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EACH Quality Account 2012-2013 The EACH Vision All families of children and young people with life-threatening illnesses or complex health care needs are able to access appropriate services of high quality. 1 Contents Item Page number Part 1 Chief Executive’s statement 3 Part 2 Priorities for improvement and 4 statements of assurance from the Board 2.1 Priorities for improvement 2013-14 4 2.2 Statements of assurance 6 2.2.1 Review of services 6 2.2.2 Participation in national clinical audits 7 2.2.3 Participation in local audits 7 2.2.4 Participation in clinical research 8 2.2.5 Use of the Commissioning for Quality 9 Improvement and Innovation (CQUIN) payment framework 2.2.6 What others say about EACH 10 2.2.7 Data quality 10 2.2.8 Clinical coding error rate 11 Part 3 Review of quality performance 11 3.1 Priorities for improvement 2012-13 12 3.2 Additional quality markers 16 3.3 Involving children and families 22 3.4 Involving EACH staff 23 3.5 Statements from Healthwatch, Clinical 23 Commissioning Groups and Overview and Scrutiny Committees 2 Part 1. Chief Executive’s Statement I am delighted to present the first EACH Quality Account. On behalf of myself and the Board of Trustees, I would like to thank all of our staff and volunteers for their achievements over the past year. Despite the current economic climate, the hospice has continued to provide specialist palliative care to more children and families and remains financially sound, thanks to generous support from our local communities and our partnerships with the statutory sector. EACH has a culture of continuous quality improvement, in which opportunities to improve care delivery and any shortfalls are identified and acted upon quickly. The safety, experiences and outcomes for children, young people and their families are of paramount importance to us all at EACH. Our clinical governance committee, a sub committee of the EACH Board, provides assurance, oversight and scrutiny on all matters relating to the quality of care. The Care Quality Commission inspected each of our three hospices services based at Milton, Cambridge, Quidenham, Norfolk and the Treehouse in Ipswich, Suffolk and assessed that the treatment and care provided was fully compliant with all of the essential national standards for care. Service users are encouraged to tell us about their experiences through a variety of means. These include one to one reviews with families, the EACH website feedback section for families, comments slips in the family newsletter, Facebook and twitter. There are also three locality based family forums and three Trustees with service user experience on the Board and Clinical Governance Committee. In 2012, EACH invested in a three year care development programme to improve further the safety and quality of care and the experience of children, young people and families who require specialist palliative care. Priorities for development were identified from the findings of three independent evaluations carried out in the previous year – an evaluation of the EACH model of care, our approach to delivering psychological support and the neonatal care pathway. These evaluations included the involvement of service users, staff and external professionals. The objectives of the three year programme informed the priorities for improvement for 2012/13. To the best of my knowledge, the information reported in this Quality Account is accurate and a fair representation of the quality of health care services provided by EACH. Graham Butland Chief Executive 21st May 2013 3 Part 2. Priorities for Improvement for 2013/14 and Statements of Assurance from the Board 2.1 Priorities for Improvement for 2013/14 The priorities for 2013-14 have been informed by: The three year care development programme objectives Key areas of clinical risk The successful bids to the Department of Health to fund capital improvements to care facilities, equipment and vehicles The priorities cut across all three domains of quality- patient safety, clinical effectiveness and service user experience. Priority 1 Ensuring Quality and Consistency across EACH (clinical effectiveness & service user experience) This priority will be achieved by: - completing the root and branch review of all care processes from referral to discharge including link working, short breaks allocations and bookings procedures and implementation of these new approaches. - implementing an evidence based and outcomes driven approach to delivering emotional health and wellbeing support for children and families. This includes agreeing a range of clinical tools to identify needs and goals and measure outcomes, agreement of interventions to meet all levels of need, revising job roles and responsibilities and associated competencies. Progress will be monitored against the change plan milestones and reported to the EACH Management Executive. Oversight is provided by the clinical governance committee. Priority 2. Ensure the specialist and increasingly complex care needs of children are met safely by competent staff (patient safety, clinical effectiveness & service user experience) This priority will be progressed in two parts: Ensuring the continued competence of care staff as the complexity of care and the amount of end of life care increases. Ensuring safe medicines management as the complexity of children’s medicines regimes increases and the requirements relating to medicines management continues to change. There will be a particular focus on IV therapy, management of cytotoxic and hazardous medicines and the handling of controlled drugs 4 2.1 Ensuring Staff Competence This will be achieved by: - Identifying new areas of knowledge and skill required to care for a child at the point of referral and implementing required training for care commences - Implementing the revised three year rolling programme approach to clinical competencies for care staff. Progress will be monitored by: The locality weekly referrals and complex care panels Carrying out audits of competencies achievement, the core knowledge and skills programme, the revised induction programme and by seeking feedback from staff and managers as to the effectiveness of the new approaches 2.2 Ensuring safe medicines management in the hospice and in the community This will be achieved by: -Implementing the revised Controlled Drugs (CD) policy and Standard Operating Procedures (SOPs) and the redesigned CD register - Implementing the cytotoxic and hazardous medicines management SOP and Intravenous therapies SOP - Auditing compliance with the new medicines management SOPs introduced in 2012 13. This will be monitored by the Pharmacy Strategic group and will include: An audit of the implementation of the new Controlled Drugs SOPs Completing the annual Accountable Officer Controlled Drugs audit Continued monitoring of medicines incidents and implementing any resulting changes to practice and shared learning from them. An audit of medicines administration and reconciliation. Priority 3 EACH model of clinical leadership is implemented and embedded into the culture and practice of EACH (patient safety, clinical effectiveness and service user experience) This will be achieved by: Carrying out clinical leadership model road shows led by the EACH Care Management Team to engage with staff and the family forums to explain the model of leadership, what it means to individuals and how it will work in practice. 5 Recruiting a symptom management team service manager to provide additional time and focus for the nurse consultant to oversee and champion the implementation of the EACH approach to clinical leadership and clinical leadership activities Care managers changing ways of working to work across 7 days to provide highly visible leadership in the care areas This will be monitored by Evaluation of the road shows by staff Care managers providing evidence of clinical leadership activities. Evidence of staff involvement at all levels in clinical development activities including audit, reflective practice activities, review and development of clinical policies and SOPs Priority 4 Improvements to EACH Hospice care facilities, equipment and care vehicles This will be achieved by completing the refurbishment of the facilities at Milton and Quidenham and purchase and use of the fleet vehicles to provide care in the community and transport for families to access EACH care services. A detailed project plan incorporating key milestones will provide the basis for monitoring of this priority. Work must be completed by the end of March 2014. 2.2 Statements of Assurance from the Board The following are statements that all providers must include in their Quality Account. Many of these statements are not directly applicable to specialist palliative care providers, and therefore explanations if what these statements mean are also given. 2.2.1 Review of services During 2012-13 EACH provided the following NHS services to children and families living in Norfolk, Suffolk, Cambridgeshire and North and West Essex: Short breaks End of life care Symptom management Family support for all family members before and into bereavement Music therapy Specialist play Family Information service 6 Care is delivered across a range of settings in line with the preferences of the family. This includes in the family home, hospice or hospital and in the wider community including reaching into residential schools. End of life care and symptom management for the child including face to face care and access to telephone support

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