
Mrs A complained about the poor nursing care that her father (“Mr M”) received whilst an inpatient at the Royal Gwent Hospital between December 2013 and
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March 2014. Her concerns included poor communication and the ward in which her father was being cared for being unhygienic and untidy. Mrs A also complained about poor/inaccurate record keeping by nursing staff. 3.3 The Ombudsman’s investigation concluded that whilst some aspects of Mr M’s nursing care were broadly reasonable and tailored to his needs, there were instances when the care fell below reasonable standards. Areas where shortcomings were identified included Mr M’s cannula care and the failure to put in place a care plan to manage his infection. The Ombudsman was also concerned that the records for some periods of care were so poor that it was not possible to comment on the quality of nursing care delivered to Mr M. Mrs A’s complaint was upheld.
The Ombudsman recommended that the HB apologises to Mrs A for the failings identified in this report and makes a payment to her of £500 for the distress caused.
That the HB writes to Mrs A detailing the measures the HB have now put in place to address her concerns.
That the HB reminds staff of their professional obligation when it comes to ensuring record keeping complies with the NMC guidance.
That the HB, if it has not already done so provide training to nursing and medical staff around capacity, in the context of a patient’s deteriorating condition, and how this is communicated to family members.
That the HB ensures Ward nursing staff are fully compliant with national guidance on cannula care. Additionally, the HB should explain to the Ombudsman’s office how they audit adherence to the guidance.
That the HB provides documentary evidence that the recommendations have been carried out within the timescales set out above.
PSOW ref 201504530 HB ref 2015068 Summary
Ms B complained that her partner, Mr C, did not receive adequate medical or nursing care during his hospital stay. Ms B also complained that the HB failed to contact her when Mr C's condition deteriorated the night before he died.
The investigation found that the medical care was reasonable but that although the nursing care was generally reasonable, there was a concern about the hygiene standards on the ward, therefore the complaint about nursing care was partially upheld. The HB has agreed to review hygiene standards on the ward to address this concern.
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The investigation also found that the HB should have contacted Ms B when Mr C's condition deteriorated. The HB had already acknowledged this in the complaint correspondence and apologised for this, therefore no further action was necessary. 3.3
The Ombudsman recommended that the HB should undertake a review of compliance hygiene standards on the Ward concerned. If the ward is found not to be compliant with targets the HB should produce an action plan to show how these standards will be met.
PSOW ref 201505698 HB ref 2015079 Summary
Mr and Mrs D complained about the care Mr D received when he attended the ED following a chest injury. Mr D later underwent emergency surgery. Mr and Mrs D complained about insufficient and/or delayed observations, investigations and monitoring, which led to a delay in diagnosis and treatment.
The investigation found areas of concern in Mr D’s initial presentation which were not acted upon or escalated by the ED. The investigation also found shortcomings in the ED’s record keeping which led to a delay in Mr D being reviewed by a Consultant. Recording and monitoring of Mr D’s condition only became consistent when he deteriorated. Although the HB had taken action in respect of record keeping and used Mr D’s experience as a teaching case, the complaint was upheld on the basis that the failings identified left Mr and Mrs D with uncertainty as to whether Mr D’s experience and outcome might have been different.
The Ombudsman recommended that the HB should provide evidence of reminders given to staff of the importance of keeping full and accurate records, undertake a sample audit across the ED to monitor and review the use of early warning charts, provide evidence of the use of Mr D’s experience as a teaching case, and ensure that training in the use of its early warning chart is up to date for all relevant staff.
PSOW ref 201505562 HB ref 2015089 Summary
Mrs B complained about the care and treatment that her daughter (“Ms R”) received at the Maternity Unit at Nevill Hall Hospital (“the Hospital”) in the period leading up to the delivery of her stillborn baby girl (“baby M”) in 2014. In particular, Mrs B said that when they contacted the Maternity Unit for help and advice on 4 January they were “put off” attending as it was busy. Mrs B believed that had her daughter been advised to attend then monitoring would have highlighted that baby M was distressed. This would have led to appropriate action being taken and the outcome being very different.
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The Ombudsman’s investigation concluded that there was a failure to rule out the possibility that Ms R’s membranes might be ruptured. The Ombudsman was also critical that carrying out a vaginal examination without first excluding ruptured membranes was inappropriate as it risked introducing infection. He was also 3.3 critical that when it was identified by clinicians that baby M had died Ms R was allowed to remain in labour for almost five and a half hours before she received an epidural. These aspects of Mrs B’s complaint were upheld.
The recommendations that the Ombudsman made included the HB apologising to Mrs B and through her paying Ms R the sum of £750 in recognition of the distress caused to her as a result of the shortcomings in care. The HB was asked to ensure that the guidelines issued by the Royal College of Obstetricians and Gynaecologists (on ruptured membranes and pain management) were brought to the attention of its midwifery and medical staff.
The Ombudsman recommended that the HB apologises to Ms R for the failings in this report and makes a payment of £750 to Ms R in recognition of the distress caused to her by the delay in delivering baby M and inadequate pain management.
That the HB shares the Ombudsman’s final report with the Midwives and Obstetrics and Gynaecology staff involved in Ms R’s care and discuss the findings at individual team meetings.
That the HB ensures that the guidelines issued by the Royal College of Obstetricians and Gynaecologists are brought to the attention of its midwifery and medical staff highlighting the importance of excluding a ruptured membrane and pain management.
That the HB provides documentary evidence once the recommendations have been complied with.
PSOW ref 201602440 HB ref 2016034 Summary
The Ombudsman upheld the complaint that the Pharmacy dispensed incorrect medication on to Mr Y on 2 occasions as a result of a failure to follow and correctly apply the Pharmacy’s SOP. As a result, Mr Y was without his prescribed medication for some time.
The Ombudsman recommended that the Pharmacy should provide Mr Y with a payment of £200 in recognition of the distress caused by the failings identified in this complaint and the unnecessary time and trouble spent pursuing his complaint.
That the Pharmacy should ensure that all staff involved in the dispensing process have read and understood its SOP and have signed the document when they have done so and also review its SOP.
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PSOW ref 201505394 HB ref 2015097 Summary 3.3
Mrs A complained about the GP Practice and ABUHB. Mrs A’s complaint about the Practice related to the care her mother received from the GPs between 28 July and 8 September 2014. This included a failure to refer her mother to the Pain Clinic and review her potassium levels on 5 September. In relation to the HB, Mrs A was unhappy with the care her mother received whilst an inpatient at the RGH between 27 August and 9 September 2014. Mrs A also complained about the HB’s handling of her complaint.
The Ombudsman’s investigation concluded that broadly the care provided by the GPs was reasonable and appropriate. However administratively, he found shortcomings in record keeping and a failure to review Mrs B’s blood test result on 5 September and upheld this aspect of the complaint. In relation to the patient’s care in hospital, again the investigation found no shortcomings in care. However, the Ombudsman was critical that clinicians had not communicated with Mrs A when her mother’s condition deteriorated. He was also critical about the HB’s handling of Mrs A’s complaint. These aspects of Mrs A’s complaint were upheld.
The Ombudsman recommended that the HB should apologise to Mrs A for the failings identified in this report and should apologise to Mrs A for the failure to respond to her complaint about her mother’s GP care and pay her a sum of £300 in recognition of the distress and frustration that this has caused.
That the HB should, as part of a wider learning process, share this report with the clinicians involved in Mrs B’s care so that they can reflect on the learning points Mrs A’s complaint raises.
That the Practice should apologise to Mrs A for the failings identified in this report on the care provided to Mrs B detailing the actions it has taken to prevent similar reoccurrence.
PSOW ref 201505839 HB ref SH/OMB/2015103 Summary
Ms D complained about the care and treatment that her elderly mother, Mrs M, received at Ysbyty Ystrad Fawr following her admission for investigations of unexplained seizures and confusion. Ms D complained that during the admission clinicians failed to fully assess Mrs M’s confusion and failed to refer her to the physiotherapy service. Ms D also complained that Mrs M fell on two occasions during her admission and sustained severe bruising. Ms D suggested that these falls were preventable and came about as a result of the failure of nurses to promptly respond to Mrs M’s call bell. Finally, Ms D complained that clinicians
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were slow to investigate and treat a DVT that Mrs M’s developed in her lower right leg.
The Ombudsman upheld Ms D’s complaint that clinicians did not adequately 3.3 assess Mrs M’s confused condition and failed to refer her to hospital-based mental health professionals. The Ombudsman also partially upheld Ms D’s complaint that there was a short delay in nurses escalating Mrs M’s reports of pain in her lower leg. However, the Ombudsman concluded that the call bell response time was not a contributing factor to Mrs M falls and that nurses took steps to prevent her from falling as far as was possible. The Ombudsman was also satisfied that Mrs M did receive appropriate physiotherapy.
The Ombudsman recommended that the HB provides a fulsome, written apology to Ms D that recognises the failings identified in this report. The apology should make reference to the failure to assess Mrs M’s mental health/capacity.
That the HB, in recognition of the distress caused to Mrs M and the family as a result of the injustice identified in paragraph 42 - i.e. there was no evidence in the records that any process of referral to psychiatric-liaison services or other mental health professionals was carried out, or that any attempt was made to respond to Mrs M’s confused condition in accordance with the care plan - (and as a result of the failings identified in its complaint response letter to Ms D of 29 January 2016), makes a payment to Ms D in the sum of £300
That the HB demonstrates to this office that it has taken measures to remind clinicians on the Ward of the requirement to accurately assess, record and monitor the mental state/mental capacity of patients and, where appropriate, to make referrals to mental health teams, link nurses and psychiatric liaison nurses.
That the HB provides an update to the Action Plan (completed in April 2016) which reports on the outcome of ongoing monitoring of call bell response times, cleanliness of patients’ rooms, the dispensing of medication and the falls training programme.
PSOW Ref 201602418 HB Ref 2016036 Summary
Mrs A complained about issues which arose during her aunt, Mrs B’s, stay at two hospitals in the Health Board’s area. She said that the Health Board failed to provide appropriate interpretation facilities for Mrs B, who is deaf; she also complained that information about Mrs B had been given to a third party she had specifically requested should not have such information, and despite a password being put on her records to prevent this happening.
The Ombudsman upheld the complaint. He found that, although a sign language interpreter was provided for Mrs B on two occasions, when her consent was required for surgery, there was no plan for communicating with Mrs B, no record of the information contained in notes the Health Board said were passed to her,
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and no evaluation of the effectiveness or appropriateness of this. The Ombudsman also found that there had been some confusion over the existence of the password on Mrs B’s records, although he could not determine how the third party came to know the password. 3.3
The Health Board had already addressed the issue of communication with people with sensory loss, and the use of the password system. The Ombudsman therefore recommended that the Health Board apologise to Mrs A and Mrs B. The Ombudsman recommended that the HB, within a month of the issue of the final report, apologises to Mrs A and to Mrs B for the failings identified.
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Aneurin Bevan University Health Board 3.4
Health & Safety
Health & Safety, Fire, Violence and Aggression Prevention, Manual Handling and Incident Management
Annual Report 2016 – 2017
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Contents 3.4
1 INTRODUCTION ...... 3 2 HEALTH & SAFETY ...... 3 3 FIRE ...... 10 4 VIOLENCE AND AGGRESSION PREVENTION ...... 17 5 MANUAL HANDLING ...... 20 6 DATIXWEB INCIDENT REPORTING ...... 21 7 SERVICE PRIORITIES 2017/18 ...... 25 8 CONCLUSION ...... 25
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1 INTRODUCTION 3.4 This report has been prepared to provide assurance to the Health Board that the Health Board’s health and safety risks have been appropriately managed during 2016/2017.
The Health and Safety Committee is chaired by the Director of Therapies and Health Science and meets every two months. The committee is represented by senior managers of all Divisions within the Health Board and reports to the Quality and Patient Safety Committee. Regular agenda items include the corporate Health and Safety risk register, Health and Safety Policies, Statutory/Mandatory Health and Safety training compliance, Violence and Aggression and relevant topical issues for discussion.
The Health and Safety team consists of a total of 17.2 W.T.Es. The key function of the team is to provide advice, support and training in Health and Safety, Fire, Manual Handling, Violence and Aggression and DatixWeb, the electronic incident reporting system.
The team consists of a strategic team based at Llanfrechfa Grange who set the direction for the department, supported by operational teams covering the North and South of the Health Board, based in the two General Hospital sites, namely, the Royal Gwent Hospital and Nevill Hall Hospital.
The team work closely with Divisions to ensure a strong safety culture is embedded throughout the organisation.
It should be noted that there have been significant staffing shortages throughout this year, with recruitment difficulties, particularly within the Health and Safety profession. It has therefore been necessary to re-think the structure and skill mix, in order to develop a sustainable and quality workforce for the future, whilst working within financial budget. This is currently ‘work in progress’.
2 HEALTH & SAFETY
2.1 Statutory / Mandatory Training
Statutory/Mandatory training is a regular agenda item for all Corporate Health and Safety Committees, where compliance is closely monitored. However, since the introduction of Core Skills training (on line) and the loss of the ‘OWL’ contract, compliance has dropped significantly. There have been ongoing issues with introduction and roll out of the new system, with access difficult and recording onto ESR being inaccurate. This is beyond the control of the Health Board, as it has been led by WfIS on an All Wales basis. The team have led on the production of the Health and Safety courses and have provided significant input into setting consistency mapping and quality control across Wales.
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The target for training compliance has been increased to 85% to align with the PADR target, as approved by the Quality and Patient Safety Committee. 3.4
It is expected that the new ESR will improve training compliance as it is now easier to access training and as staff log on to ESR, they will immediately see what their training compliance currently is at. Equally, the manager will be able to see the compliance of the whole team they are responsible for.
Classroom training utilises a significant amount of the team’s resources, but the team offer flexibility and bespoke training packages where required.
The chart below demonstrates the radical changes to training compliance throughout the journey:-
Training Compliance 90 80 70 60 50 40 30 Training moved to ESR and 20 Learning @ NHS 10 change to compliance
0 frequency for H&S and PSA
Jul-16
Jan-17
Jun-13 Jun-14 Jun-15
Oct-12 Oct-15
Apr-13 Apr-14 Apr-15
Sep-16 Feb-13 Feb-14 Feb-15 Feb-16
Dec-12 Dec-13 Dec-15
Aug-12 Aug-13 Aug-14 Aug-15
Nov-16
Mar-12 Mar-17
May-12 Deccember 14 Deccember
Required fire training % health and safety training % manual handling training % personal safety training %
As part of the core skills learning, training compliance for health and safety and personal safety changed to 3 yearly updates in 2016 on an All Wales basis. This will account for some of the upward trend in compliance towards the end of 2016.
Health and safety training for managers has been imbedded into the Core Skills for Managers and Supervisors Level 4 Management programme. This ensures that new managers and supervisors receive the appropriate information and responsibilities in relation the management of health and safety.
2.2 Incident management
Incident management is an important function of the Health and Safety team. The following charts illustrate the numbers of incidents that have occurred throughout the reporting period. The chart also shows the number of incidents managed by the Health and Safety team, all of which are reviewed by an advisor.
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3.4 All Incidents occuring between 01/04/2016 & 31/03/2017
1500
1000
500
0 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Incidents affecting PATIENTS Incidents affecting STAFF, Visitors or Contractors Environment / Resources / Fire & fire risks / Security Incidents reviewed by Health & Safety Team
Type of incidents managed within the H&S team
70
843
107
2025
Health & Safety Incidents Manual Handling Incident Violence & Aggression Fire Incidents
2.3 Health and safety (sharps instruments in healthcare) regulations 2013
A significant amount of work has been input across the Health Board since the implementation of these Regulations. In 2016, the Health and Safety Executive (HSE) visited 40 NHS premises across England, Wales and Scotland. 45% of these organisations visited were issued with Improvement Notices, ABUHB not being one of these.
All sharps injury’s result in an investigation, so lessons can be learned from incidents where things have gone wrong. The Health and Safety team have continuously monitored these incidents throughout the last four years and have proactively provided bespoke training for some areas. Data is beginning to show a change in trend, whereby although a similar number of incidents are occurring, less are resulting in harm, hence a reduction in claims. Within the aforementioned
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year, there were actually only 3 new needlestick claims. We will continue to build upon this data and work with our legal team to correlate with claims data. 3.4
2.4 Audit
In 2016 a total of 79 Health and Safety audits/inspections were carried out across two Divisions:-
2.4.1 Facilities
A total of 58 areas/departments were audited or inspection within Facilities and the average overall compliance rating for the Division was 85%.
There were a total of 455 non-compliances identified within this process and the key areas of concern related to 1) compliance with statutory and mandatory training, 2) quality of risk assessments and risk management system and 3) incident reporting and investigation. The Division have recently recruited a Health and Safety Officer to address the health and safety concerns locally.
2.4.2 Corporate Services
A total of 11 areas/departments were audited or inspected within Corporate and the average overall compliance rating for the Division was 92%.
There were a total of 66 non-compliances identified within this process and the key areas of concern related to 1) compliance with statutory and mandatory training, 2) quality of risk assessments and risk management system and 3) portable appliance testing.
The remaining 10 audits/inspections were carried out in the scheduled care division, but these will be updated when the remainder of the Division is completed.
Unfortunately this piece of work was put on hold in November 2016 due to staff shortages, but will resume as soon as new recruits have completed induction. Development work has commenced with the scheduled care division, to identify if the Health and Care Standards Assessment could include Health and Safety Audit, hence aiming for a holistic assessment across all areas of safety.
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2.5 Health and Safety Policies, guidance and information 3.4
The Health and Safety department own the following policies:-
Date Update Name published Due Under First Aid at Work Policy 11/04/2013 review Control of Substances Hazardous to Health COSHH 22/05/2014 21/05/2017 Handling Violence and/or Aggression (Internal Sanctions) Policy and Procedure 10/10/2014 09/10/2017 Local Health & Safety Policy Template 09/12/2014 08/12/2017 Fire Safety Policy 16/03/2015 15/03/2018 Display Screen Equipment Risk Assessment Form (DSE) 27/03/2015 26/03/2018 Management of Water Systems Policy (incorporating the Water Safety Plan) 20/11/2015 19/11/2018 Health & Safety Obligations at Work for Pregnant Employees and those Returning from Maternity Leave 21/12/2015 20/12/2018 Incident Reporting Policy and Procedure 21/12/2015 20/12/2018 Safer Manual Handling Policy 21/12/2015 20/12/2018 Policy for the procurement and use of portable items of non-clinical electrical equipment 26/09/2016 26/09/2019 Use of Restrictive Physical Intervention Policy 26/09/2016 26/09/2019 Use of Bedrails and Bedrail Covers Policy 14/03/2017 13/03/2020 Occupational Health & Safety Policy 12/04/2017 11/04/2020 Prevention of Violence to Staff Policy and Procedure 12/04/2017 11/04/2020
In addition the team provide guidance documents in:-
Date Name published Fire Policy - New Hospital Developments 11/04/2013 Guidelines for Risk Assessment and the Development of Health & Safety Risk Registers 03/06/2011 Guidance relating to Hoists and Slings 24/01/2013 Supporting Information for Developing Local Health & Safety Policies and Procedures 24/01/2013 CoSHH - Guidance for Completing Risk Assessment Request Form 22/05/2014 CoSHH Risk Assessment Request Form 22/05/2014 Guidance for the Transfer of Patients Between Wards & Departments within Hospitals 17/04/2015 Latex Allergy - Guidance for the Prevention and Management 17/04/2015 Management of ‘Red Alerts’ from the Lone Worker Alert System Protocol 17/04/2015 Inspection and Testing of Portable Electrical Equipment Strategy & Procedure 21/01/2016
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From time to time the team produce Health and Safety information sheets. These 3.4 are specific to an issue that may have been identified following and incident investigation and is a way of sharing learning across the organisation.
2.6 Health and Safety Risk Register
This again is a regular agenda item for the Corporate Health and Safety Committee, where it is monitored and any changes are approved by the Committee. Additionally, it is the Committee that determine or approve any requests for escalation to the Executive Team, the Quality and Patient Safety Committee or the Board as appropriate.
2.7 Reporting of Injuries, Diseases and Dangerous Occurrence Regulations (RIDDOR)
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ABUHB RIDDOR Incidents 3.4 100 90 80 70 60 50 40 30 20 10 0 11/12 12/13 13/14 14/15 15/16 16/17
In 2012 there was a significant change to RIDDOR Regulations whereby injuries resulting in over 7 days absence following an injury at work became reportable, rather than the previous over 3 day absence. This would attribute to the downward trend in RIDDOR reporting. Also, all potential RIDDOR reportable incidents are scrutinised by senior members of the team to ensure accuracy in reporting. It is also worth noting that stress related illness is not reportable, even if following an absence from work.
2.8 Partnerships
The Health and Safety Team continue to build on strong partnership working with the South Wales Fire and Rescue Service, Gwent Police, Crown Prosecution Service and NHS Wales Shared Services Partnership – Specialist Estates Services (NWSSP-SES).
The team also represent the Health Board at the following All Wales Meetings:-
Safety Managers Forum Once Wales (Risk Management Database) National Association of Hospital Fire Officers Violence and Aggression Case Managers Manual Handling DatixWeb
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2.9 Enforcement Actions 3.4 HSE Enforcement Notices 14
12
10
8
6
4
2
0 2012 2013 2014 2015 2016 2017
All Wales ABUHB
It is pleasing to note that there have been no formal enforcement actions within the Health Board since prior to 2012. The above graph illustrates the position as compared with the rest of Wales.
2.10 Health and Safety Executive (HSE) - Fee for Intervention (FFI)
Since the introduction of Fee for Intervention (FFI) in October 2012 one charge has been made against the Health Board. A visit requested by HSE to review compliance with the Health and Safety (Sharps Instruments in Healthcare) Regulations 2013. Whilst feedback from the review was good, the formal feedback identified a material breach for a lack of suitable and sufficient risk assessment in a specific area. Whilst this appeared harsh, on balance all Health Boards across Wales had FFI applied and many additionally had formal enforcement notices served, from this review. The cost for ABUHB amounted to £1240.
3 FIRE
3.1 Risk Assessment
The fire risk assessment programme continues to operate on the following basis below, however; the frequency can vary depending on the perceived risk at the time of the inspection.
Annually – all sleeping risks Bi-annually – all clinical areas (non-sleeping) Tri-annually – all non-clinical areas and health centres/clinics
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All Health Board Fire Risk Assessments are recorded on the NHS Wales Shared Services Partnership – Specialist Estates Services database. Fire Risk Assessments 3.4 are reviewed regularly and updated accordingly and where necessary with the South Wales Fire and Rescue Service inspection programme. A report of the significant findings from the risk assessment is forwarded to the appropriate Department / Ward Manager for management at a local level. Fire Risk Assessments are being continually improved to ensure that the Health Board fully complies with current fire legislation. A series of “workshops” involving the Fire Safety Advisors have been carried out to ensure that there is consistency and accuracy in recording information as part of the assessments.
The numbers of assessments conducted on the major sites are:
North South
Nevill Hall Hospital: 41 Royal Gwent Hospital: 39 Ysbyty Aneurin Bevan 3 Ysbyty Ystrad Fawr: 19 Chepstow Community Hospital: 5 St Woolos Hospital: 23 County Hospital: 27 St Cadocs Hospital: 12
Total = 76 Total = 93
The frequency of the inspections conducted above is allocated via a dashboard incorporated into the shared Services System which automatically dates the next inspection once it has been submitted onto the system.
3.2 South Wales Fire and Rescue Service Inspections
The Strategic Fire Safety Officer and Fire Safety Advisors meet regularly with Fire Service Officers during the course of their duties. Meetings take place referencing fire safety audits, fire risk assessments, evacuation exercises and consultation meetings in relation to new Health Board building developments and alterations to existing premises.
Throughout the last year the fire service have decreased the number of inspections they carry out and have not included any night time visits due to the proactive response from the Health Board which allowed them to audit other healthcare premises where they had concerns. By working in partnership with the fire service we are able to prioritise and agree a way forward, to achieve the best standards within limited resources.
3.3 Strategic Fire Safety Committee
This committee meets on a Quarterly basis. It is chaired by the Director of Therapies & Health Sciences and its function is to agree the Strategic direction of fire safety management of the Health Board. Other priorities include overseeing the Capital Expenditure for fire and to monitor Aneurin Bevan University Health Board compliance with legislation. The meeting reports to Aneurin Bevan
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University Health Board Health & Safety Committee. Regular agenda items include: 3.4
Capital Fire Expenditure update. Unwanted Fire Alarm reports. Fire Reports. Update from NWSSP-SES.
3.4 NHS Wales Shared Services Partnership – Specialist Estates Services (NWSSP-SES) Audits
Consultation in relation to fire safety standards particularly with new building developments takes place with the Strategic Fire Safety Officer and NWSSP-SES Fire Officers.
NWSSP-SES have also carried out a detailed review of compartmentation / management in Ysbyty Ystrad Fawr. More audits are planned in the future, which aim to identify and share best practice within Wales.
3.5 Welsh Government Department for Health and Social Services and Chief Fire Officers Association Fire Safety Concordat Meetings
Concordat meetings have been set up between the Welsh Government and Chief Fire Officers Association. The Health Board has representation at both National and Regional Level. 3.6 Fire Risk Register
This original format for this database was designed and developed in 2006 it was developed to include all significant findings from internal fire risk assessments and fire service audits with the information gathered used to prioritise fire safety works in Health Board premises. Whilst this has been a useful tool, a recent update of this database has been done using “DatixWeb” which is a more robust system allowing greater interrogation and detail.
3.7 Capital Allocation for Fire Works
The Health and Safety team continue to manage the Capital Allocation for Firecode works. The detailed information that exists within the fire risk register is used to support the capital bid for fire work. The capital bid for fire safety has been prepared and the management of expenditure will be prioritised and monitored by the Health and Safety team in conjunction with the Strategic Fire Safety Committee. In 2016/17 £100k was allocated to support high risk issues identified from fire risk assessments and an additional £200k was allocated to support the replacement of the fire alarm system at Maindiff Court Hospital. The overall outstanding expenditure on the Fire Risk Register to date totals £1.85 million; this
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sum only reflects the minimum standards required by Firecode and the Regulatory Reform (Fire Safety) Order 2005 to ensure compliance. 3.4
3.8 Fire Exercises
The rolling programme of fire exercises continue to be carried out across various sites in conjunction with the South Wales Fire and Rescue Service. Feedback from debriefs following the exercises indicate that this type of practical training is well received by staff, and considered an essential training tool by the Fire and Rescue Service. Fire evacuation exercises are made more realistic by using non toxic synthetic smoke. The details of the drill have been adapted to suit the needs of the differing types of premises throughout the Health Board. The numbers of planned and completed exercises are tabled below:
Primary Area Primary Area Date of Date of Premise (Ward/Depart Premise (Ward/Depart Exercise Exercise ment) ment) 13 Apr Nevill Hall 10 Aug Monnow Ward 2/1 Whole site 2016 Hospital 2016 Vale Ysbyty 25 Apr Nevill Hall 14 Oct Catering Aneurin Sirhowy Ward 2016 Hospital 2016 Bevan Ysbyty 1July 17 Nov Cwmbran Aneurin Catering Whole Building 2016 2016 Clinic Bevan
21 July Greenvale 18 Nov Ysbyty Tri Lanfrechfa Whole Building 2016 Laundry 2016 Chwm
Blaenavon 6 Dec A & T 07 Mar Resorce Mental Health Whole Building 2016 Lanfrechfa 2017 Centre
22 Nov Ysbyty 27 Mar St Cadocs Catering Catering 2016 Ystrad Fawr 2017 Hospital Department
27 Jan Nevill Hall Ward 4/4 2017 Hospital
3.9 Training
Training has been developed to include practical scenarios to enhance interaction with delegates. This is delivered within the classroom setting. Also a new e- learning fire safety training package has been developed and is used in accordance with the training needs analysis requirements. The e-learning also includes specific additions applicable to Aneurin Bevan in the use of Vertical Evacuation equipment.
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The chart below illustrates the numbers of staff trained between 1/4/2016 & 3.4 31/3/2017.
Training Format The chart below illustrates the number of staff trained during 01-04-2016 to 31-03-2017
The Fire Wardens monitor fire safety arrangements in their specific areas on a day-to-day basis, which will in turn assist managers in carrying out their responsibilities in relation to complying with fire safety regulations.
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3.10 Fires 3.4
During the period 1/4/2016 – 31/3/2017 there have been 9 fire incidents recorded all of these incidents have been minor in nature. The incidents are as follows:-
One due to contractors failing to observe protocols; Electrical fault on external water feature igniting waste from a tumble dryer vent; 2 incidents involving waste in Mental Health facility; Plastic container placed on hot cooker hob; Dust from a portable fan illicitly brought in for a patient; Faulty timer on a microwave oven; Cigarette not fully extinguished igniting paper waste (Mental Health); Carelessly disposed cigarette igniting paper waste in an external bin.
All of these incidents were fully investigated by the relevant Fire Safety Advisor and recorded on the Shared Services incident recording system and in addition presented at the Strategic meetings.
It should be noted that whilst the Fire & Rescue Service attended each incident, they were all successfully extinguished by staff without Fire Service intervention and without excessive disruption to the Health Board.
3.11 Unwanted fire Alarms
This is an area that causes concern for both the Health Board and the Fire & Rescue Service who have stipulated that their role is to attend fires and not unwanted fire or false alarms. However, unwanted fire alarms continue to be monitored and where necessary investigated by the Health and Safety Team. The findings, actions and results are presented at Strategic meetings. A new form for the works and estates engineers has also been introduced to assist in making recording of activations more accurate.
As a result of this monitoring process it was highlighted that there was a large number of unwanted fire alarm incidents being generated in Mental Health. As an initiative, meetings have been arranged to resolve the issue. It was decided to replace the existing manual call points with the key operated type. Since their installation, the number of calls has been substantially reduced. As a result of this success it will now form part of the design process where new and refurbished mental health facilities are considered.
3.12 Pilot conducted with South Wales Fire and Rescue Service at RGH and Directive issued by South Wales Fire & Rescue Service
The Fire and Rescue Service in an attempt to reduce their levels of attendance to “unwanted fire alarms”, proposed with the cooperation of the Health Board to run a pilot scheme of reduced attendances for a period of three months at the Royal
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Gwent Hospital. The scheme allowed for a member of the Fire and Rescue Service to maintain a presence at the Royal Gwent throughout the pilot to monitor how 3.4 the Health Board responds, reports and investigates activations.
At the end of the pilot there was little that the Fire and Rescue Service could comment on the way the Health Board deals with this issue and were satisfied with the manner in which the Health Board cooperated fully. However, prior to full evaluation of the pilot, due at the end of March 2017, a decision was made by SWF&RS to implement this policy across Wales, to all premises.
The principles of the service provided are outlined below:- 08.00 – 18.00 – 1 fire engine will be mobilised to investigate. 18.00 – 08.00 – If there is an appliance able to respond within 3 minutes of the receipt of the call, then that appliance will respond to investigate. Where there is no appliance within a 3 minute turnout radius, the full predetermined attendance for the premises will be mobilised. In all cases, a phone call to fire control confirming a fire will result in additional resources based on the information passed to control. In all cases a phone call to fire control confirming a false alarm will result in fire engines being recalled, so there will be no attendance.
3.13 What’s New?
The Fire Team are currently actively involved in a number of current projects namely:
New Resource Centre in Brynmawr. New GP Surgery in Llanbradach. Ward 4.2 refurbishment at NHH. Planning stages for SCCC.
In addition within 2016 / 2017 there have been successful building works carried out in which fire precautions have been enhanced.
Major extension to Emergency Department at RGH. Complete refurbishment of NICU (RGH). New Fire Alarm system for Maindiff Court. Complete replacement of detection at RGH.
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4 VIOLENCE AND AGGRESSION PREVENTION 3.4 The chart below illustrates the top three reported types of incidents affecting staff:-
2500
2000
1500
1000
500
0 12/13 13/14 14/15 15/16 16/17 Violence & Aggression Needlestick injury or other incident connected with Sharps Slips, trips, falls and collapse
This clearly shows that incidents of Violence and Aggression abuse to staff is the highest of all incidents. This is not acceptable, staff do not come to work to be abused.
The chart below shows the total number of Violent and Aggressive incidents reported via DatixWeb. It is important to note, that ‘other’ V&A incidents does include self harm. We have deliberated whether to separate these incidents from V&A, but due to the robust review of the incident process by the H&S team, opportunities have been identified to improve the safety of the estate, from near miss incidents i.e. a £10K capital bid was obtained last year to secure the fire exit at the Cordell Centre, following a patient threatening to jump off the roof.
3703 3670 4000 3422 3500 2960 3000 2354 2500 1988 1865 1860 2000 1685 1682 1562 1318 1275 1838 1500 1036 1000 500 0 12/13 13/14 14/15 15/16 16/17
Other V&A incidents Staff V&A Incidents All V&A incidents
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The chart below shows the number of V&A incidents by Divisions:- 3.4
1200
1000
800
600
400
200
0 Unscheduled Community Corporate Facilities Mental Primary Care Scheduled Family & & Acute Care Services Health & & Networks Surgical & Therapy Learning Critical Care Services Disabilities
12/13 13/14 14/15 15/16 16/17
This, as would be expected, shows that most incidents occur in the Mental Health and Learning Disabilities Division. Many of these incidents are unintentional and due to the clinical condition of the patient. However, those incidents occurring within unscheduled care are usually more difficult to manage, often requiring police assistance and restraint. We are effectively working with the police to ascertain more charges and provide feedback to staff and support where required. This can be in conjunction with the Wellbeing Service, Occupational Health or the Victim Support Service.
The chart below illustrates the number of Police referrals and sanctions:-
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60 3.4
50
40
30
20
10
0 Person taken Formal Removed / Fine issued / No police Community Prison Verbal into custody Caution issuedescorted from person action Order issued sentence warning issues (Arrested) premises charged
14/15 15/16 16/17
Prior to 2014, there was little engagement with the police, so we have worked with them and our ED colleagues to strengthen this. Additionally, there are a further 11 incidents awaiting outcomes for the period of the report.
Promotion of the use of the Violence and Aggression Internal Sanctions Policy has been fundamental, particularly to send a positive message to persistent aggressors, that bad behaviour is not acceptable. It has also been used to set up multidisciplinary meetings, sometimes police led or sometimes HB led, to agree on the management of certain difficult patients. The use of this policy has increased from 0 in 2013/14 to 21 in 2016/17.
4.1 Training
In October 2015, physical restraint training transferred to the Mental Health and Learning Disabilities Division. This was after much research and consultation, but it was felt this is where it better sat, so that the clinical needs of the patient could be considered alongside the restraint to be used. This training was only ever provided to those staff within the aforementioned acute part of the Division, the elderly and LD models had always been managed within the Division, so it made more sense to transfer it for consistency.
In December 2016 a training course demonstrating ‘Breakaway’ skills was bought in for Emergency Department staff. We are currently considering ways to build on this and look at ‘in-house’ delivery, subject to resources available.
4.2 All Wales Activity
The All Wales NHS Violence and Aggression Training and Passport and Information Scheme is currently being reviewed.
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The Memorandum of Understanding between the NHS, the Police and the Crown Prosecution Service has just obtained confirmation of a multi agency review. 3.4
5 MANUAL HANDLING
Musculoskeletal disorders include back pain, neck or arm strain and diseases of the joints. It accounts for 40% of all sickness and absence in the NHS and can be caused by work related injuries. The aim of the manual handling service is to promote safe moving and handling practice for patient and staff safety, ultimately to reduce the risk of musculo-skeletal work related injuries. This is achieved by the provision of training, incident investigation support; risk assessment, advice and support. In addition the service provides a risk assessment and advisory service for Display Screen Equipment (DSE) and workstation set up and supports staff with musculo-skeletal issues when in work and returning to work following a period of absence.
5.1 Training
Training is in line with the All Wales Manual Handling Passport and Information Scheme training standards. To manage the large numbers of staff requiring training a cascade training strategy is in place. The manual handling service provides “train the trainers” courses and annual updates; bespoke training e.g. medical staff and senior nurse practitioners and a limited number of foundation and update courses for staff.
During the reporting year the team are producing dashboards to monitor trainer activity in terms of training staff as well as trainer’s compliance, with their own updates. Those who are out of compliance or inactive (not training staff) are being contacted and offered support/ advice.
In order to reduce paperwork the staff workbooks have been reduced to a detailed training record only. Whilst this is a change in culture it has been supported by the Health Board’s legal service and robust teaching plans and archive processes are in place to track training content if required.
5.2 Risk Assessment
Increasingly the service is providing risk assessments, particularly for Display Screen Equipment. This is largely due to the fact that the ‘on line’ assessment has not been available due to the change in on-line learning. This should reduce in the near future.
ASSESSMENT Year 2015/16 Year 2016/17 Following an incident 4 11 Occupational Health referral 16 43 Request by individual 61 69 Request by Manager 84 120 Request by service or dept 9 19
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TOTAL 174 262 3.4
TYPE OF ASSESSMENT Year 2016/17 Display Screen Equipment 164 Patient handling 14 Bariatric patient handling 21 Object handling 12 Return to work assessment 34 Workplace assessment 17 TOTAL 262
5.3 Equipment
Following submission of an options paper in 2016 to QPSOG, phase 1 of a hoist replacement programme was implemented to replace aging passive hoists. To date 105 passive hoist have been replaced and staff provided with training in their use. Further audit revealed other hoists in the Health Board that were aging and incurring high costs to repair. In March 2017 to complete phase 2 the Health Board took delivery of a further 4 specialist hoist for physiotherapy and 29 active hoists to support patients to stand in wards and physiotherapy departments.
6 DATIXWEB INCIDENT REPORTING
6.1 Progress
The number of staff to be trained for the management of incidents on DatixWeb was originally estimated at 10% of staff in the Health Board - between 1400 and 1500 staff. We currently have 1300 staff registered on DatixWeb.
Following the introduction of DatixWeb, in June 2010, there was a significant drop in Incident reporting compared to previous years. This Reduction in reporting is a statistic reported across all Health Boards introducing the DatixWeb reporting System.
They also report a significant increase of incident reporting once the system is embedded in the organisation and this is borne out by the graph below which shows that there has been a steady increase in the number of incidents reported:-
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Reported Incidents by Month and year 3.4 2500
2000
1500
1000
500 DatixWeb introduced June 2010 0
Number reported Mean
6.2 Development of the DatixWeb system
The Health Board is currently on the latest available DatixWeb platform (Version 14.0.11) which provides enhanced benefits to both administrators and the end users of the system
6.3 Disaster Recovery
In 2015/2016, a capital bid was submitted and was successful to provide a Disaster recovery for Datix. This has been implemented and is managed by IT Services.
6.4 Management of Incident reports
One of the critical factors to reporting is ensuring that the right people are registered, in the correct role, to respond to an Incident submission. There is a concern that there is a shortfall of managers, in the Health Board, who are actively managing Incidents.
A major issue for uploading incidents to the National Patient Safety Agency is the need to have incidents approved in a timely manner, with responsibility for approval sitting with local managers.
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This is being addressed via the Health and Safety Committee, whereby discussions have been instigated and targets set. 3.4
6.5 Divisional Ownership
While there are areas of excellence, ownership at a Divisional level is a concern with a growing number of open investigations being an example.
As above, this is being addressed via the Health and Safety Committee whereby discussions have been instigated and targets set.
Divisional Statistics are published weekly on the ABUHB Intranet – an example shown below:-
6.6 The Actions Module
From within an Incident report actions can be assigned to individuals with due dates and relevant information to complete the action.
The Actions Module has undergone extensive development to assist both QPS and Health and Safety.
A list of Actions arising from QPS meetings has been incorporated in to the System and can be assigned to individuals from relevant incident reports.
Health and safety audits are recorded on the DatixWeb System and Actions arising from them can now be assigned to individuals.
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6.7 The Equipment module 3.4 The Equipment module has been developed and is being utilised as a register of Equipment associated with Manual handling and Fire Rescue Equipment. The system will produce reports that show when any given item is out of compliance or due for replacement / maintenance etc. or taken out of service.
6.8 Request for Information (RFI) Module
The Team have worked with both Access to Health records and Freedom of Information teams to ensure that the Request for Information (RFI) module is fit for purpose for both groups.
This is an important aspect of the Health Board’s commitment to providing information to groups and individuals on a timely manner.
6.9 Change control.
Changes to the System are based on the needs of the Health Board, or specific groups, and sometimes on the observations of individuals. No changes are made without approval of the Datix review group or Senior Management.
The team continue to rationalise the existing database and develop the DatixWeb application - so that flow is achieved “behind the scenes”. To encourage reporting by simplifying the Datix incident reporting form (DIF1) web page design, so that data entry is kept as simple as possible.
The challenge continues to be maintaining simplicity while capturing a comprehensive range of Data.
The continued goal of the Datix team is to simplify the flow of data capture throughout both the reporting and management of incident process, to the point that:
1. Incident reporting can be undertaken by anyone within the ABUHB 2. Notification of, and access to, incidents is provided to the correct staff. 3. That Responsible persons will have the ability to update an incident with a higher level of relevant detail and to escalate where necessary from within the report
In this regard the Datix team continue to offer support and repeat training to Users of the system.
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6.10 Internal Audit 3.4 Within 2016/2107 Internal Audit carried out a review of Datix to provide the Health Board with assurance that the controls in place for access to the Datix application are sufficient and working effectively.
The level of assurance given as to the effectiveness of the system of internal control in place to manage the risks associated with Datix is Reasonable Assurance.
The team are working through the recommendations made.
7 SERVICE PRIORITIES 2017/18
Further develop a sustainable structure for the department Monitor and enhance training compliance in health and safety Support the implementation of the Once Wales (Information systems) initiative Review local fire procedures and support fire wardens by means of a workshop Support the revision of the All Wales Violence and Aggression Training Passport and information scheme Explore the feasibility of using data warehousing systems to link with Datix information systems Pilot and evaluate the delivery of the health and safety audit programme into the Health and Care Standards tool Support of review of the Memorandum of Understanding between NHS, Police and CPS on an All Wales basis Support the development of the Grange University Hospital Monitor manual handling training, trainer’s activity and compliance via dashboards. Audit and produce a condition reports for non mechanical stand aids across the Health Board Development of bariatric moving and handling guidance Investigate quality, use and cost of disposable slide sheets versus washable to aid patient handling Development of a process to manage requests for staff returning to work and for Occupational Health referrals.
8 CONCLUSION
As this report demonstrates, there has been a significant programme of work carried out by the Health and Safety team, offering specialist expertise on a wide range of subject matter. The team continue to develop their skills and strive to identify best practice for implementation across the Health Board.
Report prepared by: Judith McEwan Head of Health & Safety
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Report sponsored by: Alison Shakeshaft 3.4 Director of Therapies & Health Sciences
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Aneurin Bevan University Health Board 3.5
Clinical Audit – The Way Forward and the Programme for 2017-18
Purpose of the Report:
This report describes the corporate approach to Clinical Audit, with the way forward over the next year, the response to the Internal Audit report on clinical audit, and the clinical audit programme for 2017-18, including the Welsh Government National Clinical Audit and Outcome Review Plan for 2017-18, which is provided as appendix 2.
Recommendation:
The QPSC is asked to approve this report and note that the Annual Report on National Clinical Audit and the Clinical Audit Strategy will be brought to future meetings of the QPSC.
The Board is asked to: (please tick as appropriate) Approve the Report x Discuss and Provide Views Receive the Report for Assurance/Compliance Note the Report for Information Only Executive Sponsor: Paul Buss, Medical Director Report Author: Kate Hooton, Assistant Director, Quality and Patient Safety Report Received consideration and supported by : Executive Committee of the Board Team [Committee Name] Date of the Report: 31 August 2017 Supplementary Papers Attached: NCAOR Plan 2017-18
2 Background
At its inception in 1946, there were few formal quality assurance structures and processes employed within the NHS. However during the 1980s unwarranted variations in the provision of care and health outcomes, changing attitudes within medicine, public expectation and the acknowledgement that clinical activities should
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be included in quality initiatives set the scene for formal legislation regarding the regular auditing of medical care. 3.5
In 1989, the white paper, 'Working for Patients', was published by the Department of Health. This mandated and provided funding for the performance of regular and systematic medical audit by doctors. In the early 1990's, the move towards multi-disciplinary, team based care led naturally to the development of Clinical Audit – audit of clinical care undertaken by and covering the whole multi- disciplinary team.
Since the 1990s, clinical audit has been a core quality improvement and assurance process within the NHS. When Medical Audit was mandated in 1989, it was essentially the only routinely used clinical assurance/improvement mechanism. In ABUHB and its predecessor organisations, clinical audit activity was primarily undertaken at a directorate level. Most of the clinical audits on the audit programmes were undertaken by junior doctors, with National Clinical Audits seen as just one of the audits on the directorate programme. The completion of an audit was part of the junior doctors’ training, but they were usually not in the same specialty long enough to implement any change and re-audit to see whether there had been an improvement. From 2006/7, ABUHB became more involved in quality improvement work using improvement methodologies. This work was able to demonstrate measureable improvement, unlike most clinical audits. The decision was therefore taken to use the corporate resources available to support quality improvement and the 1000 Lives campaigns, rather than clinical audit at the directorate level.
From 2011, the Welsh Government have been raising the profile of National Clinical Audit, as a way of measuring the performance of a Health Board’s clinical services against consistently improving standards, and bench mark this performance against organisations across the UK. Each year, they have published a National Clinical Audit and Outcome Review (NCAOR) Plan, which confirms the list of National Clinical Audits and Outcome Reviews that all Health Boards and Trusts are expected to participate in. The monitoring of this activity by Welsh Government has gradually increased.
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Quality and Patient Safety Committee 13 September, 2017 Agenda Item: 3.5
3 Current Context 3.5 It is recognised that clinical audit takes place across the organisation, in all disciplines and specialties, to provide assurance as to whether clinical standards are being met or as a part of improvement programmes or as part of training programmes. It is not possible to have a programme that captures all of this audit activity, and this might serve only to reduce the amount of clinical audit undertaken. In addition to this, data, which is not audit data, is captured in real time on many aspects of clinical activity and services, and used to drive improvement, such as the data captured by ABC Sepsis and the Outreach Teams. ABCi is running improvement collaboratives, which also capture real time data that is used to drive improvement.
Many services/disciplines have programmes of regular data capture/audit, like the pharmacy medicines data. All Consultants have to complete a clinical audit as part of their revalidation process. These are captured on the revalidation system and reviewed as part of the process. Junior doctors have to undertake small scale audits as part of their training. These are captured in their e-portfolio. Many audits are undertaken on wards to review the standards, principally of nursing care, which are captured in a number of systems at different levels in the organisation. There have been so many ward audits that have developed over recent years, that there is an initiative in Scheduled Care to reduce duplication of data capture in the multiple ward audits through one recognised audit tool that covers all the main nursing standards.
The focus in ABUHB on quality improvement methodologies and 1000 Lives from 2006/7, meant that there was less focus on clinical audit in ABUHB for a number of years, and ABCi has been at the centre of quality improvement activity. The current vision and strategy for value based health care means that Teams are also now concentrating efforts on real time data collection of clinical, functional and experience outcome measures. However, the prioritisation of National Clinical Audit (NCA) by the Welsh Government has meant that there is a need for an overall corporate approach to clinical audit.
In ABUHB, participation in the National Clinical Audits has always been the responsibility of the appropriate Directorate, which appoints a Clinical Lead for the audit. The Directorate, led by the Clinical Lead, has also reviewed the results and made any changes required to improve performance against standards within the audit.
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Quality and Patient Safety Committee 13 September, 2017 Agenda Item: 3.5
With the requirement to participate in the audits on the NCAOR Plan, the Medical Director’s Support Team is working with the 3.5 Directorates to ensure there is full participation in these audits. It is now also implementing a process to ensure the results of the audits, both where there is good practice or where practice requires improvement, are disseminated throughout the Health Board, to the Division and Executive Team, and that appropriate actions are pursued to make the changes that will improve performance against the standards. The results and the actions being taken to improve performance now also have to be reported to Welsh Government for the NCAs on the NCAOR Plan.
4 The Response to the Recommendations of the Internal Audit of Clinical Audit
Internal Audit completed a review of Clinical Audit and Assurance in April/May 2017. The level of assurance given as to the effectiveness of the system of internal control in place to manage the risk associated with Clinical Audit and Assurance was Limited Assurance. The report acknowledged that the Medical Director’s Support Team (MDST) had been functioning with reduced resource and an increase in workload. The vacancies and additional posts have now been filled and the Team is working to address the backlog in responding to published National Clinical Audit Reports, and implementing clear processes going forward.
Actions were proposed to address the recommendations made in the Internal Audit report. These have been brought together into an action plan in order to ensure that the actions are taken forward in a timely way. This is provided in Appendix 1.
4 The Way forward for Clinical Audit
There are 2 strands to the Corporate approach to Clinical Audit in ABUHB:
Full participation in all the National Clinical Audits on the NCAOR Plan A small programme of local clinical audits, on issues that impact across the Health Board, highlighted by complaints, incidents and claims, mortality reviews or other internal mechanisms, or external review.
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Quality and Patient Safety Committee 13 September, 2017 Agenda Item: 3.5
National Clinical Audit: We will focus on the NCAs in the NCAOR Plan with the aim to ensure that we can discharge the 3.5 responsibilities for Health Boards outlined in the plan and are working towards success based on the success criteria in the plan. We will present an annual report on NCA to the November 2017 QPSC which will show where we are in relation to this aim. The Welsh Government NCAOR Plan for 2017-18 is attached as Appendix 2.
Local Clinical Audit: We will develop a small programme of local clinical audits for ABUHB, which will be co-ordinated by the Medical Director’s Support Team (MDST). Some of the audits may be carried out by other Departments. The Local audits will look at issues that have been highlighted as through a range of processes within the Health Board, or by external review. A small programme has been initiated in 2017-18, with an audit of the recognition and response to the Deteriorating Patient underway and an audit of the Consent form planned. An audit of Record Keeping is being discussed with the Information Governance Department, as they conduct an audit regularly which can cover the standards. The Clinical Audit Strategy will set out the process for agreeing the programme of audit going forward.
4 Recommendation
The QPSC is asked to approve this report and note that the Annual Report on National Clinical Audit and the Clinical Audit Strategy will be brought to a future meeting.
Assessment of the Impact of the Report: Financial Additional resource has already been Assessment provided for the MDST. Resources required to make improvements against standards in NVCAs will be taken forward in business cases and as part of IMTP on a case by case basis.
Link to Integrated Changes required to make improvements Medium Term Plan against standards in audits will be included within the IMTP where necessary
Risk Assessment Clinical Audits both provide assurance and
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Quality and Patient Safety Committee 13 September, 2017 Agenda Item: 3.5
identify gaps/risks in clinical services. If the risks identified are significant, they will be 3.5 included on the Divisional Risk Registers. Without a programme of clinical audit, there is a potential increased clinical risk to the organisation
Quality, Safety and Clinical Audit is a key mechanism for Patient Experience improving quality and safety in the Assessment organisation. Health and Care Clinical Audit is a key requirement within the Standards Health and Care Standards. Equality and Advice will be sought form the HR Diversity Impact department, but NCAs have already been Assessment approved through National mechanisms. (including child impact assessment)
rows
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Appendix 1
Action Plan for the Recommendations in the Internal Audit of Clinical Audit and Assurance 2017
Action Responsible Officer Timescale Update Development and agreement of Strategic Assistant Director – Quality November 17 In development.
Quality & Patient Safety Committee - 13th September 2017-13/09/17 September - 13th Committee Safety Patient & Quality Documents for ABUHB Clinical Audit to cover: and Patient Safety The governance structure, including links to the risk register, and responsibility for audit programmes at different levels in the organisation A programme methodology for identifying clinical audits for the local audit programme Reporting/monitoring of clinical audit results and actions for improvement in the corporate programme Clear dissemination and escalation processes Initiate Programme of Local Clinical Audit Assistant Director – Quality May 17 Local programme initiated, with audit of and Patient Safety Deteriorating Patient underway and Consent Form audit planned Process for agreeing a clinical audit annual Assistant Director – Quality November 17 Will be part of the Strategic documents programme, to include the NCAOR plan and and Patient Safety local clinical audits Take forward a review of assurance Assistant Director – Quality September 18 To be initiated December 17 mechanisms to clarify here and how assurance and Patient Safety is provided on clinical risks in the Health Boar. This will include consideration of how the
Health Board moves towards an assurance plan marrying together traditional assurance with
real time data from the outcomes and values work 147 of 175 147 3.5 148 of 175 148 Tab 3.5 Developing Our Approach to Clinical Audit
Development of a spread sheet to monitor: Lead for National Clinical Audit July 17 Complete Participation in audits
Review and dissemination of findings Identification of actions based on the findings Production of an Annual Report on National Assistant Director – Quality November 17 In development Quality & Patient Safety Committee - 13th September 2017-13/09/17 September - 13th Committee Safety Patient & Quality Clinical Audit in ABUHB and Patient Safety Lead for National Clinical Audit Address backlog of reporting to WG on NCAs Lead for National Clinical Audit November 17 In Progress
published since September 16 Initial Training on audit methodology for Assistant Director – Quality June 17 Complete members of MDST and Patient Safety
Regular 1-1s between Assistant Director – Assistant Director – Quality August 17 Complete Quality and Patient Safety and MDST members and Patient Safety at which training needs can be identified as staff develop in their roles
3.5 Tab 3.5 Developing Our Approach to Clinical Audit
3.5
National Clinical Audit and Outcome Review Annual Plan 2017/18 © Crown copyright 2017 WG324040 ISBN-978-1-78859-108-9 © Crown copyright 2017 Mae’r ddogfen yma hefyd ar gael yn Gymraeg. / This document is also available in Welsh. Welsh. in document is also available This / Mae’r ddogfen yma hefyd ar gael yn Gymraeg.
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NHS Wales National Clinical Audit and Outcome Review Plan
Annual Rolling Programme from 2017/18 3.5
This is the 6th annual National Clinical Audit and Outcomes Review Plan confirming the list of National Clinical Audits and Outcome Reviews which all health boards and trusts are expected to participate in 2017-18 (when they provide the service). The Plan also confirms how the findings from audits and reviews will be used to measure and drive forward improvements in the quality and safety of healthcare services in Wales.
As with previous reports, to ensure consistency, changes to the list of audits and reviews have been kept to a minimum, but some audits have now ended.
1. What do we want to achieve?
In November 2011, the Minister for Health and Social Services launched “Together for Health”, a five year vision for the NHS in Wales which called for significant improvements in health across all areas and groups in Wales. This initiative recognises that sharp differences remain between the best and worst health in Wales, and that our performance lags behind similar countries in some important aspects. It called for more use to be made of proven methods for assessing services to improve practice and for clinical staff to constantly compare their performance with others, both inside and outside Wales.
NHS Wales needs to be a learning organisation which regularly seeks to measure the quality of its services against consistently improving standards and, in comparison with other healthcare systems across the UK, Europe and the World. This measurement should be used to set improvement priorities and, the standardised improvement methodology taken forward by 1000 Lives Plus is a recognised approach for how this work should be taken forward within NHS Wales.
In 2014, the Welsh Government confirmed NHS Wales’ commitment to the principles of prudent healthcare to help meet the twin challenges of rising costs and increasing demand, while continuing to improve the quality of care. Participation in the national clinical audit programme is entirely in line with the principles of prudent healthcare. It clearly demonstrates the commitment to make the most effective use of all skills and resources and, to reduce inappropriate variation using evidence based practices consistently and transparently.
Clinical audit is an integral component of the quality improvement process and is embedded within the Welsh healthcare standards. The requirement to participate and learn from audits is also a central component of the suite of Delivery Plans developed for NHS Wales e.g. Stroke Delivery Plan, Diabetes Delivery Plan, Heart Disease Delivery Plan etc.
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2. What is the role of the National Clinical Audit and Outcome Review Advisory Committee? 3.5 To encourage greater focus on Welsh priorities a National Clinical Audit and Outcome Review Advisory Committee (from hereon referred to as the Advisory Committee) has been established to:
Provide national leadership and professional endorsement for NHS Wales participation in a rolling annual programme of clinical audit and review. Ensure that audits, reviews and national registries are relevant to Wales and provide clearly identifiable Welsh data, where appropriate. Maximise the benefit by encouraging widespread learning. Promote action to improve the quality and safety of patient care through application of the 1000 Lives Plus standardised improvement methodology in areas prioritised by the audit. Recommend a programme of national clinical audits and clinical outcome reviews which all health boards and trusts who provide the relevant services must participate in as a minimum. This programme will be reviewed annually, and may be subject to additions during the course of the year if the Committee supports Welsh participation in any new National Audits being developed. Liaise with HQIP in respect of NHS Wales’ requirements.
New proposed audits are assessed by the Advisory Committee against the following criteria. Proposals must;
Have national coverage of all relevant providers (achieved or intended)
Focused on improving the quality of clinical practice
Provides comparison of providers at an organisational, hospital or unit level
Evaluates practice against clinical criteria/guidelines and/or collects outcomes data
Publishes regular open (public) reports of findings
Applies the complete audit cycle and/or monitors clinical/patient outcomes data in an ongoing way as part of a programme of driving change
Is prospective - i.e. does not include retrospective reviews of adverse outcomes such as confidential enquiries
Collects data on individual patients and includes patients in their governance – recruits data from patients during the current financial year.
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The agreed NHS Wales programme of audits is likely to include the majority of audits currently supported by the National Clinical Audit and Patients Outcome Programme (NCAPOP) managed by the Healthcare Quality Improvement Partnership (HQIP), 3.5 but also includes a number of other national or multi-organisational audits recognised by the Advisory Committee as being essential. The programme is slowly being developed to be more inclusive of primary and community care.
The Clinical Outcome Review Programme (formerly Confidential Enquiries) is commissioned by HQIP on behalf of the Welsh Government, NHS England, NHSSPS Northern Ireland, ISD Scotland and the Channel Island and Isle of Man governments. The programme is designed to help assess the quality of healthcare and stimulate improvement in safety and effectiveness by systematically enabling clinicians, managers and policy makers to learn from adverse events and other relevant data.
The final agreed list of audits and reviews will be published annually (when possible in March). The programme for 2017-18 is attached at Annex A.
Full list of Advisory Committee membership:
Prof. Peter Barrett-Lee, Medical Director, Velindre NHS Trust, (Chair) Jane Ingham, CEO, Healthcare Quality Improvement Partnership Prof. Ronan Lyons, Secure Anonymised Information Linkage (SAIL) Rhidian Hurle, Medical Director, NHS Wales Informatics Service Arlene Shenkerov, Chair, Welsh Clinical Audit & Effectiveness Association Jayne Elias, Ass. Director of Nursing, Velindre NHS Trust Prof. John Watkins, Public Health Consultant, Public Health Wales Gill George, Delivery & Service Unit, NHS Wales Karin Phillips, Deputy Director, Major Health Conditions, WG Kate Hooton, Ass. Dir. Patient Quality &Safety, Aneurin Bevan UHB Adrian Thomas, Exec Dir of Therapies and Health Science, Betsi Cadwaladr UHB Anthony Turley, Clinical Dir. Cardiff & Vale UHB Dr Ceri Brown, Consultant Anaesthetist, Hywel Dda UHB Anne Biffin, Clinical Effectiveness & Governance Manager, ABM UHB Howard Cooper, Head of Clinical Governance, Powys THB Emma Coles, Head of Major Health Conditions, Welsh Government Dr Heather Payne, Senior Medical Officer, Maternal & Child Health, Welsh Govt. Alison Strode, Therapies & Health Science Advisor, Welsh Government Dr Karen Gully, Senior Medical Officer, Primary Care, Welsh Government Lisa Howells, Senior Dental Officer, Welsh Government Chris Connell, National Institute for Health & Care Excellence (NICE) Janet Davies, Head of Healthcare Quality, Welsh Government Olivia Shorrocks, Head of Major Conditions, Delivery & Performance Darren Hatton, Healthcare Inspectorate Wales Liz Smith, Public Health Wales Trevor Smith, Action Head of Clinical Audit and Effectiveness, Betsi Cadwaladr UHB Alexandra Scott, Patient Safety and Quality Ass Manager, Cardiff and Vale UHB Sharon Rağbetli, Clinical Audit & Effectiveness Manager, ABM UHB
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3. What is the role of the National Clinical Lead for the National Clinical Audit & Outcome Review (NCA&OR) programme. 3.5 Working with health boards and trusts the National Clinical Lead will ensure a co-ordinated approach to audit across Wales. Their role will embed the participation in National Clinical Audit using the recommendations from audits to champion service improvements, better standards of care and patient outcomes.
4. How will participation, learning and action on findings be encouraged throughout Wales?
This will be achieved by:
Improved communication and encouragement of audit:
The National Clinical Lead will develop close relationships with health boards and trusts, providing support to clinical audit leads. Their meetings with Welsh clinical networks will serve to promote and encourage consideration of audits. With the regular publication of a National Clinical Audit and Outcome Review e-bulletin highlighting developments and findings from recent reports. Feeding back on the benchmarked performance of individual providers within clinical audits and reviews to these organisations as appropriate for reflection and action. By raising the profile of clinical audit with boards, patient groups, clinicians and all staff working within the NHS. To include national events, organisational visits and liaison with professional bodies in Wales to encourage audit amongst their disciplines and specialism. Developing closer partnerships working with health boards/trusts clinical audit teams to improve knowledge and understanding of national and local audit/review activities. Working in partnership with other healthcare organisations e.g. Public Health Wales, National Welsh Information Service to promote and encourage a culture of participation in audit and action on findings.
Identifying areas needing a national approach to improvement:
Reviewing common issues for all Welsh healthcare providers arising from audit and reviews and sharing solutions. Through the development of closer links to 1000 Lives Plus improvement programme. By ensuring the findings and recommendations from audits are fully considered by the appropriate Delivery Plan implementation group
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Working in partnership, via HQIP and with audit project teams to ensure the provision of Welsh-specific findings and potential solutions, and develop and organise workshops and events to disseminate them. 3.5
Addressing clinical services where performance may give cause for concern:
Clearly identifying the comparative performance of individual provider organisations and understanding the reasons for any disparity. Ensuring issues are considered in regular performance review meetings between health boards/trusts and the Welsh Government Performance & Delivery Unit. Developing and publishing a protocol confirming the arrangements for the identification and handling of organisations identified in audits and reviews as being “Outliers” including such activity designed to improve and encourage quality improvement.
Greater transparency:
By seeking to improve the way in which the findings, recommendations and improvement actions from audit and reviews are made available to patients, public and all staff working in the NHS.
5. What is the Role of Welsh Government?
In partnership with NHS England and HQIP the Welsh Government supports and funds the cost of NHS Wales’ participation in the National Clinical Audit and Clinical Outcome Review Programme. Through improved communication, leadership, feedback and by building on the advice that it receives from the Advisory Committee, the Welsh Government also seeks to encourage greater participation and learning from clinical audits and reviews leading to improved services, better patient outcomes and safer patient care.
Given ongoing financial restraints the Welsh Government will continue to work closely with NHS England and HQIP to systematically review the current programme with a view to reducing costs where possible from 17/18 onwards.
6. What are the responsibilities of Welsh health boards and trusts?
Welsh health boards and trusts should provide the resources to enable their staff to participate in all audits, reviews and national registers included in the annual plan (where they provide the service). They should ensure the full audit cycle is completed and that findings and recommendations from audit link directly into the quality improvement programme and lead to improved patient care and outcomes.
To ensure the maximum benefit is derived from the clinical audit programme health boards and trusts should:
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Ensure the necessary resources, governance and organisational structures are in place to support complete engagement in audits, reviews and national registers included in the annual Plan. 3.5 Appoint a clinical lead to act as a champion and point of contact for every National Clinical Audit and Outcome Review which the health board is participating in. Health boards and trusts should also encourage and support clinical leads to take on the role of all-Wales representative on audit steering groups where required. Ensure there is a formally recognised process for reviewing the organisations performance when reports are published. This review should include consideration of improvements (planned and delivered) and an escalation process to ensure the executive board is made aware when issues around participation, improvement and risk identification against recommendation are identified. Complete the assurance pro-forma developed and agreed by the NCA&OR Advisory Committee which should be used for providing internal and external assurance of the actions being taken to address audit report findings. The assurance pro-forma should be completed within four weeks of audit report publications and should be regularly updated. Have clear lines of communication which ensures full board engagement in the consideration of audit and review of findings and, where required, the change process to ensure improvements in the quality and safety of services take place. Facilitate the wider use of data from audit and national registries to be used as supporting information for medical revalidation and peer review. Ensure learning from audit and review is shared across the organisation and communicated to staff and patients.
7. How Will We Measure Success?
In October 2016 the Welsh Government commenced a new assurance protocol. An assurance pro-forma, issued to each health board/trust following the publication of a final audit report. The assurance pro-forma is made up of two parts;
Part A asks the health board/trust to identify areas where improvement is needed. This part also asks the health board/trust to identify specific areas where the audit recognises they are doing particularly well.
Part B contains details of what actions the health board/trust has already, or will be taking, to address the findings of the audit report that they identified in Part A
By year on year consideration of audit reports and in comparison with other UK, European and International healthcare systems to determine how compliance with best practice and achievement of healthcare outcomes compares to national and international benchmarks.
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The following key criteria will also be used for judging success:
100% participation, appropriate levels of case ascertainment and 3.5 submission of complete data sets by all health boards and trusts (where applicable) in the full programme of National Clinical Audits and Clinical Outcome Reviews. Less variation between local services and measurable year on year improvements in performance to achieve the highest standards. Organisations recognised as being above the audit “average” or within the top quartile for each audit and maintaining that level. Improvements in the quality and safety of patient outcomes and experience brought about by learning and action arising from the findings of National Clinical Audit and Clinical Outcome Review reports.
8. How Will We Maintain Success?
It is one thing to attain success and another to maintain it sustainably. The audit and quality improvement approach has the advantage of engaging those placed to make change and those expected to deliver and maintain change on a daily basis. This approach has a demonstrated track record of delivering and maintaining service improvement for a range of issues in a range of settings. Where there are expectations of delivering and maintaining better quality care and outcomes, the audit and quality improvement should be the normally used first-line approach.
9. Conclusion
The findings and recommendations from national clinical audit, outcome reviews and all other forms of reviews and assessments will be one of the principal mechanisms for assessing the quality and effectiveness of healthcare services provided by health boards and trusts in Wales. In line with our stated ambition to develop a healthcare service that is recognised as being one of the best in the world, and to drive forward improvement, the clinical audit process will also be used to assess Welsh healthcare services against similar services being provided in other countries across the UK, Europe and Internationally.
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Annual Programme for 2017 - 18 of National Clinical Audit and Outcome Reviews in which all Welsh health boards and trusts must participate (where services are provided) 3.5
Acute Audit website Main Contact Collecting homepage data in 2017/18 National Joint www.njrcentre.org.uk Elaine Young Yes Registry * [email protected] (W, E & NI) National www.nela.org.uk Jose Lourtie Yes Emergency [email protected] (W & E) laparotomy Audit * Case Mix www.icnarc.org Bernadette Light Yes Programme (CMP) [email protected] (W, E & NI)
Major Trauma https://www.tarn.ac.uk/ Antoinette Edwards Yes Audit # antoinette.edwards@manche (W, E & NI) ster.ac.uk National https://www.nodaudit.org.u Beth Barnes Yes Ophthalmology k/ [email protected] (W & E) Audit (Adult Cataract surgery) *
Long Term Audit website Main Contact Collecting Conditions homepage data in 2017/18 National Diabetes General: (W & E) Audit * https://digital.nhs.uk Foot care Footcare: Julie Michalowski Note this covers http://content.digital.nhs.u [email protected] four audits : k/footcare National NaDia: Inpatient Yes Diabetes http://content.digital.nhs.u Sharon Thandi Foot Care k/diabetesinpatientaudit [email protected] Yes Pregnancy: Audit http://content.digital.nhs.u Pregnancy in Diabetes National k/npid Cher Cartwright Yes Diabetes Core: [email protected] Yes Inpatient http://content.digital.nhs.u Audit k/nda National Core Diabetes (NaDia) - Cher Cartwright [email protected] reporting
data on services in England
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and WalesNatio nal 3.5 Pregnancy in Diabetes Audit National Core Diabetes Audit
National Diabetes www.rcpch.ac.uk/npda Holly Robinson Yes Paediatric Audit [email protected] (W & E) (NPDA) * # [email protected]
Prof. Justin Warner, Audit clinical lead and Welsh representative on audit steering group [email protected] k
Inflammatory Yes Bowel Disease http://ibdregistry.org.uk/ [email protected] (W & E) Registry *
National Chronic https://www.rcplondon.ac. Viktoria McMillan Yes Obstructive uk/projects/national-copd- Juliana Holzhauer-Barrie (W & E) Pulmonary audit-programme [email protected] Disease viktoria.mcmillan@rcplondon. * # ac.uk
Patrick Flood-Page - Welsh representative on audit steering group [email protected] hs.uk Renal Registry https://www.renalreg.org/ [email protected] Yes (Renal hs.uk (W, E & NI) Replacement Hilary Doxford Therapy) Hilary.Doxford@renalregistry. # nhs.uk
Rheumatoid & www.rheumatology.org.u James Thomas Yes Early Inflammatory k/eia-audit james.thomas@northgate- (W & E) Arthritis is.com Final Report to * # be publ. July
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2016 All Wales http://gov.wales/topics/he [email protected] Yes Audiology Audit alth/cmo/committees/scie (Wales only) 3.5 # ntific/reports/audiology- standards/?lang=en
http://www.wales.nhs.uk/ sitesplus/866/page/63126
Older People Audit website Main contact Collecting homepage data in 2017/18 Stroke Audit www.strokeaudit.org Alex Hoffman Yes (SSNAP) [email protected] (W, E & NI)) * Dr Phil Jones, Wales Clinical lead for Stroke & Welsh rep on audit steering group
Falls and Fragility https://www.rcplondon. General email: Yes Fractures Audit ac.uk/projects/falls- [email protected] (W, E, NI)) Programme and-fragility-fracture- Including: audit-programme-fffap- Inpatient Falls 2014 Inpatient Naomi Vasilakis / Vivienne Falls Burgon [email protected] National Hip Fracture Hip Fracture Database Database Fracture Vivienne Burgon Liaison [email protected] Service Database Naomi Vasilakis [email protected] * Dr Antony Johansen, Audit clinical lead & Welsh rep on steering group National Dementia www.nationalauditofde Chloe Hood Yes Audit mentia.org.uk [email protected] (W & E) * [email protected]
National Audit of https://www.nabcop.org Ms Jibby Medina Yes Breast Cancer in .uk/ [email protected] (W&E) Older People [email protected] (NABCOP)
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*
3.5
Heart Audit website Main contact Collecting homepage data in 2017/18 National Heart https://www.ucl.ac.uk/ni Akosua Donkor Yes Failure Audit cor/audits/heartfailure [email protected] (W & E) * [email protected] Cardiac Rhythm https://www.ucl.ac.uk/ni Akosua Donkor Yes Management cor/audits/cardiacrhythm [email protected] (UK) * [email protected]
National Adult https://www.ucl.ac.uk/ni Anthony Bradley Yes Cardiac Surgery cor/audits/adultcardiac [email protected] (UK) Audit [email protected] * National Audit of Percutaneous https://www.ucl.ac.uk/ni Kathleen Reinoga Yes Coronary cor/transparency/2014/p [email protected] (UK) Interventions (PCI) ci (Coronary Angioplasty) * National http://www.ucl.ac.uk/nic Sarah Ajayi Yes Congenital Heart or/audits/congenital [email protected] (UK) Disease Audit * # Tracy Whittaker [email protected] Myocardial www.ucl.ac.uk/nicor/aud Kathleen Reinoga Yes Ischaemia its/minap [email protected] (W, E & NI) National Audit Project (MINAP) Gethin Ellis – Welsh * representative on audit steering group [email protected]
National Vascular www.vsqip.org.uk Sam Waton Yes Registry Audit [email protected] (UK) (includes Carotid [email protected] Endarterectomy Audit) *+ Cardiac http://www.cardiacrehab [email protected] Yes Rehabilitation ilitation.org.uk/ (W, E & NI) Audit
Cancer Audit website Main contact Collecting homepage data in
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2017/18 National Bowel http://content.digital.nhs. Joanne Speight Yes Cancer Audit uk/bowel [email protected] (W & E) 3.5 * Martyn Evans – Welsh representative on audit steering group [email protected]
National Lung https://www.rcplondon.a Rosie Dickinson Yes Cancer Audit c.uk/projects/national- [email protected] UK & Rep. I. * lung-cancer-audit Rosie.Dickinson@rcplondon .ac.uk
Neil McAndrew – Welsh representative on audit steering group [email protected] s.uk
Oesophago- www.hscic.gov.uk/og Julie Michalowski Yes gastric Cancer [email protected] (W & E) (NAOGC) * [email protected]
Tom Crosby – Welsh representative on audit steering group [email protected]
National Prostate www.npca.org.uk Dr Julie Nossiter Yes Cancer Audit [email protected] (W & E) *
Women’s and Audit website Main contact Collecting Children’s homepage data in Health 2017/18 Paediatric www.picanet.org.uk Liz Draper Yes Intensive Care [email protected] (UK) (PICaNet) * # Sophie Butler [email protected]
Jodie Singh [email protected] [email protected]
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National www.rcpch.ac.uk/nnap Calvin Down Yes Neonatal Audit [email protected] (W & E) Programme 3.5 Audit Roshan Adappa - Welsh * # representative on audit Project Board [email protected] k National http://www.maternityaudit.o Hannah Knight Yes Maternity and rg.uk/pages/home [email protected] (W, E & S) Perinatal Audit
Other Audit website Main Contact Collecting homepage data in 2017/18 Epilepsy 12 http://www.rcpch.ac.uk/epil Calvin Down TBC Children and epsy12 [email protected] Young People National Clinical Audit National Clinical TBC – will be included on Dr Alan Quirk TBC Audit of the following webpage: [email protected] Psychosis http://www.rcpsych.ac.uk/w orkinpsychiatry/qualityimpr ovement/nationalclinicalaudi ts.aspx
(* denotes NCAPOP Audits) (# denotes reports likely to include information on children and / or maternity services)
Clinical Outcomes Review Programme
Service provider contracts for these programmes have been awarded to the following suppliers (links are provided to website homepages):
Clinical Audit website homepage Main Contact Collectin Outcomes g data in Review 2017/18 Programm
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e Medical and http://www.ncepod.org.uk/ Dr Marisa Mason Yes Surgical 3.5 programme [email protected] (W, E) g.uk Mental http://research.bmh.manchester.ac.uk Dr Pauline Turnbull Yes Health /cmhs/research/centreforsuicidepreve programme ntion/nci pauline.turnbull@ma (W, E) nchester.ac.uk Child Health http://www.ncepod.org.uk/ Kirsty MacLean Steel Yes Clinical Outcome kmacleansteel@ncep (W, E) Review od.org.uk Programme Maternal, https://www.npeu.ox.ac.uk/mbrrace- Professor Jenny Yes Newborn uk Kurinczuk and Infant (UK) Clinical jenny.kurinczuk@npe Outcome u.ox.ac.uk Review Programme
Medical and Surgical programme # : National Confidential Enquiry into Patient Outcome and Death (NCEPOD) >> http://hqip.org.uk/national- confidential-enquiry-into-patient-outcome-and-death-2/
Mental Health programme # : National Confidential Inquiry into Suicide and Homicide for people with Mental Illness (NCISH - University of Manchester) >>
Child Health programme # : Royal College of Paediatrics and Child Health (RCPCH) >>http://hqip.org.uk/royal-college-of-paediatrics-and-child-health/
Maternal, Newborn and Infant programme # : MBRRACE-UK >>
Children's Head Injury Project # : University of Cardiff >>
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Quality and Patient Safety Committee th Wednesday 13 September 2017 Agenda Item: 4.1
Aneurin Bevan University Health Board
Minutes of the Quality and Patient Safety Committee held on Monday 12th June 2017 4.1
Present: Chris Koehli - Chair, Independent Member (Finance) Dr Janet Wademan - Independent Member Prof. Dianne Watkins - Independent Member (University)
In Attendance: Judith Paget - Chief Executive Alison Shakeshaft - Director of Therapies and Health Science Dr Paul Buss - Medical Director Bronagh Scott - Director of Nursing Kate Hooton - Associate Director, Patient Quality and Safety Elizabeth Warren - Community Health Council Penny Gordon - Corporate Lead for Incidents & Complaints Dr Steve Edwards - Deputy Medical Director Andrew Pryse - Head of Corporate Services, HIW Stephen Chaney - Internal Audit (observer) Gareth Roberts - Consultant, Nephrology Adele Cahill - Associate Director Value-Based Health Care Martine Price - Assistant Director of Nursing Deb Jackson - Head of Midwifery and Associate Director of Nursing Jayne Beasley - Assistant Head of Midwifery Moira Bevan - Lead Infection Control Nurse Rachel Moore - Corporate Services Manager (Secretariat)
Apologies: Frances Taylor - Independent Member Colin Powell - Associate Independent Member (Chair, Health Professionals Forum) Philip Robson - Vice Chair, ABUHB Sarah Aitken - Interim Director of Public Health James Quance - Head of Internal Audit
QPSC 1206/01 Welcome and Introductions
The Chair welcomed members and officers to the meeting, and in particular welcomed guests and observers who were attending.
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QPSC 1206/02 Declarations of Interest
There were no Declarations of Interest made relating to items on the agenda.
QPSC 1206/03 Understanding Patient Experience 4.1
Martine Price and Adele Cahill gave a presentation on understanding Patient Experience, including what we were doing as an organisation, where patient experience could take us as a Health Board and how patient stories could be used as part of the Committees work. The following key points were noted:
In March 2017 ABUHB procured an IT Platform (Dr.Doctor) that allowed the opportunity to communicate and manage patient experience and outcomes in an integrated seamless way; The Health Board developed a programme of work, looking at 3 different work streams, for a number of important reasons: o to understand what it feels like for patients and their families to use the services; o to use their feedback to continuously improve what we do; o to develop a person centred approach to how we develop and deliver care and services o to work in partnership with patients and their families to achieve the best outcomes and efficiency in care delivery; Dr.Doctor was being used as a platform to text and email as a means of communicating acknowledgements, appointments, and reminders to patients and to make relevant clinical information accessible to them to help them engage with their care; Next steps would be to issue reminders for treatment (admissions, e.g. endoscopy) and basic automated rescheduling, including auto-offer of any released slots to patients with a future date booked; Since the implementation, DNA rates had reduced by 30%; The Health Board had commenced a systematic collection and measurement of outcomes and costs across ‘the whole cycle of care’, to ensure outcomes that matter to people and ensure they meet their needs (Value-Based health care);
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ABUHB was the amongst the first Health bodies worldwide to consider Value-Based health care; ABUHB had been key in hosting national work; The third sector have been involved and have been provided with the technical hardware for dementia to take the questionnaire into patients homes; 4.1 A new patient experience framework had been developed and approved by the Patient Experience Committee, which would be presented to the Quality & Patient Safety Committee in the future; The Health Board developed a multi-layered approach to systematically gain feedback at scale by asking patients and providing the opportunity to tell us how it was for them so we can listen, learn and act.
The Committee discussed the text service and appointment system. It was confirmed that patients were currently given an appointment date and time but could amend if necessary themselves. The Committee heard examples of patient stories and emphasised that they were integral to the Value- Based work and the way we deliver and re-design our services.
It was noted that the language used was important and it was questioned whether the term ‘patient experience’ should be used as opposed to ‘patient stories’ following patient feedback at a recent event. It was reported that studies into on-line clinics (Skype etc.) work was progressing as was focusing on the right skills at the right place.
The Committee discussed how soon Dr.Doctor could be rolled out to other condition areas. It was clarified that the system would be used for three months in a single area initially and evaluated. It was agreed for the evaluation to be presented at a future Committee meeting. ACTION: Secretariat
The Committee was informed that there were a number of programmes with staff and patient engagement work taking place to ensure health professional have the appropriate skills and that the feedback received makes a difference. The Committee emphasised the importance of patients receiving information in-between follow-up appointments to provide reassurance.
The Committee discussed the forward work plan. It was reported that within 3-5 years the Health Board would have
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at least 12 patient pathways where the cost, outcomes and patient experience would be understood. It was acknowledged that the work was central to the way the Health Board develops the IMTP.
QPSC 1206/04 Renal Disease and Value 4.1
Gareth Roberts gave a presentation on renal disease and data utilisation, including the history, process, data captured and lessons learnt. The following key points were noted:
Data utilisation was currently being used within the renal service but could be used across other specialities where patients need to make an informed decision; The required outcomes of the data was to determine if the Health Board was funding the most cost effective therapies and if there was any variation across regions; Recorded information included patient variables, cost and whether or not treatment options were discussed and why; The Clinical Frailty Scale was used to record quality of life; When recording choices made by patients, the Health Board can look at areas to target in order to improve; Outcome data shows that average data was meaningless in comparison with individual data; Capturing quality of life data provides bespoke decision making and assists patients in making a real informed decision; Cost data was captured and linked to survival and quality of life, generating QALY scores and cost reductions.
The Committee discussed and praised the excellent work that had been carried out. It was confirmed that the questions asked were determined by the Clinicians and refined over time. It was added that Cardiff and Vale Health Board have changed their approach and the nurse now attends the first home appointment to establish what the patient wants as an outcome and their quality of life.
It was emphasised that data utilisation provided the Health Board with a visual, real way forward for both clinicians and patients. It was recognised that it could be rolled out to other clinics such as cardiac and used for other specialities where the patient makes the decision regarding treatment choices.
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It was reported that the ICHOM data was currently being collected and the Health Board was looking at how to bring all the work together. It was noted that the Health Board was leading in Wales and would be the first in the world to generate cost for QALYs. It was recognised that support for ABUHB to grow within the role was required. 4.1
The Committee discussed the role out to other areas and recognised that Dr Gareth Roberts required support in his role to take the work forward. It was acknowledged that the tool fits excellent into the quality cycle, patient experience and value based care work.
It was agreed for the work to be raised with the Board as a good news story. ACTION: Secretariat
QPSC 1206/05 Quality, Safety and Performance Overview
Dr Paul Buss presented the Quality, Safety and Performance Report. The Committee reviewed the report, noted the progress being made in many areas and highlighted the issues.
It was reported that lower RAMI in comparison to other Health Boards in Wales had generally been maintained through 2016 to date. However, there had been an increase in mortality for January, which was higher than normal, even for winter months. It was added that other Health Board’s and Trusts also had a higher than usual mortality rate in January 2017, but the relative increase for ABUHB was more than other Health Board’s and Trusts.
It was noted that a review of data for January 2017 was underway to understand the different factors that had contributed to the increase and to enable the Health Board to learn lessons. It was reported that there was an increase in the number of admissions of older people, particularly 80-89 year olds, and an increase in the percentage of deaths in people admitted with a respiratory diagnosis. It was explained that this was supported by the senior clinicians that carried out mortality reviews on these cases and confirmed that their deaths were not avoidable. It was added that there was no indication of breach of care and the decision making was appropriate with clear plans in place.
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The Committee discussed the anticipatory care plan agenda and noted that DNACPR was improving and the Health Board was getting better at having the relevant conversations. It was reported that mortality reviews have identified a rise in elderly frail coming into hospital for the last few days of their lives and it was questioned whether this was the best option. 4.1
The Committee discussed the interface with care homes and nursing homes and using data across sectors. It was acknowledged that joined up working with the care home sector had improved, looking at advanced care planning etc. The Committee discussed the national audit on bowel cancer and agreed to schedule an update for the next Committee meeting in September. ACTION: Secretariat
It was reported that when the new Stroke Divisional Manager takes up post they would review the pathway and Business Case to bring back to the Board in the future. It was added that rehabilitation on wards needed to be addressed.
QPSC 1206/06 Risk Assessment Overview
The Committee discussed the Risk Register and noted that the risks were consistent with the Committee’s work programme.
The Committee received the assurance report from the Quality and Patient Safety Operational Group (QPSOG) meeting which was held on 18th May 2017. It was reported an update was received regarding the use of unknown patient barcode for blood glucose monitors. It was noted that progress was encouraging with a significant reduction in the use from 3700 times per month in 2014 to 339 times per month in April 2017.The most significant reduction was seen in RGH and YYF, with RGH emergency department using the barcode 5 times in the latest month.
The Point of Care Testing Team and the Divisional Nurses were thanked for their hard work and persistence with respect to this issue and it was agreed that usage would continue to be monitored and reported back to QPSOG in six months.
QPSC 1206/07 Maternity Services Update
Deb Jackson presented the Maternity Services Update to provide assurance of the quality of maternity care delivered
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within ABUHB. It was reported that between 1st April 2016 and 31st March 2017 there were 5997 births in total for ABUHB.
The Committee was informed that there were 782 incidents reported onto Datix across the four sites during April 2016 4.1 – March 2017. The main themes highlighted for these incidents included postpartum haemorrhage, staffing issues and communication/documentation. It was noted that staffing issues consisted of escalation of activity and the movement of staff from one area to another, which was common within maternity as the service was provided in relation to the need and activity of labouring women. It was added that bank staff were used to support sickness and the Health Board remains Birth Rate Plus compliant with staff levels. It was emphasised that all themes and lessons learnt were discussed at Quality & Patient Safety meetings, cascaded through mandatory training and cascaded through the relevant forum of meetings.
It was reported that the Health Board had successfully gained UNICEF Baby Friendly accreditation, which was a national standard for excellence for breast feeding. It was noted that the Health Board was looking to increase breast feeding rates in hospital to 70%. It was acknowledged that there was a similar picture across the UK with breast feeding rates dropping off after community discharge.
It was noted that the Health Board was the first organisation in Wales to employ 15 volunteers for peer support with breast feeding, which was an excellent project to help and support mothers to continue with breast feeding in the community, as rates fall to 33% at 28 days. It was added that the data was starting to be collected and results should be seen in around 6 months’ time.
The Committee discussed the number of incidents for postpartum haemorrhage (PPH). It was acknowledged that the rates of PPH had increased across the UK and the Health Board was not an outlier. It was noted that the complexity of women had caused the national increase e.g. high BMI. Assurance was provided that each PPH and lessons learnt were discussed at the risk forum and would be escalated in accordance with the PPH Escalation Policy.
The Committee discussed the number of complaints and questioned why the numbers were higher in the Royal Gwent
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Hospital compared to Nevill Hall hospital. It was confirmed that the numbers were higher due to higher activity levels generally and more complex cases at the Royal Gwent Hospital (RGH). It was recognised that reconfiguration of the services in the interim to assist with the workload in RGH was required. 4.1
It was recognised that ways to encourage births at Ysbty Ystrad Fawr (YYF) needed to be considered. It was acknowledged that maternity needed to work more closely with obstetric colleagues to ensure patients were moved back to maternity care when they were no longer under paediatrics.
The Committee discussed the aging maternity workforce and acknowledged the high rate of staff over the age of 55 which had increased sickness levels. It was noted that succession planning was taking place and there had been a 40% uplift in training for midwifery. It was emphasised that there were no issues with recruiting.
The Committee was informed that the still birth rate within the Health Board was the lowest in Wales. It was added that ABUHB maternity was involved with research and was proactive in all trails to improve quality and safety of the maternity service. It was added that ABUHB was the only Health Board in Wales that had taken part in the Affirm trail to implement a revised pathway for women presenting with reduced fetal movements. Though there results would not be available until autumn 2017, it was noted that preliminary findings were favourable.
The Committee received an update regarding the Senior Midwifery Clinicians (SMCs) which were appointed to cover the tier 1 gap at Nevill Hall hospital to maintain the maternity service. It was reported that the SMCs were a dedicated, proactive, highly skilled and reliable asset to the midwifery and obstetric team in Nevill Hall Hosptial. It was added that they have an enviable attendance record and were respected and valued by colleagues and they were recently highlighted in the ABUHB staff recognition awards for their dedication to their role.
QPSC 1206/08 C-Difficile Update
Moira Bevan presented the report and provided an update in relation to a rise in cases of C.difficile across the Health
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Board, including divisional progress with targets and interventions to address the situation.
It was reported that a number of practices had been strengthened which play a large role in reducing Health Care Acquired C-difficile (HCAI) such as cleaning hours and 4.1 antibiotic compliance. It was noted that hand hygiene audits had been reviewed and Infection Control Team surveillance had been provided to ensure the robustness of hand hygiene audits. It was added that a programme of deep cleans across Unscheduled care wards in the Royal Gwent Hospital had commenced.
It was highlighted that relapse cases were accounting for a significant number of reported cases so the management and treatment of patients who have acquired C-difficle was being scrutinised. It was added that education programmes were being reviewed to facilitate access by ward staff.
The Committee was informed that as a result of engaging with staff across all sites and strengthening the surveillance of HCAI, the Health Board was now seeing a slowing down of the number of reported cases at the end of May and first week in June 2017 (5 cases). It was noted that the infection Control Team would continue to monitor progress against the action plan and would report back to the Quality and Patient Safety Committee in September 2017. ACTION: Secretariat
The Committee discussed the report and emphasised the need for infection control to be embedded. The Committee praised the work of the team to respond quickly to the situation and commended staff across the Health Board for their tremendous leadership.
QPSC 1206/09 Committee Annual Report
The Committee was informed that the Annual Report now included the Committee Effectiveness section. It was noted that the Annual Report would be reported to the Board in July 2017.
The Committee approved the Annual Report.
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QPSC 1206/10 Minutes of the Meeting held on 5th April 2017
The minutes of the previous meeting were agreed as a true and accurate record.
QPSC 1206/11 Action Sheet 4.1
The Action Sheet was reviewed and it was noted that all actions had either been completed or there were actions in place to address the areas identified.
QPSC 1206/12 Report from WHSCC Quality and Patient Safety Committee
The Committee received the report from WHSCC Quality and Patient Safety Committee for information.
QPSC 1206/13 Items for Board Consideration
Patient Experience – Good news story regarding renal work to discuss how to take forward and roll out to other areas.
QPSC 1206/14 Date of Next Meeting
It was confirmed that the next meeting of the Committee would be on Wednesday 13th September 2017 at 9.30am in Conference Room 2, Conference Centre, Health Board Headquarters, St Cadoc’s Hospital, Caerleon.
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Quality and Patient Safety Committee 13th September 2017 Agenda Item: 4.2
Quality & Patient Safety Committee Wednesday 13th September 2017
Action Sheet 4.2
(The Action Sheet also includes actions agreed at previous meetings of the Quality & Patient Safety Committee and are awaiting completion or are timetabled for future consideration for the Committee. These are shaded in the first section. When signed off by the Quality & Patient Safety Committee these actions will be taken off the rolling action sheet.)
Agreed Actions – Wednesday 2nd November 2016
Minute Agreed Action Lead Progress/ Reference Completed QPSC Ligature Risk Improvement Ian Thomas National 0211/06 Programme Briefing Paper guidance still Ruth Derrick explained that they awaited from were currently awaiting the WG. memorandum of understanding Confidential draft paper and agreed to share this once discussed at All received. Wales GM meeting in May 17 but not yet approved or available for circulation.
Agreed Actions – Monday 12th June 2017
Minute Agreed Action Lead Progress/ Reference Completed QPSC Understanding Patient Secretariat Complete – 1206/03 Experience item added The Committee discussed how to forward soon Dr.Doctor could be rolled work out to other condition areas. It programme was clarified that the system would be used for three months in a single area initially and evaluated. It was agreed for the evaluation to be presented at a future Committee meeting. QPSC Renal Disease and Value Secretariat Complete – 1206/04 It was agreed for the work to be item sent to
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Minute Agreed Action Lead Progress/ Reference Completed raised with the Board as a good Board news story. Secretariat
QPSC Quality, Safety and Secretariat Complete – 1206/05 Performance Overview item added 4.2 The Committee discussed the to forward national audit on bowel cancer work and agreed to schedule an programme update for the next Committee for meeting in September. November 2017 QPSC C-Difficile Update Secretariat Complete – 1206/08 It was noted that the infection item on Control Team would continue to agenda monitor progress against the action plan and would report back to the Quality and Patient Safety Committee in September 2017.
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