CLINICAL AUDIT AND EFFECTIVENESS ANNUAL REPORT 1 April March 2015 (Final)

Transcription

1 CLINICAL AUDIT AND EFFECTIVENESS ANNUAL REPORT 1 April March 2015 (Final) 1

2 CONTENTS Page(s) 1. Chairman s Foreword 3 2. Executive Summary 4 3. Introduction 5 4. Governance Accountability and Assurance Financial Information Mechanism for Assessing Clinical and Quality 6-7 Improvement Proposals 4.4 ing Clinical and Quality Improvement work Organisational arrangements for the support of Clinical 7 and Quality Improvement 4.6 Training and Education (for non-audit staff) 8 5. Achieving Effective Clinical and Quality Improvement (Project reports) Summary Statistics Clinical Clinical Outcome Reviews, formerly Confidential Post-operative Enquiries (NCEPOD) 5.4 Local Clinical Implementing NICE Guidance and All Wales Medicine s 20 Strategy Group (AWMSG) Guidance 5.6 Involving Patients, Carers and Users in Clinical and Quality Improvement 5.7 Mortality Review Priorities for References 23 2

3 1. CHAIRMAN S FOREWORD Cwm Taf University Health Board (CTUHB) undertakes a wide-ranging programme of clinical audit and quality improvement projects across the organisation. Clinical is a process designed to improve the quality of care using clearly recognised standards, to ensure that what should be done is being done and where this is not the case, providing a framework to enable improvements to be made and sustained. The Welsh Government introduced the first NHS Wales Clinical and Outcome Review Plan (NCAORP) in The launch of the current plan (Welsh Government 2014) marked the third in the series to date. The NCAORP is used to provide evidence of measured continuous quality improvement in areas of healthcare considered to be important. 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. The CTUHB forward plan for clinical audit and continuous improvement is entirely in line with the principles of prudent healthcare. It clearly demonstrates the commitment to make the most effective use of resources and skills and, to reduce variation using evidence-based standards e.g. NICE. As part of the process of learning from audit reports we report and/or seek advice from the Quality Improvement and Clinical Operational Group and where there is a particular concern about audit findings the Quality Steering Group. The Mortality Review process continues to develop in terms of quality and the quantity of reviews, and has been rolled out to the community hospitals in , supported by the clinical audit team. As with my previous annual reports, I wish to thank the Clinical Leads within directorates/services for their continued support during this period and to the Clinical team for their enduring enthusiasm and support, without which it would have been difficult to make such progress and pace this year. I commend the Annual Report to you. Thank you. Dr Iyad Al Muzaffar Clinical Lead Clinical and Quality Improvement 3

4 2. EXECUTIVE SUMMARY The NHS Wales Clinical and Outcome Review Plan has reinvigorated the way in which health boards prioritise their clinical audit work, to ensure participation in national clinical audit, where they provide a service. Its purpose is to engage all healthcare professionals across Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement and deliver better outcomes in the quality of treatment and care. During we participated in 98% of national clinical audits and 100% of clinical outcome reviews (formerly Confidential Enquires), where we were eligible to participate. We aim to participate in 100% of national clinical audits and outcome reviews during The health board has appointed a clinical lead for all national audits and this year a focus has been to develop a process to provide assurance of how the findings and recommendations from published national clinical audit reports and outcome reviews are fully considered and acted upon at a local level. The CTUHB Mortality Review process continues to be facilitated and supported by the clinical audit team. Considerable efforts have been made to capture and analyse patient experience through clinical audit, so that we can take targeted action to improve our services for present and future patients. Details of the clinical audit and quality improvement projects undertaken are too vast to include in this report but are available in a separate project report on the Intranet at: 4

5 3. INTRODUCTION The annual report brings together the activity that has taken place throughout the year and, as such, serves to provide assurance to the Board via the Quality and Safety Committee (QSC). The year starts with the development of a forward plan of activity for clinical audit and continuous improvement. This is compiled into an integrated single document for the Health Board which covers, national audits, organisational priorities, Directorate, department or service requirements and local audits. Clinical leads within directorates and services are asked to submit the activity their directorate or service intend to undertake, this also assists the clinical audit team to plan the resource implications for them to provide support. Performance against the plan is monitored at different levels, for example, by the Quality Steering Group and Quality Improvement and Clinical Operational Group via narrative and dashboard reports. The Clinical and Effectiveness team continue to have a key role in ensuring that best practice standards are identified and measured to enable services to deliver clinical excellence and cost effective healthcare. The department is responsible for the co-ordination, facilitation and support to the CTUHB Mortality Review process which has been rolled out to the community hospitals also. In addition, the team supports provision of evidence for Welsh Risk Pool Management Standards, and respond to high risk issues identified through the Concerns process e.g. Consent to treatment. The Clinical and Effectiveness Manager provides operational support to the directorates and services for the annual Internal of the Standards for Health Services in Wales. The Clinical team is responsible for the co-ordination of the Institute of Health and Clinical Excellence (NICE) Implementation process, thus ensuring guidance, in its various forms, and of relevance to CTUHB is implemented and monitored. To ensure robust financial planning, the team works in collaboration with the Medicine s Management Directorate for specific high cost NICE Technology Appraisal Guidance and All Wales Medicine s Strategy Group (AWMSG) drugs. In , a notable development has been the creation of a fast-track system for the implementation of NICE Technology Appraisals. The Clinical audit team continues to support the implementation of NICE Technology Appraisals and Clinical Guidelines by establishing Implementation Steering Groups (ISG) and measuring compliance through baseline clinical audit and monitoring. 5

6 4. GOVERNANCE 4.1 Accountability and Assurance The Quality Improvement and Clinical Operational Group(QICAOG) met four times in The main business of the group was to receive the forward plan, an annual report of the previous year s activities, and national and local publications, reports and action plans and updates from activities within the rolling programme. The Group has representation from all clinical directorates, departments and services via nominated Clinical Leads and their representatives. The QICAOG reports via the QSG to the Quality and Safety Committee (QSC). The Clinical Lead Quality Improvement and Clinical, chair s the QICAOG and is a member of the QSC. One of the responsibilities of the QICAOG is to oversee the annual review, validation and sign-off of the assessment against Standard 6 Participating in Quality Improvement activities and Standard 7 Safe and Clinically Effective Care of the NHS Wales Standards for Health Services, aligned to the fore mentioned Internal process. Within directorates, departments and services most operate a system of monthly audit meetings. This usually translates into nine or ten meetings per year, during which clinical staff meet to discuss the progress of directorate, department or service audit plans and receive presentations on completed projects. Responsibility rests with the Clinical Lead and/or Facilitator to provide regular feedback to their respective Directorate Integrated Governance Groups. Quarterly reports are regularly provided to the Directorates to inform and support their clinical governance arrangements and to improve patient outcomes. 4.2 Financial Information In the Health Board allocated , to support the activity, of which 312,953, related to staff. This includes a contribution from the SIFT allocation to support medical students to undertake quality improvement work during their placement. 4.3 Mechanism for Assessing Clinical and Quality Improvement Proposals The Assessment Criteria developed for clinicians to use so that clinical audit activities are both consistent and rigorous, continues to be used. 6

7 Other key document templates in use include: Clinical and Quality Improvement Registration form Patient Satisfaction Registration form Report template (where appropriate) Presentation template Action plan template The clinical audit department s intranet page reflects the work of the team as well as being a source of information and support to health board staff. All of the above documents and templates are available from the Clinical and Effectiveness Intranet Pages. A link is now available to the health board s Quality Hub. 4.4 ing Clinical and Quality Improvement Work During the year, central support has been provided by the Information Communication and Technology (ICT) department to establish a bespoke database to support the production of reports of all clinical audits undertaken. The clinical audit registration form has been revised to reflect the audit database. This important development has further strengthened our assurance processes. Where immediate improvement action is required these matters are reported to the QSG for support and resolution, via the Assistant Medical Director Clinical Governance and Quality Improvement. 4.5 Organisational arrangements for the support of Clinical and Quality Improvement Clinical and Quality Improvement activity is supported by a corporate Clinical and Effectiveness Team at Cwm Taf University Health Board. The Clinical and Effectiveness Manager is responsible for leading, directing and supporting the work of a small team of Clinical Facilitators, who are based at the District General Hospitals. The remit of the team covers all departments across the Health Board, and incorporates responsibility to provide clinical audit advice to Primary Care to support quality improvement. The team has continued to provide a supportive service to clinicians across the organisation however capacity to meet demand is an ongoing challenge, which is managed by prioritisation. Exciting plans are in place to implement a more sustainable structure within the team, aligned to the Patient Care and Safety Unit s 3 year rolling plan, and to support succession planning. 7

8 4.6 Training and Education (for non-audit staff) The Clinical team provide a number of opportunities (one to one and group-based) to improve the knowledge and skills of individual clinical staff wishing to participate in clinical audit and quality improvement. An Introduction to Clinical is a three hour workshop that provides grounding in clinical audit and effectiveness methodologies for healthcare professionals. Twenty workshops have been held this year, with 167 staff from a range of professional teams, including staff from primary care taking part in the programme. Evaluation continues to indicate that an average of 99% of attendees scored the training as being good or excellent. Overall feedback from the workshop attendees showed very good levels of delegate satisfaction. The Clinical team have all completed the Bronze and Silver level of Improving Quality Together (IQT) and are active in providing support and advice to staff wishing to engage in quality improvement work. Cwm Taf University Health Board welcomes the involvement of students in its clinical audit and quality improvement forward plan. All students are encouraged to present their findings to the appropriate audit group and it is felt that their work has proven to be a valuable addition to the programme. 5. ACHIEVING EFFECTIVE CONTINUOUS QUALITY IMPROVEMENT THROUGH CLINICAL AUDIT AND QUALITY IMPROVEMENT CTUHB is firmly committed to providing effective, high quality care, consistently to all patients. During , 327 clinical audit and quality improvement projects were undertaken, covering diverse topics and incorporating all areas of clinical care. 94% had standards set as part of the audit, of which 70% resulted in changes or to a change in practice, or have changes being progressed. These results reflect the commitment of our clinical staff to deliver evidence-based practice. PROJECT REPORTS FOR Summary Statistics Table 1 Number Percentage % Total Number of s % FIRST % RE-AUDIT (2 nd Stage) % CONTINUOUS AUDITS (on 32 10% going) Standards set as part of % Multidisciplinary % 8

9 Direct patient involvement in s with changes implemented or identified as ready to occur 21 6% % Clinical and Quality Improvement work in has sustained its momentum whilst maintaining the diversity of projects performed. 5.2 Clinical During CTUHB participated in national clinical audits identified in the NHS Wales Clinical and Outcome Review Plan. Clinical is designed to improve patient outcomes across a wide range of conditions. Its purpose is to engage all healthcare professionals in systematic data collection projects which compile comparative data on compliance with best practice, and the achievement of identified clinical outcomes against evidence-based standards. clinical audits are a rich source of information about the quality of care provided. Building on many years of experience, national clinical audits and registries have become increasingly sophisticated in the ways in which they collect, analyse and feedback data. They are distinguished from other forms of clinical audit by their national coverage and hence the ability to benchmark performance. In general they are prospective and on-going, collecting patient level data. There is an apparent appetite for more such audits and registries particularly as health boards require more assurance that investigations and treatments are carried out to an acceptable standard. And yet, despite all of this, their potential as a resource to support systematic improvements in the quality and safety of patient care is still not fully realised. In March 2014, Welsh Government asked health boards to provide details of how they ensure the findings and recommendations from published national clinical audit and outcome reviews are fully considered and acted upon. Cwm Taf University Health Board was one of the first health boards invited to attend the Clinical and Outcome Review Advisory Committee to demonstrate the system in place to maximise the learning from reports and improve services wherever weaknesses are identified. A flow chart has been developed to outline key responsibilities for the escalation process following the publication of audit reports (Figure 1). 9

10 The following are examples that aim to demonstrate CTHUB s involvement in the NHS Wales Clinical and Outcome Review Plan Title ACUTE: Joint Registry Emergency Laparotomy Lead Mrs Lisa Williams Dr Al Shamma Dr P Fitzgerald Mrs D Cairns Mr X Escofet Explanation of Actions and Improvements made Prog ress The NJR was established to collect information on all arthroplasty procedures. Data collection is continuous on all primary and revision joints. Data collection period 01/04/ /03/2015 NELA was established to examine the inpatient care and outcomes of patients undergoing emergency laparotomy and provide comparative data to hospitals to improve local quality improvement. Ongoing registry used as a monitoring tool so no national recommendation. Reasons for PCH being highlighted as an outlier in relation to the rate of Hip Revisions to be investigated. Ensure uniformity in the completion of data across PCH and RGH, especially for component use etc. PROMs results to be collected and submitted nationally. Surgical, anaesthetic and critical care teams should be appropriately staffed to allow for 24 hour operating without compromising elective activity Elective and emergency workloads should be organised to allow for effective prioritisation of cases 24 hour support service should be available to include interventional radiology and pathology reporting Routine daily input from elderly medicine should be available Sepsis pathway should be incorporated 10

11 Case Mix Programme (ICNARC) Trauma and Research Network (TARN) Dr T Szakama ny Dr L Srinivasa Mr Michael Obiako LONG TERM CONDITIONS: Diabetes Dr P Evans Dr N Agarawal Dr L Millar- Jones The aim of ICNARC is to determine the quality of care provided for critically ill patients. The audit is a continuous registry of all patients admitted to critical care units. The annual report considered patients admitted between 01/04/2013 and 31/03/2014. The TARN database includes data from all major trauma that presents to the hospital. Data is collected on a continual basis. The Diabetes measures the effectiveness of diabetes healthcare against NICE Clinical Guidelines. The data is collected from Primary and Secondary Care for patients with diabetes. Data collection was between 2012 and into the care of patients requiring laparotomy Multidisciplinary reviews of processes and patient outcomes should be held for all emergency laparotomy patients. Structured handover of care is required at all times by all clinicians Pathways for pancreatitis and postcardiac arrest to be agreed and implemented. Post-cardiac arrest bundle being developed. Pathway for care of patients with longterm invasive ventilatory needs to be developed in the future. Delayed Transfers of Care to 5% by May 2014 for CTUHB. CTUHB did not participate in last round of audit From April 2014, A&E PCH are participating. Cases presenting to RGH are not currently included pending confirmation of the future of trauma services at the site. Preventing, detecting and treating Heart failure should become a Diabetes management priority with the management of hypertension being a key priority. Engage HCP s in diabetes inpatient care. Improve foot assessment and foot care for patients admitted with foot problems. To involve patients in their care more. Inflammator y Bowel Disease Dr M Patel Dr N Hawkes This report examines the inpatient care provided to people admitted to hospitals in the UK for treatment of UC between 1 January 2013 and 31 December Data period January December 2014 Requirement to increase Clinical Nurse Specialist time in line with recommendations. To establish an IBD database provisional work has commenced supported by the ICT department. Increase Dietetic support currently under provision of nutritional support team within the health board needs review. Chronic Obstructive Pulmonary Disease Renal Registry Dr Hand Dr Matt Jones Consisting of a number of audit worksteams, the national COPD audit aims to bring together primary care, secondary care, rehabilitation and patient experience. The UK Renal Registry provides healthcare data on patients dependent on renal replacement therapy. The report included all patients requiring therapy in Increase and improve access to specialist respiratory care during weekdays and weekends Increase access to smoking cessation services Increase dietetic services Continue to improve the level of palliative care services CTUHB did not participate in last round of audit CTUHB now participating with the next report due in Rheumatoid Dr R A retrospective case note audit was Cwm Taf Rheumatology department 11

12 and Early Inflammator y Arthritis Goodfello w Dr S Smale undertaken along side service user and staff questionnaires to assess the performance of services across the UK. have been commended as among the highest recruiters for the audit. A report on the outcomes of the audit is awaited. All Wales Audiology Mr J Arthur The review of audiology services was undertaken to provide an overview on the performance of services against the Quality Standards for Paediatric Audiology (Wales). Service providers were asked to complete a self-assessment to outline the service. An external audit was later undertaken at each Health Board. Overall compliance within Cwm Taf exceeded the national targets in all areas feedback confirmed that the scope for further improvement was limited within a one year period. In light of this external audits are now to reduce to every two years. Awaiting amendments to the standards to determine the need for improvement. Pain Dr N Database Saxena MENTAL HEALTH: Schizophreni a Dr S Joseph N/A CTUHB did not participate Based upon the NICE Guidelines for Schizophrenia, the national audit aimed to provide an in-depth examination of the care provided to service users across the UK. Health Boards were asked to submit data on 100 patients under their care who have been affected by a schizoaffective disorder. Data was collected through an Consultant survey on their practice, a service user survey and a carer survey. identified that service users were satisfied with the care provided within Cwm Taf Findings disseminated to all staff within the Mental Health directorate Action planning team established and a task and finish group set up to undertake development work in three key areas: Psychological services Improving the monitoring of physical health Improving prescribing practice Learning Disability of Psychologica l Therapies (and Welsh Government Review of Access to and Implementat ion of Psychologica l Therapy Treatment in Wales) Dr P Davies Dr J Delport Feasibility study only. To determine whether a national audit would be able to capture reliable data on the quality of services and its scope in driving improvement within organizations. A retrospective case note audit was undertaken along side service user and staff questionnaires to assess the performance of services across the UK. All data was collected for inclusion in the report between April 2013 and January Feasibility study identified that people with learning disabilities and mental health problems would access specialist services and not those provided by Cwm Taf. It was therefore determined that Cwm Taf would not be able to recruit sufficient numbers to participate in the national audit Outcomes of the national audit have not been received Service staff need to provide service users, carers and referrers with better information on the remit of the service. Improvement in Information sharing and confidentiality. Health Board to ensure that services are able to demonstrate they provide therapies that are adherent to NICE guidelines. Supervisors need to have received specific training in providing supervision. Services need to take active steps to address service user sources of dissatisfaction and allow for anonymous user feedback Action plan being taken forward in conjunction with Service review plans. 12

13 WOMENS AND CHILDRENS HEALTH: Neonatal Programme Childhood Epilepsy UK Obstetric Surveillance NURSING: Fundamental s of Care Dr I Al- Muzaffar Dr E Afifi Dr D Deekollu Dr J Natarajan Mr J Rogers Mrs D Griffiths Mrs B Wilding The role of the NNAP is to ensure consistent care across all neonatal units. The audit is undertaken of all babies admitted to identify areas for improvement in NNU units in relation to delivery and outcomes of care. Data collection all infants discharged in The audit includes all children with a suspected or confirmed diagnosis of epilepsy. The audit consisted of a clinical audit supplemented with a patient experience questionnaire. Data collection period 01/05/2013 to 31/10/2014 The UK Obstetric Surveillance choose areas of surveillance on a monthly basis and request data pertaining to that from each site to determine potential trends or issues. Data collection included in the 2014 report November 2012 to October Fundamentals of Care draws upon 12 aspects of care (for example communication, safety and personal hygiene) to ensure best care for patients. Each aspect is audited regularly to maintain a high standard across all areas. Ensure that all mothers who deliver babies between and weeks gestation given antenatal steroids. Identify what proportion of babies <33 +o weeks gestation at birth are receiving their mother s milk on discharge from a neonatal unit. Improvement required in poor documentation of consultation with parents by a senior member of the neonatal team within 24 hours of admission to meet 100% Standard. NNAP: Two year follow up audit. 100%of patients surveyed described the staff as friendly and polite. Refer all patients to Epilepsy Nurse Specialist or neurologists as appropriate. Document events and examination clearly. Mention required development, learning and schooling issues. Aim to improve syndrome classification. ECG in children with convulsive seizures. Undertake MRI as indicated. Avoid inappropriate prescription of carbamazepine for non-epilepsy indication in children with epilepsy. UKOSS report card to be used. The information gained from UKOSS studies may be used to inform counseling of women, development of guidelines for prevention or treatment and for service planning. Studies using UKOSS may be undertaken by any investigator who identifies a suitable topic. Suitable disorders to study are those which are uncommon; as an important cause of maternal or perinatal morbidity or mortality. results are reported separately. Improvements made to the auditing of data however include the involvement of CHC volunteers to assist in collecting data and engaging with the multidisciplinary teams such as pharmacy. HEART: Heart Failure Dr J Taylor Dr G Ellis The Heart Failure was established with the aim of monitoring and improving the care of non-elective patients admitted with heart failure. All admissions with a diagnosis of heart failure are included. Data collection period within report Improve compliance in cases included in the audit. All patients with LVSD should be treated in line with the NICE clinical guideline. All patients with LVSD should be offered a beta blocker. ACE inhibitor/arb and beta blocker prescription rates should be at or near 13

14 Cardiac Rhythm Management of Percutaneou s Coronary Intervention Procedures Myocardial Ischaemia Project (MINAP)+ The Cardiac Rehabilitatio n Vascular Registry (includes Carotid Endarterecto my Dr Bleasedal e Dr J Taylor Dr G Ellis Dr J Taylor Dr G Ellis Ms T Buck Mr Lewis Mr Conway April 2013 to March %, with contraindications accurately recorded. Patients should be stable on oral therapy before being discharged from hospital. All those admitted to hospital with acute heart failure, should be seen by a member of the multi-disciplinary heart failure team, within two weeks. Patients should be treated on a cardiology ward or if not possible by a Consultant specialising in heart failure. Continued investment in personnel and time with support to participate in national clinical audit. The CRM reviews cardiac device implantation performance in each hospital and is an inclusive audit of all patients who require a pacemaker. Data collection period for the 2014 report January to December The national audit reviews the treatment and outcome of all patients who require percutaneous coronary intervention to improve cardiac function. Data published in the report is of patients admitted between January and December MINAP collects data of all patients who are treated for a myocardial infarction or other acute coronary syndrome to determine the quality of care provided. Data collection period - April 2013 March 2014 The 2014 NACR report covers clinical services and outcomes for all patients attended the cardiac rehabilitation service. The report covers all patients between the period of Supported by the Vascular Society, the Vascular Registry collects data on all index vascular procedures, supports the Carotid Intervention and is linked to the AAA Screening Programme. Cwm Taf reported results that were comparable to the national average; recommendations were therefore to maintain the level of compliance with the set standards and to ensure that all cases continue to be entered onto the audit. To improve reporting individual PCI Consultant Operators for revalidation purposes and monitor the quality of their own data. From January 2014 there will be a minimum data standard and all PCI centres. Improve joint working and continue to strengthen the link with the MINAP audit. Work is underway to align the two datasets to minimise duplication of work for hospital staff. Promote transparency through publication of PCI Consultant Operators individual data. Importance of nstemi data collection - The identification of nstemi needs to be improved. Rapidity of transfer for angiography following nstemi. Continued investment in time, personnel with support to participate in national clinical audit. The national audit report focuses on improving compliance with the data entry of all cases into the audit database. The standard from first symptom to surgery was met in only 47% of patients, with a median of 15 days and an interquartile range of Results were discussed at the Surgical meeting in November and an action plan produced and submitted to the Medical Director. Progress was monitored via the Surgical group throughout

15 CANCER: Bowel Cancer Lung Cancer Head and Neck Cancer Oesophagogastric Cancer Prof Haray Miss Clements Dr A Gibson Dr A Pandit Dr R Rhys Mr X Escofet OLDER PEOPLE: SSNAP + Dr Dewar Senitel Dr White of all patients diagnosed with bowel cancer. A total of 220 cases were submitted from CTUHB, a 120% increase on the figure predicted by PEDW. Data collection period April The national audit looks at all patients with a first diagnosis of lung cancer. Data collection January to December 2013 The audit includes all patients with a diagnosed head or neck cancer between 1 November 2012 and 31 October The national audit collects data on all patients diagnosed with stomach or oesophageal cancer after April Data collection period 01/04/2012 and 31/03/2013 The audit subsection of the SSNAP collects data from every patient that The next report is due for publication in September Data capture sheet developed to improve quality of data submitted Radiologist to add pre-treatment stage in report Feedback provided to improve documentation of pre and post treatment stage Pathologist to clearly document distance to CRM Database prepared to log metachronous lesions Health Boards to submit data on all patients presenting to secondary care diagnosed with lung cancer Improved data completeness Histological/cytological confirmation rates below 75% should be reviewed Non-Small Cell Lung Cancer, not otherwise specified rate of more than 20% should be reviewed. For patients undergoing bronchoscopy at least 95% should have a CT scan prior to the procedure. Surgical resection rates for NSCLC below the average should be reviewed. Active anti-cancer treatment rates below the average should be reviewed. Chemotherapy rates need to be reviewed if not within national figures Pre-treatment seen by Clinical Nurse Specialist (CNS) with nutritional assessment, SALT, dental assessment and CT/CXR Resective pathology discussed at MDT CTUHB s good level of compliance was highlighted at an All-Wales meeting in November Key aspects of the audit are the clinical staging, pathology staging for surgical patients and co-morbidity scoring. Work is currently ongoing within Wales to develop CaNISC further to record additional data on the patient pathway, including dental, Speech and Language and nutritional assessment. To investigate results of key areas further including:-route to referral, staging investigations, curative treatment for oesophageal SCC, monitoring of complication rates and markers for effectiveness of surgery for both open and MI surgery and low reported use of brachytherapy. To discuss with GP s why more patients are presenting as an Emergency; although less GP referrals are being made. All actions highlighted in the report have been taken forward through work 15

16 Stroke Programme Falls and Fragility Fractures Programme (FFFAP), includes Hip Fracture Database + PATHOLOGY: SHOT Serious Hazards of Blood Transfusion Comparative Blood Transfusion Mrs L Williams Dr R Biswas Dr K Myers Dr H Habboush Dr K Myers Dr H Habboush is treated for a diagnosed stroke within secondary care. The audit is ongoing with a quarterly report released to monitor results. The most recent report was related to patients admitted between 1 January and 31 March The Health Board participated in the Hip Fracture Database component of the FFFAP. All hip fracture cases were recorded for April 2013 to March Compliance was at 59% PCH and 88% RGH. SHOT is the UK s independent, professionally-led haemovigilance scheme. All incidences of adverse events and reactions in blood transfusion are submitted to the scheme for inclusion in the study. Data published in the 2014 report relates to incidents occurring in A one-week snapshot of physician managed inpatient cases was derived from each hospital site and a random sample then audited to determine the use of blood transfusion. Data collection period for the 2014 report included cases from September to December of Stroke Steering Group aligned to the Intelligent Targets for Stroke Services to improve the pathway for patients following a Stroke. Significant improvement in exceeding the 95% target with regards to the 3 hour, 34 hour, 3 day and 7 day bundles. Both hospitals are 100% compliant in the use of the 3 hours and 7 day bundle. Direct access from A&E to the stroke unit introduced in Dec 2013 through ring-fencing of a fast-track stroke bed on each of the acute stroke wards Access to CT head scanning has improved thanks to the introduction of a shift system for radiographers. This has helped reduce the time from admission to scan and Cwm Taf is now better than the national average for scanning stroke patients within one hour We have now secured funding to develop an Early Supported Discharge service, as required by the RCP, to help stroke patients return home sooner with the appropriate support of community based stroke therapists. #NOF Pathway group established, led by Dr R Jones, AMD Quality Assurance and Governance. Regular monitoring of length of stay, mortality and time to theatre through local audit. Consistent and accurate submission of data ensured through changes in data collection process Greater orthogeriatric support required which resulted in a pilot service being implemented. Greater improvement now required in osteoporosis care. Correct and positive patient identification remains absolutely essential A zero tolerance policy for the identification of all pathology specimens. Hospital and primary care staff should work at building relationships to improve communication and handover. Staff responsible for blood transfusion must know how to recognise anaphylaxis and other acute transfusion reactions. Incident reviews and root cause analyses should be completed and the findings reported back to the participants Hospital staff should report near miss as well as actual incidents. Actions taken forward through robust 16

17 quality control mechanisms within Pathology. 5.3 Clinical Outcome Reviews, formerly Confidential Postoperative Enquiries (NCEPOD) There were ten Clinical Outcome Reviews in taking place throughout the year and we participated in all of the relevant studies. These studies generally report aggregated results approximately one year after the initial data submission. In addition, we continue to evaluate and implement recommendations from previous studies; these include Perioperative care, Surgery in Children and Cardiac Arrest. Some examples are found below: Title Lead Explanation of Actions and Improvements made Prog ress Subarachnoid Haemorrhage Dr Dewar Dr White The review into Subarachnoid Haemorrhage requested that all hospitals provide data for all adult patients presenting the secondary care following an ASAH. The results of this audit are being monitored via an action plan. All required actions are being addressed through the Stroke Steering Group. Tracheostomy Care Dr Al Shamaa Mr Escofet Dr Scott Ms Clements The NCEPOD study looked at all patients who underwent a new tracheostomy insertion or a laryngectomy within the critical care unit or theatre. Data collection period 25/02/ /05/2013 To take forward the six principal recommendations described within the full report, The Assistant Director of Clinical Governance and Quality Improvement requested the establishment of a Tracheostomy Care Steering Group within CTUHB, to be led by the Clinical Director for the Head and Neck directorate. The first meeting will focus on the production of a local action plan was held in October Lower Limb Amputation Sepsis Mr Conway Mr Rocker Dr T Szakmany Dr O The clinical audit identified all patients over the age of 16 years that required a lower limb amputation due to vascular insufficiency. The data collection period was between October 2012 and March The aim of the study was to explore remediable factors in the process of care in patients undergoing major lower limb amputation. All adult patients diagnosed with Sepsis and seen by the critical care outreach team between 6 th 20 th May Action plan of local findings in development. recommendations include: The development of a clinical care pathway to support the development of a MDT and increased vascular theatre lists Collaborative working between surgeons and diabetologists to provide comprehensive review pre and post surgery in line with the national guidelines Rehabilitation and follow-up to be organised by a named individual with access to Consultant service at all times Decision to proceed with amputation should be made by a MDT rather than a sole Consultant Consultant presence during all operations Compliance with NICE guidance with regards to time of review, nutritional support, management of diabetes and access to therapies services All relevant cases identified from Cwm Taf have been audited and data submitted to NCEPOD. 17

18 Gastro- Intestinal Haemorrhage Maternal, Newborn and Infant programme: MBRRACE- UK Pemberto n Dr P Toth- Tarsoly Dr R Alcolado Mr J Pembridg e Mr Rogers The aim is to identify and explore avoidable and remediable factors in the process of care for patients with known or suspected sepsis. A review of all patients admitted between January and April 2013 with a diagnosis of a GI bleed was undertaken. The aim was to identify the remediable factors in the quality of care for patients who required >4 units of blood due to GI bleed. Awaiting publication of the national findings in November Findings published in July Awaiting presentation and discussion to formulate an action plan Acute Pancreatitis Mr Escofet Organisational audit only this round Awaiting second phase of audit to commence Mental Health Programme : A continual review is undertaken of all episodes of suicide, homicide and sudden unexpected death. Future suicide prevention is dependant upon community response Sharing this report with Local Service Board as preventative strategies are Confidential wider-reaching than health board Inquiry into Suicide and Homicide for people with Mental Illness (NCISH) Dr Winston influence alone Continue building a statistical analysis every year so we have the ability to examine data in 5 year cycles. Work with partners to implement an ageless local suicide reduction plan Child Health The Child Health Programme is a Action plan is available and monitored Programme: national review examining mortality to identify successful approaches to all Dr E Afifi Royal and morbidity in children and young types of Child Protection. Dr College of people. Involvement required from multiagency collaboration and recognition of Natarajan Paediatrics & Child Health children s wellbeing. MBRRACE is a programme of work to investigate maternal deaths, stillbirths and infant deaths. All cases that occur within the hospital are submitted for inclusion in the programme. Review of Asthma Deaths : Royal College of Physicians Dr Hand Dr Neil A national review was undertaken by a consortium of asthma professionals of the circumstances surrounding the deaths of patients with asthma. Pre-pregnancy counseling for women with pre-existing illness Professional Interpretation Services when required. Immediate access to Multidisciplinary Specialist Teams for care. Efforts to be taken to identify the acutely sick patient through monitoring and prevention of hypertension and sepsis Robust mechanisms for reporting critical incidents and deaths Improvement in specialist maternal autopsy services Action plan to be formulated by the action planning group Investment needed in Primary and Secondary care by lead asthma specialists Capacity of clinics to be increased Advertising campaign to be undertaken within the Health Board Ongoing audit of asthma to be established with spot checks in A&E and Primary Care 18

19 5.4 Local Clinical Whilst much of the Health Board s clinical audit activity is driven by the NHS Wales national clinical audit plan, it is important to include local clinical audit, as many of the best proposals are identified where staff or patients recognise an area of practice in need of improvement. The following are some examples to demonstrate improvements made through our activities. Title of Chronic Obstructive Airways Disease Fluid Management Consent Inadvertent Peri-operative Hypothermia MRI Scans Urinary Tract Infection Pneumonia Antimicrobial Ward round Management of Head Injuries Mortality Reviews Physician input in the management of fractured neck of femur at PCH 30 day mortality following Endoscopy Directorate / Service Health board wide Hospital-wide Hospital-wide Anaesthetics, Critical care and Theatres Maxillofacial Children and Young People Medicine Medicine Trauma and Orthopaedics Accident and Emergency Trauma and Orthopaedics/ Medicine Gastroenterology Improvements made Collaborative working with Primary care and the Pharmaceutical industry has reaped numerous rewards in terms of increased education of staff, development of practical tools and patient information, for example, smoking cessation advice. Indicated a need for improved documentation of management plans and assessments. Implementation steering group established to develop an action plan for improvement and monitoring. Observed a good level of compliance with the documentation of risks and benefits. Better access to information leaflets will further improve compliance. Patient warming methods and routine temperature monitoring implemented. Improvements in patient counseling before the scan have been made to ensure they are adequately prepared for the scanners noise and environment. Patient information developed to ask parents and families to stop antibiotics after a negative culture has been identified to help with antimicrobial stewardship. Development of the Pneumonia Care Bundle launched in line with the new microbiology guidelines in November MDT established to review patients daily with complex antimicrobial needs. Antimicrobial prescribing and duration of treatment has greatly improved. Improvements made in the reporting of CT scans out of hours. Improvement in communication amongst teams and a swift transfer to the relevant specialty. Clear benefits of an orthogeriatrician on hip fracture care demonstrated through routine osteoporosis prescribing and falls assessment. Improvement made in ASA grading of patients. No PEG related deaths and no complications during any of the procedures. 19

20 5.5 Implementing NICE Guidance and All Wales Medicine s Strategy Group (AWMSG) Guidance By the end of March 2014 the Institute of Health and Care Excellence (NICE) had published 417 Technology Appraisals, and 338 Clinical Guidelines. CTUHB undertakes an assurance process on each piece of relevant NICE guidance published. For Technology Appraisals, the Medicines Management Expenditure Committee approves the managed entry, monitors expenditure and plans future expenditure on the medicines recommended by NICE technology appraisals. As part of the Prudent Healthcare drive, this year we have reviewed practice with the NICE Do Not Do recommendations to identify if treatment is beneficial and cost effective. In March 2015, CTUHB hosted a visiting team from Welsh Government and NICE and received very positive feedback at the visit about our structure and process for NICE guidance implementation. Whilst we acknowledged that we cannot always achieve the implementation within the time frames, we were informed that we are the most mature health board in Wales with regards to our NICE process. We agreed that we would take forward 3 further actions over the next 12 months to further strengthen our process: 1. Align NICE Quality Standards with CTUHB Quality Delivery Plan for 2015/16 (Falls, Dementia, Pressure Ulcers) 2. Include NICE Quality Standards within Clinical Education and build into Eyes on the Evidence topics 3. To strengthen our evaluation of NICE guidance implementation with Patient Experience activities (focus on 2-3 over the next year) There were discussions on how to strengthen NICE and Primary Care, (in England they have short update summaries for Primary Care re NICE); to start to use the Clinical Knowledge Summaries (on NICE web site); to ensure that we align NICE guidance with regards to any Regulation 28s. 5.6 Involving Patients, Carers and Service Users The importance of understanding the patient s perspective of the care they receive, and that of their carers and relatives, is critical if we are to make continuous improvements. CTUHB has been actively involved in the All Wales Patient Survey and has undertaken local satisfaction surveys across clinical areas. In addition, progress has been made this year within the surgical specialities on Patient Reported Outcome Measures (PROMs) to elicit the views of patients at separate intervals following surgical interventions. These are 20

21 especially useful tools for measuring improvement in patient outcomes and can be used to inform Consultant revalidation. Examples of improvements made are listed below. Title of Patient Satisfaction with Operating Services Patient Survey of the Head and Neck Cancer Support Group Satisfaction following Immediate Breast Reconstruction using stage 2 implants Evaluation of Maternity Care Patient satisfaction with ICU Patient Reported Outcome Measures Directorate / Service Anaesthetics and Theatres ENT Surgery Maternity Services ICU Trauma and Orthopaedics Results / Improvements made to patient experience The patient satisfaction survey identified that patients felt well prepared for surgery and found their experience to be positive. A patient survey was carried out by the Macmillan team to identify the needs of the patient and improve their service accordingly. In response to the findings a webpage was developed for the support group and meetings are now held on a bimonthly basis in alternating locations to allow for greater attendance. This patient involvement work has been shared as good practice at national events across Wales. Demonstrated a positive cosmetic and psychological outcome in the majority of cases. Scored very highly with respect to staff dedication and professionalism showed to patients and their relatives. A questionnaire is given to all patients postnatally prior to discharge from the maternity unit. The results are in the most part positive and a quarterly report is provided for the Head of Midwifery to highlight areas for improvement. Overall results of the survey were positive with the majority of relatives satisfied with the level of care provided, the communication and facilities. Areas for improvement were identified e.g. waiting room for relatives, improvement in mouthcare for patients and quicker communication in emergency situations. ly recognised PROMs questionnaires were amended to include the EQ-5D criteria for each of the orthopaedic subspecialties. The forms are sent to patients following preassessment and then at 6 months and 1 year post-operatively. Of the returns the majority have reported improvements in their pain and function. Where issues are noted the results are discussed with the Consultant and the patient invited back to clinic to check for any post-operative complications and alleviate any concerns they have. 21

22 5.7 Mortality Review The vast majority of deaths occurring in our hospital sites are either expected or considered highly likely and the Mortality Review Process continues to offer objective reassurance of that fact as well as identifying areas where improvements can be made. In particular, there is no evidence to suggest neither a systematic failure in healthcare nor that avoidable mortality is the explanation for high RAMI (Risk Adjusted Mortality Index) scores in our hospital sites (a view supported by the Palmer Review in 2014). The number of deaths in hospital relative to non-hospital sites remains high due to a lack of alternative arrangements for many patients just prior to their death, and due to a population with a high rate of co-morbidities often presenting late in the course of their illness, often as an emergency with limited options for effective therapeutic interventions during the last admission. We have now had an effective system of scrutiny in place to detect avoidable mortality for nearly two years based on system of all deaths review which is led by clinicians and provides a rich learning environment in line with ongoing NHS culture change. The main changes in the mortality review process since the previous annual report are: Improvement in performance times. Piloting of the system using a Medical Examiner framework. Increased engagement by clinicians, particularly from Medicine. Establishment in principle of a senior clinician panel to examine the Stage 3 potentially avoidable deaths in detail. Roll-out of the process to non-acute sites (YCC, YCR and Dewi Sant). Greater tie-in to the Concerns Team and Coronial investigations. Leadership role for the mortality review process for Wales held within CTUHB agreed by the Medical Directors and endorsed by the Welsh Health Minister Accumulated data which continues to support the notion that high RAMI scores are not linked to avoidable mortality. 6. PRIORITIES FOR The objectives for the CTUHB Clinical and Effectiveness team include: To demonstrate compliance with the Triple Aim patient experience, reduce inequalities, best value from resources To participate fully in the NHS Wales Clinical and Outcome Review Plan (where we provide a service) To encourage multidisciplinary clinical audit and quality improvement as part of routine clinical practice 22