Bundle Joint Audit and QSE Committee 9 November 2017

Transcription

1 Bundle Joint Audit and QSE Committee 9 November JAQS17/1 Chairs' Welcome and Opening Remarks 2 JAQS17/2 Apologies for Absence Mr M Usher, Mr K Woodward, Ms M Olsen, Dr E Moore 3 JAQS17/3 Declarations of Interest 4 JAQS17/4 Minutes of Meeting Held on for Accuracy and Matters Arising JAQS17_4 Minutes JAQS Public V0.2.docx 5 JAQS17/5 Clinical Audit Report - Mr Adrian Thomas Recommendation: The Joint Committee is asked to: *Receive the update for information. *Endorse full participation with the ongoing programme of NCAORP and Corporate clinical audit activity. JAQS17_5a Clinical Audit Report coversheet.docx JAQS17_5b Clinical Audit Report national.docx JAQS17_5c Appendix 1 Stroke Action Plan.doc JAQS17_5d Clinical Audit Report corporate.doc 6 JAQS17/6 Clinical Audit Plan 2017/18 - Mr Adrian Thomas Recommendation: The Joint Committee is asked to receive and approve the Plan for 2017/18 JAQS17_6a Clinical Audit Plan coversheet.docx JAQS17_6b Clinical Audit Plan v1.2.docx JAQS17_6c Clinical Audit Plan Appendix 1 NHS Wales National Clinical Audit and Outcome Review Plan-2017_18.pdf 7 JAQS17/7 Quality Assurance Frameworks and Governance Arrangements - Mrs Gill Harris / Mrs Grace Lewis-Parry Presentation 8 JAQS17/8 Date of Next Meeting 10.00am 6th November 2018

2 4 JAQS17/4 Minutes of Meeting Held on for Accuracy and Matters Arising 1 JAQS17_4 Minutes JAQS Public V0.2.docx 1 Minutes Joint Audit & QSE Public V0.2 Present: Joint Audit and Quality, Safety & Experience (QSE) Committees Minutes of the Meeting Held on Tuesday 11 th October 2016 in the Boardroom, Optic Centre, St Asaph Mr Ceri Stradling Mrs Margaret Hanson Cllr Cheryl Carlisle (in part) Mr John Cunliffe Ms Jenie Dean Cllr Bobby Feeley (in part) Mrs Lyn Meadows Independent Member (Joint Chair) Independent Member (Joint Chair) Independent Member Independent Member Independent Member Independent Member Independent Member In Attendance and Observers: Mr Gary Doherty (in part) Mrs Gill Harris (in part) Mrs Grace Lewis-Parry Dr Evan Moore Mrs Vicky Morris Ms Kate Parry Professor Michael Rees Ms Dawn Sharp Mr Adrian Thomas Mr Mark Thornton Mr Chris Wright Chief Executive Executive Director of Nursing & Midwifery Board Secretary Executive Medical Director Director of Quality Assurance Corporate Governance Manager Healthcare Professionals Forum Chair Deputy Board Secretary Interim Director of Therapies & Healthcare Sciences Community Health Council Vice Chair Director of Corporate Services Agenda Item JAQS16/1 Joint Chair s Opening Remarks Action By Mrs M Hanson extended a welcome to all those present. Mr C Stradling indicated it was a requirement of the Audit Committee handbook to work with the Quality Safety & Experience (QSE) Committee, and that in 2015 this had been met through the role of the former Integrated Governance Committee. JAQS16/2 Minutes of Meeting Held on for Accuracy and Matters Arising JAQS16/2.1 Accuracy The minutes were agreed as an accurate record.

3 2 Minutes Joint Audit & QSE Public V0.2 JAQS16/2.2 Matters Arising Mrs V Morris added that with regards to the Annual Quality Statement, further substantial assurances had been received on the process through an internal audit report. With regards to deteriorating patients, it was confirmed that the RRAILS audit was undertaken annually, and the matter was within the clinical audit plan and one of the Board s 14 quality and safety priorities. It was noted that clinical coding remained part of the ongoing remit for the QSE Committee. Mrs G Lewis-Parry confirmed that Committee responsibilities would be subject to further review by Mrs A Lloyd (Independent Adviser) in November. JAQS16/3 Arrangements for Reviewing Significant Internal and External Audits JAQS16/3.1 Ms D Sharp presented the paper which had been updated further to discussion at Audit Committee earlier in the year. She reminded members that the Audit Committee were responsible for tracking responses to audit recommendations and confirming that the actions undertaken were sufficient. There had been discussions in terms of the robustness of the process in ensuring the Committee could be properly assured when being asked to confirm actions as closed. The Audit Committee had concluded that when the existing tracker tool spreadsheet identified significant issues the relevant committee would be requested to follow up progress and receive an assurance report on the relevant matters. Ms Sharp outlined the role of the Committee Business Management Group (CBMG) in ensuring appropriate scheduling on Committee agendas. [Cllr B Feeley and Mr G Doherty joined the meeting] JAQS16/3.2 Mr C Stradling also stated that the Audit Committee had the flexibility to require the attendance of an Executive lead for a particular report where there was deemed to be a significant lack of progress or an unreasonable delay in progress. JAQS16/3.3 Mrs M Hanson noted the importance of the triangulation of information from a range of sources and felt there was a need for clarity on the wider programme of work across external regulators. Mrs G Lewis-Parry indicated that there was a level of coordination of plans between Welsh Government, Healthcare Inspectorate Wales, Wales Audit Office (WAO) and internal audit, and that the Audit Committee did receive the respective audit plans from WAO and internal audit. Mr C Stradling suggested that the respective audit plans for the coming year be shared at CBMG. DS JAQS16/3.4 Mrs G Lewis-Parry referred to the letter from Dr Andrew Goodhall, a copy of which had been provided, and confirmed there was a new requirement for Health Boards to share any low assurance internal audit reports with Welsh Government (WG). Officers were working with internal audit colleagues to agree an appropriate reporting template, with the second return due for submission within the next week. Mr C Stradling outlined his concern that some reports may have to be submitted to WG before they had been discussed at Audit Committee, however, Ms D Sharp confirmed that consideration had been given when planning Committee meeting dates, and that as a minimum the reports

4 3 Minutes Joint Audit & QSE Public V0.2 would have been circulated to Independent Members upon publication. JAQS16/3.5 In response to a question from Mr M Thornton, Mrs G Lewis-Parry confirmed that the level of assurance for internal audit reports was set by internal audit, with the lead Executive having an opportunity to challenge the level and agree a management response at the draft stage. JAQS16/3.6 Mrs G Lewis-Parry also reported upon a fundamental change to governance arrangements in that the Audit Committee would routinely meet in public as from December onwards, in response to a recent Welsh Health Circular. She confirmed that the flexibility to hold an in-committee session would be retained. JAQS16/6 Medical Clinical Engagement in BCUHB [Item taken out of order at Chair s discretion] JAQS16/6.1 Dr E Moore presented the paper. He reported that the results of a Medical Engagement Scale Survey within NHS Wales would be publically shared in due course. He provided his personal views on clinical medical engagement, suggesting it was a measure of how doctors felt about their organisation, how willing they would be to go the extra mile, and a measure of how valued and involved they felt. Dr Moore stated that the paper set out a range of actions to be taken forward including clarification of medical staffing structures, addressing issues around job planning, increasing the visibility of leadership and improving decision making processes. JAQS16/6.2 Prof M Rees reported that he had been directly involved in aspects of improving clinical engagement for several months and whilst there was significant enthusiasm, ideas and goodwill amongst clinicians, there were some barriers to making improvements. He suggested there needed to be more cross-discussion between clinicians and managers, more sharing of skills, flexibility to allow clinicians to undertake additional development work, and improvements to systems to ensure they were equitable and transparent. [Mrs G Harris joined the meeting. Cllr C Carlisle left the meeting] JAQS16/6.3 Ms J Dean made the point that medical engagement should not be separated out completely from the wider BCUHB staff engagement strategy. Mr M Thornton referred to discussions at a recent QSE Committee workshop with the Quality Assurance Executive, and felt that clinical engagement did need to be a priority for the Health Board. He also felt that an absolute measure of how well organisations were doing on engagement was lacking across Wales. JAQS16/6.4 Mrs M Hanson referred to the associated communications action plan and enquired as to the accountability for monitoring. Mrs G Lewis-Parry confirmed that the Strategy, Planning & Population Health (SPPH) Committee had overall responsibility for engagement, however the detail of the individual action plan would be owned by the Executive lead. The QSE Committee would require a broader level of assurance that medical engagement was being addressed and improvements made, from the perspective of its impact on patient experience. Mrs L Meadows as Chair of SPPH would ensure the Committee was sighted on the matter, and also link in with Mr Martin Jones as part of the wider BCU engagement strategy. LM

5 4 Minutes Joint Audit & QSE Public V0.2 JAQS16/6.5 Mrs G Harris felt there were opportunities for the clinical executives to work together to identify good practice and principles of clinical engagement that would be transferrable across other disciplines eg medical, nursing and therapies. JAQS16/4 Medical Equipment Good Practice JAQS16/4.1 Mr Patrick Hill (North Wales Medical Physics Department) was in attendance to deliver a presentation which detailed:- The scope for medical devices, covering all aspects of healthcare The EBME (electro biomedical engineering) sector within BCUHB The SUM approach (suitable, understood, maintained) A description of the medical devices governance and committee structures within BCUHB and the importance of multi-disciplinary approach Recommendations of the WAO report Learning from the WAO report, areas of good practice Process for incidents via Datix Examples of recent incidents Added value from the process Next steps and how the Board could help JAQS16/4.2 Ms J Dean noted that one of the benefits of an asset register was to enable the organisation to have an accurate picture of the equipment available to it and to give assurances that the equipment was appropriately calibrated or to flag when it was coming to the end of its useful life. She expressed a concern that there may not be a sufficiently resourced replacement programme to address this and recalled that in previous years, departments had utilised charitable funds for equipment replacement. Prof M Rees also suggested that replacement needed to be in a more planned and proactive way, rather than a short turnaround response to funding when it was released by WG. JAQS16/4.3 Mrs G Lewis-Parry reminded members that the WAO report on medical equipment commended the Health Board for learning from when things go wrong, and suggested that the Committees try to identify areas of best practice that could be replicated elsewhere. Mrs G Harris felt that scrutiny within the area teams was key, and clear methodologies to underpin decision making. Mrs V Morris suggested that ensuring ownership, particularly around training, was important. Mr G Doherty felt that there were some characteristics that could be replicated for example the allocation of a guaranteed budget however there were additional complexities with revenue than capital. Mr M Thornton suggested that a common culture and understanding of an approach should be strived towards. JAQS16/4.4 Mrs M Hanson thanked Mr P Hill for his attendance and the presentation. She confirmed that the Audit Committee had received the full WAO report, and that the QSE Committee should consider how to read across learning and processes into other areas. MH GH JAQS16/5 Clinical Audit JAQS16/5.1 Mr A Thomas delivered a presentation which incorporated:

6 5 Minutes Joint Audit & QSE Public V0.2 Definitions of and differences between audit and research ie research is concerned with discovering the right thing to do, and audit ensuring it is done right. The benefits and outcomes that Clinical Audit provides. The Clinical Audit Cycle. Process for prioritising audits within BCUHB. The role of the National Clinical Audit and Outcome Review Advisory Committee and the associated tiers for audit. The WG assurance proformas (copies tabled) Topics for Tier 2 audits within BCUHB and statistics for Tier 3 Additional support and activity provided through Clinical Audit Detail of the Clinical Audit team within BCUHB JAQS16/5.2 Mr A Thomas tabled a briefing paper on the BCUHB 2016/17 Clinical Audit Plan which incorporated the NHS Wales National Clinical Audit & Outcome Review Programme and the Health Board Corporate Clinical Audit priorities. JAQS16/5.3 Mrs G Harris reported that she and Mr Thomas had had conversations regarding the alignment of the audit and improvement programmes, and the need to prioritise in alignment with the organisational improvement programme. Prof M Rees felt that there should be prioritisation of audits that were productive, and that research should be encouraged alongside audit. Ms M Hanson felt that clinical audit should be used to improve an improvement journey, and there was a need to link in with the Quality Assurance Executive. JAQS16/5.4 In response to a point raised by Mr C Stradling regarding information flows and the role of QSE Committee in terms of reporting lines, Mr A Thomas outlined timing issues relating to the release of the national clinical audit programme, and accepted that the scheduling of clinical audit work into the QSE cycle of business could be improved. Mrs G Lewis-Parry reminded members that the audit plan should focus on the key priorities of the organisation. Mrs G Harris suggested that key lessons learned and red RAG ratings from various audits needed to be reported up to QAE but the overall plan would continue to be signed off by the Audit Committee. JAQS16/5.5 It was agreed that Mrs G Harris and Dr E Moore would further consider how sharing of learning and scaling this up at pace could be achieved. In addition, Mr A Thomas would look to utilise the Tier 3 proforma for other tiers. GH EM AT JAQS16/7 Issues of Significance to Inform the Chair s Assurance Report To be agreed with Chair and submitted to next available Health Board meeting. It was also agreed that the minutes of the joint meeting be submitted to the QSE and Audit Committees for noting and ensuring follow up of actions. KP JAQS16/8 Date of Next Meeting To be convened for autumn KP

7 5 JAQS17/5 Clinical Audit Report - Mr Adrian Thomas 1 JAQS17_5a Clinical Audit Report coversheet.docx 1 Joint Audit and Quality, Safety & Experience Committees To improve health and provide excellent care Title: Author: Responsible Director: Public or In Committee Strategic Goals Clinical Audit Report /17 National Clinical Audit & Outcome Review Plan Update. 2. BCUHB Corporate Clinical Audit Update: October Mr Adrian Thomas (Executive Director of Therapies & Health Sciences) Mr Trevor Smith (Head of Clinical Audit & Effectiveness, Acting) Mr Adrian Thomas (Executive Director of Therapies & Health Science) Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 3. Improve health and wellbeing for all and reduce health inequalities 4. Work in partnership to design and deliver more care closer to home 5. Improve the safety and outcomes of care to match the NHS best 6. Respect individuals and maintain dignity in care 7. Listen to and learn from the experiences of individuals 8. Use resources wisely, transforming services through innovation and research 9. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks These updates have not been received as yet by another BCUHB Committee. They have been prepared alongside Mr Adrian Thomas (Executive Director of Therapies & Health Sciences). Update contributions have been received from BCUHB colleagues, including clinical leads for individual audit projects, operational managers and the Clinical Audit & Effectiveness Department. These related papers provide firstly an update regarding BCUHB engagement with last year s Welsh Government mandatory list of clinical audit projects (National Clinical Audit & Outcome Review Plan, 2016/17) and secondly, an update regarding the BCUHB Corporate prioritised list of clinical audit projects. These papers highlight the ongoing work and participation with these streams of audit & effectiveness activity from a wide range of BCUHB

8 2 multidisciplinary staff and where this is linked with local improvement activity. Also highlighted is ongoing activity towards achievement of full participation with these prioritised projects in relation to all aspects of the audit cycle; including areas where engagement needs to be strengthened with data submission, allocation of lead roles, assurance of local implementation of national recommendations. Special Measures Improvement Framework Theme/ Expectation addressed by this paper Equality Impact Assessment Recommendation/ Action required by the Committee Leadership Governance Strategic & service planning Engagement Mental health Maternity services Primary care Due to the scope and breadth of the topics included in the work-streams reported in this update, all of the themes are of relevance. This is due to the wide reach of Divisional / Specialty services involved in the audit cycle (including those visibly represented in the Special Measures themes above); patient and carer feedback sought for some projects ( Engagement ); Strategic & Service Planning influenced by findings; Governance structures that support and are influenced by this activity; Local service and Corporate Leadership required to support engagement with the projects and resultant improvement activity. EqIA is not applicable for the preparation and presentation of this update. The Joint Committee is asked to: Receive the update for information. Endorse full participation with the ongoing programme of NCAORP and Corporate clinical audit activity. Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board Committee Coversheet v11 June 2017

9 1 JAQS17_5b Clinical Audit Report national.docx Page 1 of 57 National Clinical Audit & Outcome Review Plan (NCAORP) 2016/17 This report provides an update on progress within BCUHB in relation to participation with the National Clinical Audit & Outcome Review Plan (NCAORP) for 2016/17. The report has been compiled by the Corporate team of Clinical Audit & Effectiveness Facilitators for their aligned Divisions/Specialties. The information is an indicator of ongoing liaison with the individual site-based Clinical Audit Leads for each National topic. The audits included in the National Clinical Audit & Outcome Review Plan which are not applicable to BCUHB are listed below: National Adult Cardiac Surgery Audit National Audit of Congenital Heart Disease (due to care provided in Manchester) Paediatric Intensive Care (PICaNet) The project titles are listed within this update report under the categories used by the Welsh Government within the NCAORP. They are as follows: Acute Long term conditions Older people Heart Cancer Women s & children s health Nursing (Fundamentals of Care is now linked to Health & Care Standards Audit and reported through the Transforming Care team).

10 Acute: Title of Clinical Audit: National Joint Registry (NRJ) Host Organisation: National Joint Registry (NRJ) Date of last National report: September 2017 Page 2 of 57 Project Background and Aims: Hip, knee, ankle, elbow and shoulder joint replacements are common and highly successful operations that bring many patients relief from pain and improved mobility. Thousands of these joint replacement operations take place in the UK every year. The National Joint Registry (NJR) was set up by the Department of Health and Welsh Government in 2002 to collect information on all hip, knee, ankle, elbow and shoulder replacement operations and to monitor the performance of joint replacement implants. Since 2005 the NJR Annual Report has a Patient Reported Outcome Measure (PROMS) element whereby patients completed a pre-operative questionnaire for the NHS England national PROMs programme and consented to have their personal details held by the NJR. BCUHB-wide lead: Mr M Ganapathi (Consultant Surgeon) East lead: Mr Steve Phillips (Consultant Surgeon) Central lead: Mr B Ramesh (Consultant Surgeon) West lead: Mr M Ganapathi (Consultant Surgeon) Recommendations of last National report: The 2016 report noted that Wrexham Maelor was an Outlier for Hip revision rates, all linked primaries from This has resolved and the 2017 report makes no specific local recommendations. BCUHB actions agreed: Central: The Central Orthopaedic team uses ODEP rated implants only. We are currently using Vanguard CR, Microport PS and MP designs for our knees. Probably around 80% Vanguard and the rest Microport. Regarding the hips, we have Corail & Pinnacle system from Depuy, Exceed & Taperloc from BIOMET, Profemur XL from Microport and Exeter with contemporary/trident from Stryker. We are aware of the recent alert from Stryker regarding large metal heads with long neck options and confirm that we never used such a big head combinations. To list some of the problems with NJR entry. The data entry into NJR site is not robust. The delay seems to be one of the many issues. This is going on for very many years. I tried to organise a meeting in the past with involved people and the NJR team from the west to share their experience. However that meeting never went ahead. Besides the delayed data entry, consent taking is also very poor! We have about 40 45% compliance on this. The reasons are not clear. Perhaps the consent sheets are not filed together or lost in transit. I tried to convince the management to have an Arthroplasty proforma bundle for Hips and Knee. It is still being considered. I have given a model proforma bundle from Swansea for info. I am working with Mrs Ellis to develop our own bundle. I am aware of the fact that the trust data (CHKR) and NJR data on the number of arthroplasty cases does not tally for the last few years. This could be due wrong coding. This needs addressing. We need to get the coding right consistently. Perhaps we need to have a meeting with secretaries and theatre staff to help us on this. I am also concerned about the fact that there could be around 20 to 30 THRs done for fractures are missed completely. West and East: Response has been requested for Welsh Governance Part B update which is due for the 19 th December Date form completed: Progress with agreed actions: Central Area: The Positives: 1. We are as best as we could be on implant rationalisation. 2. All the implants are ODEP rated. 3. We are not using any MOM implants. 4. We acted appropriately with the recent Stryker alert on large metal heads. 5. We are going to discuss with our shoulder surgeons regarding the recent alert from Depuy about their TSA. The Negatives: 1. Poor coding and hence poor data collection at NJR and CHKS. 2. Poor compliance with NJR audit tool. 3. Delay in inputting the data. Quality improvement activities: 1. Arthroplasty bundle including NJR audit tool in all arthroplasty cases including trauma related THRs 2. Periodic meeting with arthroplasty surgeons regarding NJR data. 3. Meeting organised with CHKS and NJR team to improve our efficiency. This is planned for 31/10/ Form completed by (PRINT NAME): Jean Burgess, Clinical Audit & Effectiveness Facilitator.

11 Page 3 of 57 Mr B Ramesh, Consultant Surgeon (Central). Title of Clinical Audit: National Emergency Laparotomy Audit (NELA) Host Organisation: Date of last National report: Royal College of Anaesthetists 2 nd Patient Report: 5 th July 2016 Project Background and Aims: NELA aims to look at the structure, process and outcome measures for the quality of care received by patients undergoing emergency laparotomy. The contract for the provision of the NELA was awarded to the Royal College of Anaesthetists (RCoA) in June NELA is currently funded until 30 November 2017 with the potential of a further 3-5 year extension. The first patient data report was launched 30th June 2015 (patient sample for December 2013 to November 2014). The 3 rd Patient Data report has just been launched 13 th October 2017 and has been circulated to site NELA leads. BCUHB-wide lead: Dr Stephan Clements (Consultant Anaesthetist) East lead: Mr Duncan Stewart (Consultant Surgeon) Dr Campbell Edmundson (Consultant Anaesthetist) Central lead: Mr Richard Morgan (Consultant Surgeon) Dr Magdy Khater (Consultant Anaesthetist) West lead: Mr Edgar Gelber (Consultant Surgeon) Dr Stephan Clements (Consultant Anaesthetist) Recommendations of last National report: 2 nd Patient Report Published 5 th June 2016 Process measures: Process measures are sensitive indicators of performance which should be monitored over time to assess the impact of any changes. Mortality and other outcomes: Examine 30-day mortality and length of stay. The following recommendations are aimed at addressing the key themes identified in this NELA Patient Report: Commissioners. Commissioners should ensure that there is adequate commissioning of: Multidisciplinary input across the whole of the patient pathway. Capacity to deliver consultant-delivered care and other services, such as CT scanning and reporting regardless of the time of the day or the day of the week. Theatre capacity to prevent delays for patients requiring emergency bowel surgery. Some hospitals may require the capacity for emergency and elective care to continue in parallel. Critical care capacity to match high-risk caseload, such that all high-risk emergency laparotomy patients can be cared for on a critical care unit after surgery. Elderly Medicine services to provide input for older patients. Providers (Chief Executives and Medical Directors) In order to deliver high-quality care to high-risk emergency patients that meets standards, attention should be directed at organisational change in the following areas: Patients undergoing emergency bowel surgery require consultant involvement in their care 24 hours per day, seven days per week. Rotas, job plans and staffing levels for surgeons and anaesthetists should reflect this. The workload may require an increase in the number of consultants available for emergency work. In some hospitals, this may require separation of elective and emergency care so that both services can continue in parallel without competing for resources. Delivery of high-quality care can be facilitated by reconfiguring services to locate acute surgical patients within a single area. Policies should be developed and implemented which use individual risk assessment to guide allocation of resources (e.g. critical care) appropriate to the patient s needs. This can also help with capacity planning by defining a hospital s expected caseload and resource requirements. Provision of emergency theatre capacity needs to be sufficient to enable patients to receive emergency surgical treatment without undue delay, and may require capacity to allow emergency and elective care to continue in parallel. Where capacity is limited, prioritisation of time-sensitive emergency surgery can be facilitated by policies to defer elective activity.

12 Page 4 of 57 National standards for postoperative critical care admission should be adhered to. This may require an increase in critical care capacity so that emergency and elective care can continue in parallel. Data collected from NELA has the potential to inform NHS trust boards of many different aspects of emergency care provision. Local NELA Leads and perioperative teams must have adequate time and resources to support accurate data collection, review adverse patient outcomes, and to feed this back to clinical teams and hospital management including NHS trust boards. Such resources include access to individuals with audit and quality improvement skills throughout the NHS trust, allocated (job-planned) time to support data collection and analysis, and protected time for presentation of data in departmental meetings. Effort should be invested in ensuring clinical coding is accurate. Clinical Directors and Multidisciplinary Teams: In order to reduce variation in care and minimise delays, hospitals should implement appropriate pathways for the care of emergency General Surgical patients, starting at the time of admission to hospital or referral by another team. Where pathways of care do already exist, Multidisciplinary Teams (MDT) should examine these in the light of audit data to determine their effectiveness, and identify why standards are still not met. Multidisciplinary Teams should hold regular joint meetings to continuously review essential processes of care. Continuous quality improvement informed by local data should involve monitoring the impact of pathway and process changes with time-series data (run charts). NELA Leads: NELA Leads should review their local data to ensure case-submission and data completeness. NELA Leads should actively promote completion of Predictive - Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) data fields to ensure that risk estimation is accurate and avoid falsely elevated risk-adjusted hospital mortality rates. Professional Stakeholder Organisations: Professional stakeholders, such as Royal Colleges and Specialist Societies, should collaborate to: Improve clarity and remove ambiguity in the wording of standards of care. Bring together standards in a single, unified document. Highlight the issues to their members to ensure appropriate engagement. Specific issues of note for BCUHB: In response to the National Key Finding, the three BCUHB acute hospitals now use a formalised risk assessment pro-forma for all patients undergoing Emergency Laparotomy and Central have a clerking pro-forma for all emergency laparotomies. West and Central continue with paper based data collection (inputted to the NELA data base by the Clinical and Effectiveness (CA&E) Department with East using direct data entry onto the website. December 2016 Significant issues of data collection/entry became apparent at Ysbty Glan Clwyd and Ysbyty Gwynedd which made achieving the reporting deadline highly problematic, requiring a considerable level of input from the BCUHB Lead and CA&E to address. January 2017 Following staffing changes it was necessary for Ysbyty Gwynedd to cease direct data collection in theatre via Excel spreadsheet and revert to paper based data collection. Separate forms were used for each speciality, with questions ordered to match the chronology of the Anaesthetic/Surgical process. Each speciality returned completed forms to the Clinical Audit & Effectiveness (CA&E) Department for entry onto the NELA website. May 2017 NELA progressed from annual to quarterly reporting. This formalised the existing quarterly reporting initiated in the West by Dr. Clements to Dr. Paul Birch (Medical Director) and the NELA team. August 2017 In the West, working under the supervision of Mr. Abdullah, Dr. Quratulain Qureshi took responsibility for addressing historic data collection issues and began to systematically increase the lock down status of the patient records. An Information Governance compliant update mechanism for all the NELA leads, the OMD and CA&E Department has been agreed via the SharePoint site. September 2017 In Central NELA data continues to be collected from all eligible patients with rigorous quality control to prevent

13 Page 5 of 57 omissions. Changes in practice as a result of NELA include the routine use of P-POSSUM to predict mortality and morbidity, with consultant surgeon presence for all intermediate and high risk cases (also most low risk cases). October 2017 In Central: 1. Central Emergency Theatre Lead for NELA Andrew Higgins is now helping us to encourage everyone in to initiate and follow completing the forms. 2. Central Surgeons are aware they should start the NELA details for each patient before coming to the Anaesthetic Room or during the WHO. 3. Updated NELA forms (colour printed) with clear section for the Central Anaesthetist and Surgeon to complete. 4. Meetings held with Clinical Audit and Effectiveness to improve data collection - a new procedure has been devised which seems to be working well. October 2017 A 3-site VC took place ( ) for the site leads and CA&E Department to discuss ongoing issues. BCUHB actions agreed: Progress with agreed actions: Amendments to Central area WHO and booking forms. Agreed at VC meeting ( ). Additional analysis of exported YGC data regarding antibiotics, level CA&E Facilitator commencing. of severity, etc. Potential for roll-out to other areas. Discussions to be planned with site COTE Clinical Directors the key performance indicator relating to postoperative assessment of NELA Discussions to be planned. patients aged 70 years and over. Liaise with NELA Royal College project team regarding the data accessibility for quarterly review and explore ways to present in poster and presentation form outside Theatres and at Surgical / CA&E Facilitator commencing. Anaesthetic Governance meetings. Arrange dates for quarterly VC meetings for NELA site leads. To be confirmed Date form completed: 18/10/2017 Form completed by (PRINT NAME): Jodie Williams (Clinical Audit & Effectiveness Facilitator) Title of Clinical Audit: Comparative audit of Critical Care Unit Adult Patient Outcomes (casemix). Host Organisation: Date of last National report: Intensive Care National Audit & Research Centre (ICNARC) September 2017 Project Background and Aims: The Case Mix Programme (CMP) is an audit of patient outcomes from adult, general critical care units (intensive care and combined intensive care/high dependency units) covering England, Wales and Northern Ireland. BCUHB-wide lead: East lead: To be confirmed Dr Sam Sandow Central lead: Dr Richard Pugh Consultant Anaesthetist West lead: Dr Karen Mottart/Alison Ingham Consultant Anaesthetists Consultant Anaesthetist Recommendations of last National report: Quarterly reporting and Annual Report released in September Specific issues of note for BCUHB: Data compliance good in both YGC and YG. Some difficulties in Wrexham due to sickness and vacancy which resulted in the inability to submit data for Jan-Mar 16. Wrexham: In August 2016, the team appointed a data clerk for this role who has been able to get things back on track. The team has redesigned the data collection form so that clinicians (nurses and doctors) own the data and collect it themselves. They have been submitting data regularly. The data is reviewed both at departmental M&M but also at BCUHB Critical Care SIG (Improvement Group). It feeds in to all decisions about critical care throughout the Health Board. BCUHB actions agreed: Wrexham: To appoint data clerk. Address difficulties with submitting data from Jan- Mar Progress with agreed actions: Now in post in Wrexham. Data clerk now in post for Wrexham.

14 Assessing data completeness and correctness of 2015 reports. Redesign data collection form so that clinicians (nurses and doctors) own the data and collect it themselves. Date form completed: Form completed by (PRINT NAME): Dr Sam Sandow (consultant Anaesthetist) Page 6 of 57 Dr Sam Sandow had been through the previous data and corrected many aspects; however the data had been excluded by ICNARC on that occasion. Now processes for data collection and submission in place. Re-design completed. Title of Clinical Audit: National Audit of Trauma and Research Network (TARN) Host Organisation: Date of last National report: Trauma Audit & Research Network See Recommendations of last National report section below. Project Background and Aims: Already the commonest cause of loss of life under the age of 40 the burden of trauma is set to increase in the next 20 years. Taking a global view of 'life years lost' through premature death and disability, injury will be in 2nd place in A lot of the tragedies represented in these statistics are preventable as is unnecessary mortality directly due to inadequacies in the organisation and delivery of care. Research in North America identified the causes of these failures and in 1988 a Royal College of Surgeons of England working party drew remarkably similar conclusions. The College recommended changes in trauma management which included: Enhancing pre-hospital care, ensuring appropriate medical intervention Rapid transfer to the best local facility Assessing the use of helicopters Adopting ATLS principles Integrating trauma services within and between hospitals Investing in rehabilitation services Auditing and Researching injury and systems of care BCUHBwide lead: To be confirmed East lead: Dr Ash Basu (Emergency Consultant) Central lead: Mr Mark Anderton (Emergency Medicine Consultant) West lead: Dr Rob Perry (Emergency Consultant) and Dr Leesa Parkinson (Emergency & Paediatric Emergency Consultant) (Sue Owen, data input) Recommendations of last National report: Clinical reports TARN produce clinical reports for member hospitals 3 times each year. Each report contains a core section containing measures such as most senior clinician and time to CT scanning and a themed section focusing on a particular type of injury: March - Thoracic & abdominal injuries July - Orthopaedic injuries November - Head & spinal injuries In April 2017, the Major Trauma In Older People report was launched. Specific issues of note for BCUHB: West YG: IT/Coding to support production of list of patients for entry into TARN database in a timely manner. TARN reports are generated on data at 90 days and currently coding/generating the list delay this process by several months. Medical records staffing levels sometimes low which delays the provision of case notes following generation of list via IT/Coding. TARN data input co-ordinator has insufficient time to input TARN data due to being tasked with other duties such as breach data input, exception reporting and other ED administrative tasks. ED notes moved away from ED often within 2 weeks of attendance due to lack of notes storage space. Data entry stalled temporarily in July due to ED offices moving to portacabin. Moving of notes between

15 Page 7 of 57 records, data input and clinical checking is now impaired by location. Central YGC: Discussions underway regarding shortage of administration support for data entry. Update from East awaited. BCUHB actions agreed: Progress with agreed actions: YG are having trouble getting casenotes so are about 6 months behind See above. with their data input. YGC discussions underway regarding administrative support for data entry. Discussions underway. Date form completed: Form completed by (PRINT NAME): 18/10/17 Jodie Williams (Clinical Audit & Effectiveness Facilitator) Title of Clinical Audit: National Ophthalmology Audit (Adult Cataract Surgery) Host Organisation: Date of last National report: Royal College of Ophthalmology 13 July 2017 Project Background and Aims: The Royal College of Ophthalmologists has been commissioned by the Health Quality Improvement Partnership (HQIP) and funded by NHS England and the Welsh Government to manage the National Ophthalmology Database (NOD) Audit. The NOD audit was initially funded for 3 years from September 2014 to August 2017 and this has now been extended for a further two years from September 2017 to August The NOD Audit will prospectively collect, collate and analyse a standardised, nationally agreed cataract surgery dataset from all centres providing NHS cataract surgery in England & Wales to update benchmark standards of care and provide a powerful quality improvement tool. In addition to cataract surgery, electronic ophthalmology feasibility audits have been undertaken for glaucoma, retinal detachment surgery and age related macular degeneration (AMD). These have now been completed and permission from the funders to publish these is awaited. East lead: Central lead: West lead: BCUHB-wide lead: Jai Shankar (Consultant Claire Morton (Consultant Syed Amjad (Consultant To be confirmed Ophthalmologist) Ophthalmologist) Ophthalmologist) Recommendations of last National report: Cataract surgery is one of the most frequently performed surgical procedures in the UK with around 330,000 operations performed yearly in England and 16,000 in Wales. In the first annual report of the National Ophthalmology Database Audit, published by The Royal College of Ophthalmologists, historic or legacy data have been used to highlight data completeness and to establish a robust methodology for future cataract surgery audit cycles. Specific issues of note for BCUHB: Participation in the registry has not yet been established across any of the three BCUHB Acute sites. There are on-going discussions amongst Ophthalmology teams with operational management and IM&T regarding the available software options of Open Eyes and Medisoft. BCUHB actions agreed: Need to agree the IT software option to be adopted in BCUHB to enable participation in the Registry to commence. Date form completed: 20/10/17 Progress with agreed actions: Mrs Claire Morton has seen Open Eyes software in operation during a visit to an NHS Trust in the UK. Contact with IM&T has been initiated. Discussions underway across teams with Operational Managers and IM&T. Form completed by (PRINT NAME): Trevor Smith, Head of Clinical Audit & Effectiveness (Acting)

16 Page 8 of 57 Long Term Conditions: Title of Clinical Audit: National Diabetes Audit Host Organisation: Date of last National report: January 2017 HQIP & HSCIC with Diabetes UK Project Background and Aims: The National Diabetes Audit is a major national clinical audit, which measures the effectiveness of diabetes healthcare against NICE Clinical Guidelines and NICE Quality Standards, in England and Wales. The NDA collects and analyses data for use by a range of stakeholders to drive changes and improvements in the quality of services and health outcomes for people with diabetes. The National Diabetes Audit (NDA) answers five key questions:- Is everyone with diabetes diagnosed and recorded on a practice diabetes register? What percentage of people registered with diabetes received the nine National Institute of Health and Care Excellence (NICE) key processes of diabetes care? What percentage of people registered with diabetes achieved NICE defined treatment targets for glucose control, blood pressure and blood cholesterol? What percentage of people registered with diabetes are offered and attend a structured education course? For people with registered diabetes what are rates of acute & long term complications (disease outcomes)? BCUHB-wide lead: Julie Lewis (Diabetes Specialty Lead) & Christopher Lube (Head of Clinical Governance: Primary Care Support Unit) East lead: Jane Whitehurst (Diabetes Specialist Nurse) Central lead: Julie Lewis (Diabetes Specialty Lead) West lead: Debra Hughes (Diabetes Specialist Nurse) Recommendations of last National report: Structured education providers and their commissioners should follow the recently agreed communication guidance to improve recording of structured education attendance. GP and specialist services and CCGs/LHBs should use relevant parts of this report and the accompanying local level information to compare themselves to similar services and identify areas for improvement and implement local action plans. All services seek new approaches to diabetes service delivery for those aged under 65 to narrow the gap between them and older people. People with diabetes to review the results for their practice or specialist service and support any improvement initiatives. BCUHB actions agreed: Improve recording of structured education attendance: To compare themselves to similar services and identify areas for improvement and implement local action plans: Seek new approaches to diabetes service delivery for those aged under 65: People with diabetes to review the results for their Progress with agreed actions: Diabetes specialist team s record completion of all DAFNE training undertaken by all adults with type 1diabetes, and notification is sent to the relevant GP practice. GP s are notified of all adults with type 2 diabetes who have been referred to the XPERT Programme but have declined to attend the course. We are currently developing a process to ensure GP practices are notified of all patients that attend and complete the XPERT Programme. The Health Board does not currently have access to the National Diabetes Audit data for individual practices. Discussion at cluster level will be encouraged until such time as practice data is more widely available. The provision of locality diabetes teams have been established through a combination of funding received from Primary Care and GP Cluster s. Six teams within the fourteen localities have been funded to proactively support people with diabetes closer to home; a large proportion of those accessing the service will be working aged adults. Currently individual practice data is not widely available for external review. Service users do participate in all Diabetes Planning Groups, once the data for

17 practice or specialist service: Date form completed: Page 9 of 57 their practice or specialist service is in the public domain a strategy to ensure service user review and engagement will be implemented. Form completed by (PRINT NAME): Alison Smith Clinical Audit and Effectiveness Facilitator Title of Clinical Audit: National Diabetes Inpatient Audit (NaDIA) Host Organisation: Date of last National report: HQIP & HSCIC with Diabetes UK March 2017 Project Background and Aims: The National Diabetes Inpatient Audit (NaDIA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and delivered by the Health and Social Care Information Centre, working with Diabetes UK. The National Diabetes Inpatient Audit is a snapshot audit of diabetes inpatient care in England and Wales. The audit looks at the following areas: Whether diabetes management minimises the risk of avoidable complications. Harm resulting from the inpatient stay. Patient experience of the inpatient stay. The change in patient feedback on the quality of care since NaDIA began. BCUHB-wide lead: Dr Stephen Stanaway (Consultant Physician) East lead: Dr Stephen Stanaway (Consultant Physician) &Cheryl Griffiths (Diabetes Specialist Nurse) Central lead: Dr Stephen Wong (Consultant) Carolyn Thelwell (Diabetes Specialist Nurse) Julie Lewis (Diabetes Specialist Nurse) West lead: Dr Muhammed Murtaza (Consultant) & Ceri Roberts (Diabetes Specialist Nurse) Recommendations of last National report: Healthcare professionals to continue to contribute to this unique and valuable insight into the inpatient care of people with diabetes. In the face of increasing numbers of inpatients with diabetes, ensure that Diabetes Teams are adequately staffed to support other healthcare professionals and patients in the delivery of safe diabetes care. Learn from NHS Trusts and Local Health Boards where Electronic Prescribing and Electronic Patient Records work well and encourage others to adopt similar systems. Ward referral systems should be in place to ensure that all appropriate patients are promptly referred and promptly seen by the diabetes team. Continue to innovate and improve systems of blood glucose monitoring, including consideration of remote blood glucose monitoring where practical and appropriate. Higher rates of good diabetes days will translate into fewer harms and quicker recovery. Continue to focus on surveillance of inappropriate use and duration of use of insulin infusions. Continue to educate and support junior doctors and nursing staff, while also developing and testing new systems to reduce prescribing and medication management errors. Junior doctors and nursing staff should be made aware that hyperglycaemia should not be left untreated, especially in people with Type 1 diabetes. Measures should be taken to prevent nocturnal hypoglycaemia, including introduction of bed time snacks. Implementation of initiatives to improve foot examination on admissions and NICE guidance are associated with better processes and should be implemented in all NHS Trust and Local Health Boards. Variation in the apparent need for better staff knowledge requires further exploration. Specific issues of note for BCUHB: These are covered in actions below. BCUHB actions agreed: Regularly review staffing. To continue to co-operate with Wales wide diabetes information improvements. Pilot the electronic referral Progress with agreed actions: We continue to review staffing of Diabetes Teams and have increased Diabetes Specialist Nurse numbers by 3.5whole time equivalent and Dietician numbers by 2.5 whole time equivalent. Although we do have recruitment challenges, staffing issues are being regularly reviewed. BCUHB will continue to co-operate in Wales wide diabetes information improvements and is using the NHS Wales Informatics Service. In Ysbyty Glan Clwyd (YGC) a pilot scheme of an electronic referral system

18 system. Continue to train staff around the Point of Care service. Focus on surveillance Reduce prescribing and medication management errors. Continue to provide bedtime snacks for inpatients. Continue to provide and review the foot examination service on admission. Continue to provide education and competency training for staff. Date form completed: Page 10 of 57 to the Diabetes Specialist Nurse is currently being trialed. The pilot scheme s success will be evaluated prior to the system being adopted across BCUHB. The Health Board does not have plans at present for a 7 day Diabetes Inpatient Specialist Nurse Service. The installation of Point of Care remote monitoring of blood glucose in hospital is currently in progress. With patients safety at the forefront, services will go live with this system once 70% of staff are fully trained. Continuation of background insulin is included in the pathway for insulin infusion across BCUHB. Datix reviews are undertaken in BCUHB Medication Safety Meetings. Bedtime snacks can be ordered for/by inpatients with diabetes. Hypo treatments boxes are available on all wards. YGC is performing above the National average (64.6%) for providing inpatients with diabetes a specific diabetic foot risk examination within 24 hours. YGC was also recognised above the National average for ensuring diabetic patients admitted with active foot disease was seen by Multidisciplinary Foot Care Team within 24 hours (71.4%). Diabetic Specialist Nurse s currently provide staff education as well as insulin competency training. Form completed by (PRINT NAME): Alison Smith Clinical Audit and Effectiveness Facilitator Title of Clinical Audit: National Pregnancy in Diabetes Audit Host Organisation: Health & Social Care Information Centre (in collaboration with Diabetes UK and Diabetes Health Intelligence) Date of last National report: October 2016 Project Background and Aims: The National Pregnancy in Diabetes (NPID) Audit aims to support clinical teams to deliver better care and outcomes for women with diabetes who become pregnant. The audit aims to answer the following questions: Were women with diabetes adequately prepared for pregnancy? Were appropriate steps taken during pregnancy to minimise adverse outcomes? Did any adverse outcomes occur? The NPID audit measures the quality of pre-gestational diabetes care against National Institute for Health and Care Excellence (NICE) guideline based criteria and the outcomes of pre-gestational diabetic pregnancy. The NPID audit is part of the National Diabetes Audit (NDA) programme commissioned by the Healthcare Quality Improvement Partnership (HQIP). BCUHBwide lead: To be confirmed East lead: Dr Stuart Lee (Consultant) Eric Njiforfut (Consultant) Gill Davies (Diabetes Specialist Nurse) Rao Bondugulapati (Consultant) Central lead: Dr Steven Wong (Consultant), Miss Maggie Armstrong (Consultant), Kirstin Clarke (Specialist Nurse) Julie Lewis (Diabetes Specialty Lead) Recommendations of last National report: Improving preparation for pregnancy. Improving early contact with specialist support. Improving achievement of safe glucose control in pregnancy. BCUHB actions agreed: Overall quality improvement of service: Improving preparation for pregnancy : West lead: Dr Tony Wilton (Consultant) Helen Butler (Specialist Nurse) Ceri Roberts (Specialist Nurse) Dr Leela Ramesh (Consultant) Dr Noreen Haque (Registrar) Progress with agreed actions: Ysbyty Gwynedd has implemented a checklist that is filled in by the Diabetes Specialist Nurses or the Doctors, and will be kept on the front of the patient s obstetrics records. Meetings are currently being arranged with primary care

19 Improving early contact with specialist support: Improving achievement of safe glucose control in pregnancy: Of note: optimising glycaemic control preconception/during pregnancy is not an issue for Wrexham. Date form completed: Page 11 of 57 representatives in Wrexham Maelor to discuss improving prepregnancy care and increase the education around this matter. Ysbyty Gwynedd will also communicate with diabetic nurses working within GP surgeries to improve the preparation for pregnancy. BCUHB Clinical Lead for Diabetes has put forward a local enhanced service proposal requiring communication with the Area Medical Directors for Primary Care (across BCUHB) with the view to implement a pre-pregnancy counselling service for women of childbearing age who have diabetes. However this proposal needs approval and funding. Wrexham Maelor is seeking funding solutions to address the need for dedicated Consultant led pre-pregnancy secondary care clinics and a Diabetic Specialist Nurse led counselling service. Ysbyty Gwynedd will request to be sent a copy of patients retinopathy screening results from Retinopathy Screening Wales. As previously, Ysbyty Gwynedd has implemented a checklist to ensure each aspect of diabetic care is addressed during pregnancy. Form completed by (PRINT NAME): Alison Smith Clinical Audit and Effectiveness Facilitator Project Update: 05/09/17: Contacted leads to request an update on any actions, Dr Lee Consultant confirmed that there are no further updates to report. Title of Clinical Audit: National Diabetes Foot Care Audit Host Organisation: Health & Social Care Information Centre (Project Management) & Diabetes UK and National Cardiovascular Intelligence Network Date of last National report: March 2017 Project Background and Aims: National Diabetes Foot Care Audit (NDFA) will enable all diabetes foot care services to measure their performance against NICE clinical guidelines and peer units, and to monitor adverse outcomes for people with diabetes who develop diabetic foot disease. BCUHB-wide lead: Gareth Lloyd- Hughes, Head of Podiatry & Orthotics East lead: Dr Anthony Dixon (Consultant Physician) & Nicola Joyce (Podiatrist) Central lead: Dr. Aye Nyunt (Consultant Physician) & Lorna Hicks (Principal Podiatrist) Recommendations of last National report: Established pathway which can allow referral within 24 hours. People with newly occurring foot ulcers should be triaged within 2 days. Outcomes of diabetic foot disease (12 and 24 weeks) to be optimised. BCUHB actions agreed: Established pathway which can allow referral within 24 hours: Progress with agreed actions: West lead: Mr. Dean Williams (Consultant Vascular Surgeon) & Jamie O Malley/Iola Roberts (Diabetic Podiatrists) We have set up a diabetic strategy group chaired by the Head of Podiatry (West area) who has a high risk diabetic caseload of her own, as well as the 3 podiatry leads by area. The focus of this work is to align systems of working across BCUHB (where possible) to the diabetic delivery plan and the identified work as a result of NDFA outcomes. A key element of this is to achieve or get as close to achieving as possible, the 24 hour referral target. Referral to podiatry is in real time and if faxed are limited only by when the referrer

20 People with newly occurring foot ulcers should be triaged within 2 days: Outcomes of diabetic foot disease (12 and 24 weeks) to be optimised: Date form completed: Page 12 of 57 chooses to do so. This is the case in all areas. The referrals are triaged same day if linked to a diabetic foot ulcer. We have admin process in place in all areas that ensures these a red flagged (as long as referrals are clear that a diabetic foot ulcer or suspected one is the main issue) and a senior podiatrist will triage same day as receipt (Note: this is different to us getting referrals within 24 hours of presentation of an ulcer, as the referrer may hold back on referring a technicality in wording that should not be discounted). If the referral is deemed appropriate for the diabetic foot ulcer team then the triaging podiatrist will task the admin team urgently for same day transfer to the diabetic teams wait list (electronically). We have asked as part this processes in place that area diabetic foot ulcer teams check their wait list on a daily basis and book accordingly. All 3 areas hold back assessment slots per week to allow these new referrals to be booked in next day where possible. This is a process already in place in all 3 areas. At times of significant annual leave (which we to pre plan for as best we can) or sickness, we cannot guarantee 24 hours assessment from receipt of referral (which is how we are interpreting this element) but get very close to it. We do not currently work weekends so 24 hours from a Friday will not be possible. With current staffing levels we cannot run daily foot ulcer clinic in all 3 areas, west for example cannot run 5 days a week so again 24 hour access from receipt of referral is again not always possible. However I must stress that this is a significant improvement on our situation over a year ago. This links in with the process above and the detail is as outlined there. The day will be working days and so currently Monday to Friday. We do not have staff contracted to work weekends so cannot triage Saturday or Sunday. Where the referral is received on a working week day it triaged same day unless received at the very end of play that day. The triage is real time and electronic. We work closely with our affiliated admin team to achieve this and clear processes are in place. We are dealing with any known delays for reasons out of our control on a case by case basis. We reduced delays to access to antibiotics by having to relay the patient to their GP by successfully introducing our 1 st independent prescriber as of April This initial feedback is excellent and should speed up recovery times. More are in the pipeline to follow this lead in BCUHB over the next 12 to 18 months. The strategic diabetic team as mentioned in the 1 st theme is continuing its work on standardising the casting approach to offloading to link in with LEAP all Wales work. This is ongoing but all acute foot ulcer sites to have access to on site real time casting facilities. We are working closely with vascular teams at all 3 foot ulcer sites to allow for rapid / fast tracked vascular assessments for ulcerating patients where indicated. We discussed option for root cause analysis at the 1st all Wales diabetic network meeting in April this year, and it became very clear that this is a far bigger piece of work than initially anticipated and will need a coordinated all Wales approach that is practical and fair to embed. More informal review of cases to look for improvements in process and method are encouraged at all times at a local area level with feedback the BCUHB diabetic strategic group. One theme that has come from this to date is that there is a feeling with teams that one of the main reasons for delays in healing is patient compliance or rather the lack of it. I am looking at ways of introducing motivational interviews and other methods of increasing potential compliance improvements, although nothing concrete in place as yet. We are not clear as to if the 12 and 24 weeks run from the assessment date with the DFU team or the time the ulcer was first observed by a health care professional. If it is the latter there can be delays in referral to us by not fault of our own process. This is currently being confirmed with Royal College project team. Form completed by (PRINT NAME): Alison Smith (Clinical Audit and Effectiveness Facilitator). Gareth Lloyd-Hughes (Head of Podiatry & Orthotics).

21 Page 13 of 57 Title of Clinical Audit: National Paediatric Diabetes Audit Host Organisation: Date of last National report: Royal College of Paediatrics & Child Health February 2017 Project Background and Aims: The primary aim of the NPDA is to examine the quality of care in children and young people with diabetes and their outcomes. The NPDA is currently commissioned and funded by the Healthcare Quality Improvement Partnership (HQIP) and covers England and Wales. NPDA priorities Build on and improve the previous joint adult and paediatric audit Collect a clinically meaningful dataset Engage clinicians, patients and parents Improve awareness of NPDA findings and maximise their use to drive national policy Develop the use of NPDA data in local and national quality improvements Use a regional network approach to data collection BCUHB-wide lead: Dr Michael Cronin (Consultant Paediatrician) has provided feedback on this East lead: Dr Kamal Weerasinghe (Consultant Paediatrician) Karen Czerniak (Paediatric Community Nursing Team Leader) Recommendations of last National report: Completion of health checks. Structured education. Blood glucose diabetes control targets (HbA1c). Diabetes complications and risk factor. Quality and completeness of data submission. Deprivation and demographic factors. BCUHB actions agreed: Completion of health checks : Blood glucose diabetes control targets (HbA1c): Central lead: Dr Pramod Bhardwaj (Consultant Paediatrician); Teresa Jones (Paediatric Diabetes Specialist Nurse) West lead: Dr Michael Cronin (Consultant Paediatrician) & Medi Michael (Paediatric Diabetes Specialist Nurse) Progress with agreed actions: East has setup a more robust process for foot examinations provided from within the diabetes clinic itself; the plan is now to roll this out across both Centre and West (pending completion of new appointments). Improvements to the frequency of annual Hba1c checks for each patient will be tackled by the ability of teams to now increase the frequency of clinic appointments for all children with diabetes. Currently the East has the capacity to see children and young people every 3 months for Hba1c. Of note the majority of the annual care processes are completed with percentages comparable or better than other regions in England and Wales. The provision of insulin pumps needs to be stepped up particularly in Centre and West where the appointment of new diabetes staff (together with training requirements) has resulted in a temporary suspension/decrease in new pump starts but this is expected to move forward again in the second half of BCUHB has recently approved funding for CGM and this will contribute significantly to improvements in care. Priorities for each of the 3 MDTs will be training and support related to the provision of insulin pumps and CGM. The East currently has dates arranged to commence 20 families on CGMS in adherence to NICE guidelines. Deprivation and demographic factors - are significant factors contributing towards the quality of care within BCUHB. The recent enhancement in sessions for diabetes nursing, dietetics and psychology will be a significant boost for each of the 3 MDTs and will hopefully improve support to those families and patient most in need. Of note there has been a year by year improvement in the measurable targets reflecting glycaemic control for all three services.

22 Structured education : Quality and completeness of data submission : Date form completed: Page 14 of 57 A structured education program (SEREN) is now implemented, providing tools to all newly diagnosed children with diabetes. The MDT teams in BCUHB also plan to utilise these tools with existing patients. Priorities for each of the 3 MDTs will be the development of the team working structures these will include the roll out and expansion of structured education and support for schools. A patient electronic database (TWINKLE) is currently being setup for the children s diabetes service in BCU. This together with the appointment of a dedicated admin support for each MDT will ensure improvement in the quality and completeness of data submission to the NPDA. East has reported they have successfully filled the admin support for their area. Form completed by (PRINT NAME): Alison Smith Clinical Audit and Effectiveness Facilitator Title of Clinical Audit: National Diabetes Insulin Pump Audit Host Organisation: Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme (NCA). Date of last National report: July 2017 Project Background and Aims: The Insulin Pump Audit is part of the National Diabetes Audit programme (NDA). The NDA is managed by the Health and Social Care Information Centre (HSCIC) in partnership with Diabetes UK and is supported by Public Health England (PHE). This is the first time that the NDA has included the opportunity to submit pump data. This first report provides preliminary national and local feedback about pump use and also assesses the ways in which changes to the data submission process could improve the analysis, feedback and information for the future. BCUHB-wide lead: Julie Lewis Diabetes Specialist Lead East lead: See BCUHB-wide lead Central lead: See BCUHB-wide lead West lead: See BCUHB-wide lead Recommendations of last National report: Given the evidence for effectiveness, more people with Type 1 diabetes should be considered for pump treatment. The reasons for the tenfold variation in pump use by people with Type 1 diabetes between specialist centres should be investigated. BCUHB actions agreed: To follow NICE criteria when offering insulin pumps to patients. Education offered to those who have been who are receiving pump therapy. Investigation any variation in pump use across the health board. Date form completed: Progress with agreed actions: Insulin pumps are currently offered to people with Type 1 diabetes who fulfill NICE criteria. We encourage completion of structured diabetes education prior to pump therapy initiative. We have undertaken a review of the adult pump services across BCUHB s three teams. Recommendations will be discussed at the Diabetes Planning and Delivery Group. This review was undertaken by the Wales National Pump Lead. Form completed by (PRINT NAME): Alison Smith (Clinical Audit and Effectiveness Facilitator). Julie Lewis (Diabetes Specialist Lead). Title of Clinical Audit: National Diabetes Audit Part 2a Complications and Mortality Host Organisation: Date of last National report: HQIP & HSCIC with Diabetes UK July 2017

23 Page 15 of 57 Project Background and Aims: The National Diabetes Audit (NDA) is the one of the largest annual clinical audits in the world, integrating data from both primary and secondary care sources, making it the most comprehensive audit of its kind. This report from the National Diabetes Audit (NDA) covers complications of diabetes. It does not include diabetic eye disease or hypoglycaemia because presently there are no reliable records of these that the NDA can access. Most other cardiovascular and diabetes specific complications are included. Aims: To monitor progress towards reducing the prevalence of long term diabetes diabetic complications and additional mortality. To highlight variation in outcomes between health economies and stimulate service improvements. BCUHB-wide lead: East lead: Central lead: West lead: Julie Lewis Jane Whitehurst Julie Lewis Debra Hughes (Diabetes Specialty Lead) & Christopher (Diabetes Specialist (Diabetes Specialty (Diabetes Specialist Lube (Head of Clinical Governance in Nurse) Lead) Nurse) Primary Care Support Unit) Recommendations of last National report: Providers of diabetes care should: Recognise the high cardiovascular risks of all types of diabetes Include assessment of cardiovascular risk and its preventive care within every annual care planning review e.g. - Primary prevention with diet, exercise, weight management, early sustained glucose control, target blood pressure, effective statins. - Secondary prevention with all of the above plus low-dose aspirin. Providers of diabetes care should ensure that cardiovascular risk reduction especially includes people of working age and younger (about 1 in 3 people with diabetes) - they have the greatest relative risks including premature death. Specific issues of note for BCUHB: Nationally in Wales, health boards are awaiting direct enhanced service for Type 2 diabetes which should address these recommendations. BCUHB actions agreed: To provide a multidisciplinary service. Review compliance with key performance indicators. Provide preventative services and education to patients. Provide ongoing education to Health Care Professionals. Date form completed: Progress with agreed actions: Locality diabetes multidisciplinary teams are providing accredited education for patients and community staff to improve skills and knowledge in diabetes care in six of the fourteen localities. The Diabetes Community Service includes up skilling GP Practice teams through education sessions, mentorship, specific clinics in GP surgeries, provision of patient education including Daphne Courses etc. On Anglesey, specific IT software in partnership with a pharmaceutical company is being used to audit success of service in relation to the key performance indicators listed in the National Audits. Other ongoing areas include the usual monitoring in GP Practices through the QOF part of the GP contract, annual blood tests in at risk patients in GP Practices to identify patients at risk of developing diabetes and new diagnoses of diabetes, annual calculation of cardiovascular risk, smoking cessation services, weight management/lifestyle advice etc provided by GP practices. Education of GPs and other Health care Professionals is ongoing particularly with reference to diagnosis of diabetes in children and early detection of diabetic ketoacidosis, again through primary care cluster work. Form completed by (PRINT NAME): Alison Smith (Clinical Audit and Effectiveness Facilitator). Julie Lewis (Diabetes Specialist Lead). Title of Clinical Audit: National Diabetes Audit Part 2b Complications and Mortality (associations between disease outcomes and preceding care)

24 Page 16 of 57 Host Organisation: Date of last National report: HQIP & HSCIC with Diabetes UK July 2017 Project Background and Aims: The National Diabetes Audit (NDA) is the one of the largest annual clinical audits in the world, integrating data from both primary and secondary care sources, making it the most comprehensive audit of its kind. This report from the National Diabetes Audit (NDA), for the first time, investigates the associations between disease outcomes and preceding care. Limited resources and time mean that these investigations are constrained to just a few areas. In this Report 2b, the disease outcomes Heart Failure, Kidney Failure and Death have been studied. Aims: To start to investigate long term associations between disease outcomes and the NICE specified diabetes care processes and treatment targets to see if there are implications for service provision. BCUHB-wide lead: Julie Lewis (Diabetes Specialty Lead) & Christopher Lube (Head of Clinical Governance PCSU) East lead: Jane Whitehurst (Diabetes Specialist Nurse) Central lead: Julie Lewis (Diabetes Specialty Lead) West lead: Debra Hughes (Diabetes Specialist Nurse) Recommendations of last National report: Providers of diabetes care and people with diabetes should be aware of the correlation between regular review and good long term health. Providers of diabetes care should monitor poor attendance and make extra efforts to re-engage nonattenders. The high cardiovascular risks of all types of diabetes should be: Fully recognised Regularly assessed and managed using all the effective prevention interventions such as diet, exercise, weight management, early sustained glucose control, blood pressure, statins. Providers of diabetes care should ensure that cardiovascular risk reduction especially includes people of working age and younger (about 1 in 3 people with diabetes) - they have the greatest relative risks including premature death. Specific issues of note for BCUHB: Nationally in Wales, health boards are awaiting direct enhanced service for Type 2 diabetes which should address these recommendations. BCUHB actions agreed: To provide a multidisciplinary service. Review compliance with key performance indicators. Provide preventative services and education to patients. Provide ongoing education to Health Care Professionals. Date form completed: Progress with agreed actions: Locality diabetes multidisciplinary teams are providing accredited education for patients and community staff to improve skills and knowledge in diabetes care in six of the fourteen localities. The Diabetes Community Service includes up skilling GP Practice teams through education sessions, mentorship, specific clinics in GP surgeries, provision of patient education including Daphne Courses etc. On Anglesey, specific IT software in partnership with a pharmaceutical company is being used to audit success of service in relation to the key performance indicators listed in the National Audits. Other ongoing areas include the usual monitoring in GP Practices through the QOF part of the GP contract, annual blood tests in at risk patients in GP Practices to identify patients at risk of developing diabetes and new diagnoses of diabetes, annual calculation of cardiovascular risk, smoking cessation services, weight management/lifestyle advice etc provided by GP practices. Education of GPs and other Health care Professionals is ongoing particularly with reference to diagnosis of diabetes in children and early detection of diabetic ketoacidosis, again through primary care cluster work. Form completed by (PRINT NAME): Alison Smith (Clinical Audit and Effectiveness Facilitator). Julie Lewis (Diabetes Specialist Lead).

25 Page 17 of 57 Title of Clinical Audit: National Diabetes Transition Report Host Organisation: Date of last National report: HQIP & HSCIC with Diabetes UK June 2017 Project Background and Aims: The National Diabetes Transition Audit (NDTA) is a joint enterprise between the National Diabetes Audit (NDA) and the National Paediatric Diabetes Audit (NPDA) measuring the care of young people with diabetes during the transition from paediatric diabetes services to adult diabetes services. The audit seeks to answer: 1. Is the transition from paediatric to adult care associated with changes in care process completion rates? 2. Is the transition from paediatric to adult care associated with a change in treatment target achievements (specifically HbA1c)? 3. Is the transition from paediatric to adult care associated with changes in the frequency of diabetic ketoacidosis (DKA)? BCUHB-wide lead: Julie Lewis (Diabetes Specialty Lead) East lead: To be confirmed Central lead: Julie Lewis (Diabetes Specialty Lead) West lead: To be confirmed Recommendations of last National report: Clinical Commissioning Groups and Local Health Boards:- Must understand that transition from paediatric to adult care is a vulnerable period. Clinical Commissioning Groups and Local Health Boards:- Should specifically contract Paediatric and Adult Multi-disciplinary team s services to deliver appropriate, joined-up services during this period, so essential key healthcare checks are not missed, and DKA admissions do not increase. Specialist Services:- Adult and Paediatric Services should have clear transition pathways designed to make the process user-friendly but focussed on sustaining stable HbA1c and minimising DKA. Specialist Services:- Paediatric Services should ensure that children and young people with Type 1 diabetes remain in their care until at least 16 years of age before transition. Specialist Services:- Adult Services should ensure that young people with diabetes have transitioned into their service by 19 years at the latest. Specific issues of note for BCUHB: BCUHB does not to their knowledge have any young person >19 years of age still under the paediatric diabetes services. In Wrexham the paediatric team transfer Children and Young People smoothly through well planned transition but we continue to improve our model year by year. The Wrexham unit is a positive outlier in providing all 7 care processes (recent NPDA report) and were congratulated by NPDA team (letter received, cc to CEO). BCUHB actions agreed: Adult and Paediatric Services to a have clear transition pathway. Maintain links within the paediatric team during the transition. Date form completed: Progress with agreed actions: BCUHB currently have transition pathways in place for young people with diabetes moving from paediatric to adult services, ensuring the service user s needs are addressed. One of the main aims in Wrexham is to maintain ongoing links with those children and young people transitioning during this vulnerable time especially in preventing DKA admissions. Form completed by (PRINT NAME): Alison Smith (Clinical Audit and Effectiveness Facilitator). Julie Lewis (Diabetes Specialist Lead). Title of Clinical Audit: Inflammatory Bowel Disease IBD Registry Host Organisation: Collaboration between: British Dietetic Association (Gastroenterology Group); British Society of Gastroenterology; British Society of Paediatric Gastroenterology, Hepatology and Nutrition; Crohn s and Colitis UK; Primary Care Society for Gastroenterology; RCN IBD Network; CICRA Crohn s in Childhood Research Association. Contractual and legal responsibilities of the IBD Registry rest within the British Society of Gastroenterology. Project Background and Aims: Date of last National report: Last Biologics report for the IBD audit was September 2016

26 Page 18 of 57 The IBD Registry is the vehicle for the biologics audit and quality improvement programme. Teams can participate using a choice of data entry systems including existing local systems. Being part of the Registry will give teams: Local data to manage their biologics patients and IBD service more effectively The chance to be part of a national audit of the safety and appropriate use of biologics and biosimilars The Registry has the potential to become a unique resource for real-world clinical effectiveness and health economic studies in IBD care. While data can be collected on all IBD treatments, the focus for 2016/17 is on biologics. The aims are to: Transfer data collection to the IBD Registry from the RCP biological therapy audit web tool, which has now closed. Develop a near-complete UK Register of IBD patients on biologics by the end of BCUHB-wide East lead: Central lead: West lead: lead: Dr Hamid Khan Dr Aram Baghomian (Consultant Dr Jaber Gasem (Consultant To be (Consultant Gastroenterologist) & Mr Ramesh Gastroenterologist) & Iola confirmed Gastroenterologist) Rajagopal (Consultant Surgeon) Thomas (Gastroenterology Julie Hold (CNS) Specialist Nurse) Recommendations of last National report: Last Biologics report for the IBD audit was September 2016.The Inflammatory Bowel Disease National Clinical Audit Project came to an end on 28 February Following numerous successful rounds of clinical audit which supported clinical teams to achieve significant improvement against NICE standards, NHS England and the Welsh Government took the decision to decommission the project. Work continues outside of NCAPOP via the IBD Registry. BCUHB actions agreed: Wrexham Maelor Hospital: 1. At Wrexham Maelor Hospital we have been trying to get the IBD Registry since We managed to arrange funding through grants from pharmaceuticals, MVS bid etc. An application for the 'Infloflex PMS version' of the IBD Registry was submitted but were unsuccessful to get it approved because of IT and procurement issues. 2. The Biological therapy audit was merged with the IBD Registry and the IBD biological webtool discontinued by the RCP from Feb WMH has been participating in the IBD Audits since they were initiated, and the team was keen to continue with the biological therapy audits. 4. Decision made to Register for the IBD Registry Webtool at the end of last year. This has limited functions compared to the Infloflex PMS version and does not communicate with PAS. But it will allow us to continue to participate in the IBD Audits. Initially it was offered free, but since April 2017 an annual fee of 1200 has to be paid to the British Society of Gastroenterology (BSG). 5. Registration process completed for the IBD Registry Webtool. Feb Historical data imported to the IBD Registry from the Biological therapy Audit webtool Feb All IBD Patients receiving Biologicals at Wrexham have been added to the Registry Webtool. 8. Registration with NHS Digital (formerly Health and Social Care Information Centre HSCIC) completed June First set of Data submitted to NHS Digital for Biological therapy audit Sept Central: YGC are currently not participating in the IBD Registry. Recent update from Dr Baghomian informs that the issue with the registry is an IT one that has been raised and also that there were wider issues regarding funding for the expansion of the IBD service and that the plan was to identify a HMT lead on this locally to take things forward. Progress with agreed actions: Wrexham Maelor Hospital: WMH has been participating in the IBD Audits since they were initiated. Decision made to Register for the IBD Registry Web-tool at the end of last year. WMH Historical data imported to the IBD Registry from the Biological therapy Audit webtool Feb YGC: Issues raised with IT. Local discussions with HMT ongoing.

27 West: YG are not currently participating the IBD registry; however, discussions are underway within the Gastroenterology team and with IT to move forward with a solution. Date form completed: Form completed by (PRINT NAME): Dr Hamid Khan (Consultant Gastroenterologist). Trevor Smith, Head of Clinical Audit & Effectiveness (Acting). Page 19 of 57 YG: Discussions underway within Gastroenterology team and with IT. Title of Clinical Audit: National Chronic Kidney Disease Host Organisation: A partnership between: University College London, Centre for Nephrology. The London School of Hygiene & Tropical Medicine. Clinical Effectiveness Group (CEG), based in the Centre for Primary Care and Public Health at the Blizard Institute, Queen Mary University of London. Date of last National report: January 2017 Project Background and Aims: Detection of chronic kidney disease (CKD) in primary care allows identification of people at higher risk of developing end stage kidney disease, acute kidney injury and cardiovascular disease. CKD is common and harmful but its consequences are treatable providing they are detected and managed early enough. Vascular risk in CKD is high and undertreated. Early detection and management in primary care is variable. When early stage CKD is identified promptly, it is easier to reduce mortality and improve the quality of life, as highlighted in the NHS Outcomes Framework, in the most cost-effective way. It is in primary care where there is the greatest opportunity to tackle CKD. End-stage renal disease (ESRD) is a preventable condition but when present carries vast personal, social and economic burden. Read more. The National CKD Audit aims to: Improve the identification of chronic kidney disease (CKD) in primary care Understand and map the variations in patient outcomes. Improve the consistency of the treatment of early stage CKD. BCUHB-wide lead: Primary Care GP Audit (Contact Chris Lube) East lead: Primary Care Support Unit (PCSU) Central lead: (PCSU) West lead: (PCSU) Recommendations of last National report: National CKD Audit National Report (Part 1) Published: The National CKD Audit produced the largest sample of patients with CKD in primary care globally. It has examined how well primary care diagnose and recognise CKD, looked at variation in treatment patterns and developed systems to support improvement in care. There are 3 main recommendations. Recommendation 1. For people at high risk of CKD, GPs should review practice to ensure that they are including both blood tests for egfr and urinary testing for albumin to creatinine ratio (ACR). Recommendation 2. GPs should review practice to improve the coding of patients with CKD. Recommendation 3. Having identified patients with CKD, effort should be focused on regular review, management of high blood pressure, prescribing cholesterol lowering treatment, and performing vaccinations to improve health outcomes. Specific issues of note for BCUHB: Part 1 report forwarded to Primary Care Support unit for circulation to GP Practices. BCUHB actions agreed: Circulation of Part 1 report recommendations to GP Practices. Date form completed: Progress with agreed actions: Part 1 report forwarded to GP Practices via PCSU. Form completed by (PRINT NAME): Trevor Smith (Head of Clinical Audit & Effectiveness, Acting)

28 Title of Clinical Audit: National COPD Audit Host Organisation: Royal College of Physicians Page 20 of 57 Date of last National report: February 2017 (The third of the reports produced from the 2014 audit, following the publication of organisational and clinical audit reports in 2014 and 2015 respectively). Project Background and Aims: The core aim of the programme is to drive improvements in the quality of care and services provided for COPD patients. Through collecting and linking patient journey data it will enable the comparison of performance and practice, highlight variations in patient care and outcomes, and seek to innovatively drive up standards of patient care. The audit programme comprises five key work-streams: Primary care audit collection of audit data from GP patient record systems. Secondary care continuous audit continuous audit of admissions to hospital with COPD exacerbation (began on 1 February 2017). Pulmonary rehabilitation snapshot audits snapshot audits of service delivery and quality (took place in the first half of 2017). Organisational snapshot audits - snapshot audits of the resources and organisation of COPD services in secondary care and pulmonary rehabilitation (they took place in the first half of 2017). Pilot data linkage a pilot piece of work looking at linking the data across the patient journey. The National COPD Audit Programme supports the Department of Health s aims to improve the quality of services for people with COPD, measuring and reporting the delivery of care as defined by guidance standards. The programme has quality improvement integrated into all its workstreams, and hosted an event in July 2016 on moving to continuous data collection and sharing quality improvement initiatives. It is also hosting a series of quality improvement workshops in BCUHB-wide lead: To be confirmed East lead: To be confirmed Central lead: Dr Sarah Davies (Consultant Physician) West lead: Dr Samantha Jones (Registrar) Dr Damian McKeon (Consultant Physician) Recommendations of the last National report: For commissioners: To reduce readmissions and frequent admissions, we suggest that integrated COPD pathways and services for COPD are made widely available, and that local provision of high value interventions is reviewed. There is a need to develop supported discharge and admission avoidance services for COPD, as well as better links into mechanisms of support for vulnerable, frail patients. Coordinated multidisciplinary working across health and social sectors is necessary. For providers: Secondary care: To reduce inpatient mortality, early respiratory specialist review and timely provision of non-invasive ventilation (NIV) is essential. Every effort should be made to initiate treatment escalation plans (TEPs) within 24 hours of admission. There should be better identification of patients at risk of imminent or later deterioration, and we suggest space is incorporated into admission documentation to include relevant COPD-related scores and test results. To reduce readmission, hospital teams should think carefully before discharge about the total needs of COPD patients, including risk of readmission, using not only respiratory tools but also established multimorbidity and frailty scores to aid their thinking. Admitting teams should also pay greater attention to the recent admission history of their readmitted patients, to understand what has caused the readmission and to discern how care could be optimised. Primary care: To reduce readmission, we recommend early review of every discharged case by a suitable primary care team member, to identify issues that may place the patient at increased risk of readmission and to ensure high value interventions have been addressed. We recommend that primary care teams devote resource to identifying, reviewing and enhancing the management of those COPD patients on their lists who are deemed at particular risk of hospital admission. Specific issues of note for BCUHB:

29 Page 21 of 57 Currently, East Area is unable to participate in this audit. This has arisen since the move to continuous data collection in February Discussions underway as highlighted below. BCUHB actions agreed: Progress with agreed actions: East: Discussions underway. Discussions underway with Dr Paul Birch and Dr Stephen Stanaway regarding resource availability to participate in the audit. West: Registrar collecting data under the supervision of Dr Damian McKeon Data collection underway. (Consultant Physician) Central: Dr Collection underway by Dr Sarah Davies (Consultant Physician) with Data collection underway. support from Respiratory Clinical Nurse Specialists). Dr Davies attended the recent improvement event hosted in October Attendance at Royal College COPD 2017 in Liverpool by the Royal College COPD National Audit project team. National Audit Improvement event. Date form completed: Form completed by (PRINT NAME): Trevor Smith (Head of Clinical Audit & Effectiveness, Acting) Title of Clinical Audit: National COPD Audit Primary Care work-stream Host Organisation: Date of last National report: Royal College of Physicians Welsh National report published in October Local published in November Project Background and Aims: Building upon the COPD National Audit project summary in the previous template above: The National COPD Primary Care Audit (Wales) 2015 to 17 is collecting information to measure the delivery and quality of care which COPD patients received at their GP surgery. This work-stream, part of the National COPD Audit Programme, involves the collection of audit data relating to COPD patient care and management from routinely collected data in computerised primary care records. The audit is currently only conducted in Wales. The first round of the audit ran in 2015 (data from the period was collected), with a Welsh national report published in October 2016, and local health board reports published in November The English national report was published in November BCUHB-wide lead: Primary Care GP Audit (Contact Chris Lube) East lead: Primary Care Support Unit (PCSU) Central lead: (PCSU) West lead: (PCSU) Recommendations of the last National report: Key recommendations: A diagnosis of COPD should be made accurately and early. If the diagnosis is incorrect, any subsequent treatment will be of no value. People who have breathlessness and/or cough that does not go away or frequent chest infections should have access to health professionals who have been trained to know what to do and have the resources to reach a diagnosis in a timely way. Spirometry is fundamental to a diagnosis of COPD and patients should be assured that their test has been performed and interpreted in the right way. Trained and competent health workers should offer people with a risk factor and symptoms suggestive of COPD a comprehensive and structured assessment. Clinical symptoms, risk factors and evidence of post-bronchodilator airways obstruction are all essential factors when making a diagnosis. People who are at risk of COPD are at a higher risk of lung cancer, and chest X-ray is an essential part of the breathlessness assessment and diagnosis of COPD. People with COPD should be offered interventions according to value-based medicine principles. Tobacco dependence treatment is safe, well-tolerated and effective at prolonging life: it reduces flare ups and has a wider impact on health. However, it is underused. Health professionals who treat people with COPD should be trained to have the right conversation; to know how to assess dependency; and to feel confident and have the resource to treat it. Flu vaccination is effective and safe but underused in people with COPD. System leaders should identify

30 Page 22 of 57 where variation exists and ensure that people with COPD have the best information to make the right decision for them. Anyone with a Medical Research Council (MRC) breathlessness score of 3 or more should be offered and encouraged to do pulmonary rehabilitation by their primary care health professional and have timely and easy access to an appropriate provider of this evidence-based therapy. Health professionals providing inhaler therapy for COPD should have up-to-date knowledge about what devices are available and ensure that people are able to use their devices; are offered optimal bronchodilator medication; and are issued with inhaled corticosteroids (ICS) only when it is likely to be beneficial. They should ensure that safety of long-term, high-dose inhaled steroids is discussed. People with severe disease (categorised according to the extent of airflow limitation) should be identified for optimal therapy. COPD encompasses a broad spectrum of conditions and health statuses and a personalised approach is essential. People having frequent exacerbations of COPD need to be identified, as they are at higher risk of an accelerated decline in their condition and may require specialist review both to manage symptoms and to slow decline. The recording of number of exacerbations in the last year allows this group to be better identified by practices and prioritised. Long-term oxygen therapy is a life prolonging intervention for people with COPD who have hypoxia. When primary care health professionals detect low oxygen saturation in the primary care setting, referral to a suitable assessment and review service should be offered. Primary care should record the use of oxygen on patient notes as they would any other long-term medication, to ensure timely review for assessment of safety and effectiveness. There should be better coding and recording of COPD consultations, prescribing and referrals. As patient access to personal health records improves and patients involvement in their own care becomes an expected norm, there will be opportunities to support people with COPD to know their numbers or, in other words, to understand why their spirometry test is consistent with COPD. They should be able to record quality of life assessments, their ability and confidence to use inhalers and their understanding of how to help themselves through access to and involvement with self-care documentation and action plans. Much of the variation seen in the data suggests variance in electronic coding. In order to link datasets across the system in the future, we ask the wider system (whether through development of the Systematised Nomenclature of Medicine coding system or other activity) to make standard recording templates available to ensure that the right things are recorded and that health professionals can spend more time with patients by avoiding the time spent on duplicate entries or manual entry. Health boards and clusters of GP surgeries should consider the use of a standardised set of codes and templates. Specific issues of note for BCUHB: Report forwarded to Primary Care Support unit for circulation to GP Practices. BCUHB actions agreed: Progress with agreed actions: Circulation of report recommendations to GP Practices. Report forwarded to PCSU. Date form completed: Form completed by (PRINT NAME): Trevor Smith (Head of Clinical Audit & Effectiveness, Acting) Title of Clinical Audit: National COPD Audit - Pulmonary Rehabilitation Work Stream Host Organisation: Royal College of Physicians Date of last National report: Royal College state reports due as follows: Autumn 2017: Organisational and clinical service level reports. Winter 2017/18: publication of national organisational and clinical audit reports. Project Background and Aims: The pulmonary rehabilitation audit work stream will involve time-limited data collection relating to service provision and delivery of pulmonary rehabilitation for COPD. Initially a comprehensive mapping of pulmonary rehabilitation services in England and Wales will be undertaken. All providers of COPD pulmonary rehabilitation will then be invited to participate in the audit, including secondary care, community care and commercial providers of NHS care. The pulmonary rehabilitation audit 2017 ran a snapshot audit of organisation and resources of pulmonary rehabilitation services, as well as a snapshot audit of clinical care. These took place concurrently in the first half of 2017 as follows:

31 January 2017 until mid-july 2017: data collection period. 1 February 2017: launch of interactive map. July 2017 until October 2017: data analysis. BCUHB-wide lead: Dr Daniel Menzies, Consultant Physician East lead: Michelle Owen, Clinical Specialist Physiotherapist / Pulmonary Rehab Coordinator Central lead: Ann Ellis, Respiratory Occupational Therapist Page 23 of 57 West lead: Marian Arman, Respiratory Occupational Therapist Recommendations of Clinical Data Audit report: Key areas for improvement include: 1. Improving access to PR a. Providers and commissioners should ensure that robust referral pathways for PR are in place and that PR programmes have sufficient capacity to assess and enrol all patients within 3 months of receipt of referral. b. Referral pathways should be developed to ensure all patients hospitalised for acute exacerbations of COPD are offered referral for PR and that those who take up this offer are enrolled within 1 month of discharge. c. Providers and commissioners should work together to make referrers (including those working in general practice and community services) and patients fully aware of the benefits of PR, to encourage referral. d. PR programmes should take steps to ensure their services are sufficiently flexible to encourage patients who are referred for PR to complete treatment. 2. Improving the care provided by PR programmes a. All PR programmes should examine and compare their local data with accepted thresholds for clinically important changes in the clinical outcomes of PR and with the national picture. For all programmes, this should prompt the development of a local plan aimed at improving the quality of the service provided. b. PR programmes locally should review their processes to ensure all patients attending a discharge assessment for PR are provided with a written, individualised plan for ongoing exercise. c. PR programmes locally should review their processes to ensure all outcome assessments are performed to acceptable technical standards. Specific issues of note for BCUHB: a. Funding; the service is currently running as a cost pressure to Therapy Services. b. Lack of capacity to assess and enroll patients within 3 months or receipt of referral (see table 1.) The programme received 878 referrals during the period April 2014-March 2015 and 926 referrals from April March Current capacity is 682 patient/year which reflects a significant capacity shortfall. There are currently 461 patients waiting > 12 weeks. c. Lack of capacity to ensure all patients hospitalised for acute exacerbations of COPD are offered referral for PR and that those who take up this offer are enrolled within 4 weeks of discharge NICE Quality Standards (QS10) Updated Feb Table 1. Summary of audit findings: National Audit UK (median and range) BCUHB Days from referral to assessment 56 days (30-107) 363 days % of programme patients enrolled within 3 months of receipt of referral 63% 6% d. BCU pulmonary rehab service delivers a high quality programme reflected in outcome measure performance (see table 2). All patients attending a discharge assessment for PR are provided with a written, individualised plan for ongoing exercise. Appropriate patients are referred to local NERS. Outcome assessments are performed to acceptable technical standards. Table 2. Summary of audit findings: National Audit UK (median and range BCUHB % Assessed, enrolled and completed 60% 71% Improvement of minus 2 or more points (MCID) in CAT score (QOL measure) 61% 69%

32 Page 24 of 57 Improvement in 6MWD (Exs Tolerance) 50m 60m >/= 30m increase in 6MWD 70% 76% Progress with agreed actions: Update from Michelle Owen ( ): No further funding stream has been agreed in West, East or Centre of 12 programmes continue to run across BCUHB, 3 programmes in West, 2 programmes in Centre and 6 programmes in East. Due to changes in Therapies Management structure the programme in Llandudno is now managed by the team in Centre in addition to programmes at the Royal Alexandra Hospital and a community venue in Colwyn Bay. However, the programme in Colwyn Bay is on hold due to funding/staffing issues. Teams are working hard to improve efficiency and maximise throughput. The numbers of patients waiting and waiting times continue to improve (see table below). However, there is still some way to go in order to meet the British Thoracic Quality Standard: Statement 1 - Patients should be enrolled on a PR programme within 3 months (90 days) of receipt of referral. This is particularly the case in Centre where there are 241 patients waiting maximum of 68 weeks. Teams continue to allocate 1 place per 7 week programme for patients recently discharged from hospital (within 1 month) and liaise with Early Supported Discharge teams to identify suitable patients. Further work is needed to ensure all patients who accept a referral for PR following hospital admission can be seen within 1 month (BTS Quality Standard: Statement 3) Number of patients waiting Jan 2016 Longest wait Jan 2016 Number of patients waiting Sept 2017 Longest wait Sept 2017 West weeks weeks Centre weeks weeks East week weeks 2. Capacity is maximized at each site in West and East BCU. Staff in Centre are exploring alternative accommodation to increase capacity but this will be insufficient to meet demand. A common IT system is in place to support waiting list management. 3. No solution for permanent funding has been agreed. 4. Additional resources identified in BCU have not been supported. In Centre this means the backlog waiting list will remain and negatively impact their ability to deliver Early Rehab Post Discharge. Date form completed: Form completed by (PRINT NAME): Michelle Owen (Pulmonary Rehabilitation Coordinator) Title of Clinical Audit: National Audit of Renal Registry Host Organisation: The Renal Association/UK Renal Registry Date of last National report: 2016: 19 th Annual Report. Project Background and Aims: The UK Renal Registry (UKRR) is part of the Renal Association, a not for profit organisation registered with the Charity Commission. The UKRR are recognised as having one of the very few high quality clinical databases open to requests from researchers. The Registry provides a focus for the collection and analysis of standardised data relating to the incidence, clinical management and outcome of renal disease. It thus acts as a source of comparative data, for audit/benchmarking, planning, clinical governance and research. The UK Renal Registry monitors indicators of the quality as well as quantity of care, with the aim of improving the standard of care. There is currently a concentration on data concerning renal replacement therapy, including transplantation. At a later date there will be an extension to other forms of treatment of renal disease BCUHB-wide lead: East lead: Central lead: West lead:

33 Page 25 of 57 Stuart Robertson, Consultant Judith Welham, Renal Dr Mick Kumwenda, Jocelyn Jenkins, Renal Physician & Nephrologist Physician Consultant Nephrologist Unit Administrator Recommendations of last National report The full report is over 400 pages in length and therefore the recommendations not listed. There is full discussion and identification of local relevance of report contents at Renal Network meeting. Specific issues of note for BCUHB: BCUHB continue to fully participate from all 3 sites. The Renal Network group, review the Renal Registry report (and it is publically available in a non-anonymised format) but we need to bear in mind that the data is over 12 months old by the time it is published so is of limited use unless a major clinical risk or failing is identified (which it was not). Dr Stuart Robertson does note that we need to be looking at the same data internally in real time. This way, we will know that there are no surprises to come. This is done for mortality at a national level on a quarterly basis via the Welsh Renal Clinical Network so that we can be aware if we look to be developing a higher than expected mortality. There are risks of this in North Wales as we are 3 of the smallest units to report so small variations can give the impression of changes that look more significant than they are. All 3 units review all dialysis deaths on a regular basis and we have a system of reviewing each other s deaths if it is felt by the unit that anything went less than well. Ideally, he would like to move towards a single report for BCU renal services but we are not quite in a position to do that. In terms of real-time audit, this depends on developments to the national renal data system (Vital Data) which are being worked on by the national lead Dr James Chess. We hope to be in a position to do such real-time and regular audit by next year. BCUHB actions agreed: The 2016, 19 th Annual Report will be reviewed by the Renal Network that meet regularly on a BCUHB-wide basis. There is an active peer review network and agreement of an annual clinical audit programme. The Renal Network discuss the recommendations of the report and agree a BCUHB-wide action plan. Date form completed: Progress with agreed actions: See update above from Dr Stuart Robertson. For discussion at Renal Network meeting. Form completed by (PRINT NAME): Trevor Smith (Head of Clinical Audit & Effectiveness, Acting) Title of Clinical Audit: National Audit of Rheumatoid and Early Arthritis Host Organisation: Date of last National report: British Rheumatology Society (BRS) July 2016 Project Background and Aims: The audit was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and ran from 2014 to 2016.It examined the assessment and early secondary care management of all forms of peripheral joint early inflammatory arthritis in NHS secondary care settings in England and Wales. Detailed follow up and outcome data was collected on patients up to three months from recruitment. HQIP plan to commission a new audit in This will build upon earlier data collected to quantify the impact of the first audit in more detail and provide an overview of standards of care at a time of substantial organisation changes within the NH. Data collection scheduled for April BCUHB-wide lead: tbc East lead: Dr Zoe McLaren (Consultant Rheumatologist) Recommendations of last National report: East: Scores for the 4 areas below have fallen since last report : Patients seen within 3 weeks Patients offered educational support Treatment target achieved Patient has access to urgent advice BCUHB actions agreed: East Area: One Stop Clinic with diagnostic MSK ultrasound. Central lead: Dr Bijaya Roychowdhury (Consultant Rheumatologist) West lead: Dr Jeremy Jones (Consultant Rheumatologist) Progress with agreed actions: There is no movement on the early arthritis service at all. The managers

34 Central Area: We changed managers to be under Area Management Team in April 2016, and: The proposed business case for 3 rd Consultant was only considered by the Area Management Team in September 2017 and a draft business case has yet to be finalised, currently with Interim General Manager for Community Services (Central). Medical Staff seeing New patient referrals, there are still only 2 Consultants at Glan Clwyd. The 12 month ESP physio secondment was not approved until November 2016 and the Physio who had been interested had changed their mind due to the delay. Date form completed: Page 26 of 57 are behind this in principle but there is no space to accommodate the USS equipment or the clinic and there is no immediate plan to do so. We are also lacking the USS machine after having to decline the successful bid we made to MVS (who have indicated they would still fund it). Form completed by (PRINT NAME): Jean Burgess, Clinical Audit & Effectiveness Facilitator, with input from: Dr Zoe McLaren, Consultant Rheumatologist, Dr Bijaya Roychowdhury, Consultant Rheumatologist Title of Clinical Audit: All Wales Audiology Audit Host Organisation: Audiology Standing Specialist Advisory Group (ASSAG) Date of last report: August 2016 (Paediatrics) & Summer 2017 (Adult Rehabilitation) Project Background and Aims: This All Wales Audiology Audit follows a peer review audit mechanism for monitoring progress of the implementation of the Quality Standards for Audiology Services (Adult & Paediatrics). Audits are completed annually by self-assessment of services against standards. External audit visits are conducted routinely every other year for adult rehabilitation and annually for paediatric services, to verify the self assessment scores. BCUHB-wide lead: Paediatrics: Dafydd Hughes Griffiths (Head of Paediatric Audiology), Georgina Parry (Paediatric Audiology Operational Lead) Adult Rehabilitation: Susannah Goggins, Head of BCU Audiology Adult Rehabilitation and Balance Service East lead: Anna Powell Head of Adult Rehabilitation & Balance (East) Central lead: Suzanne Tyson Head of Adult Rehabilitation & Balance (Central) West lead: Heidi Jones Head of Adult Rehabilitation (West) Recommendations of last National report: Local Health Board specific report produced for Paediatrics (August2016), response to this report detailed below. In addition, a National report for the 2016/17 Adult Audiology Rehabilitation Services was circulated June 2017, including local Health Board response. Specific issues of note for BCUHB: Paediatrics: The 2015/16 external audit was again performed by Health Board not site. The audit was performed against revised Quality Standards now renamed as Quality Standards for Children s Hearing Services. The target for the 2016 audit was 75% in each individual standard and an overall target of 75%. The overall score for BCUHB was 87.67%. The service met the 75% target in all of the nine individual standards and met the overall target of 75%. The next planned self-assessment and external audit is due in Adult Rehabilitation: The 2016/17 audit against Quality Standards for Adult Hearing Rehabilitation Services (version 2) was carried

35 Page 27 of 57 out by an external audit team during April The target for the 2017 audit was 75% for each individual Standard and for the overall target of 75%. The Betsi Cadwaladr Adult Audiology Service met the 75% target in all of the nine individual standards, and met the overall target of 75%. The combined audit score representing adult Audiology services across BCUHB was 97.6%. Two individual criteria were identified for action. BCUHB actions agreed: Progress with agreed actions: Actions for Paediatrics from 2015/16 external audit: Comprehensive action plan received covering elements Progress against action plan from the 2015/16 audit is ongoing. listed below: Improvements have been made in the following areas: Standard 1 Accessing the Service Standard 2: Standard 2 Assessment Changes to the way Stage A checks are recorded has resulted in improvement to the consistency of stage A check recording. Standard 3 Developing an Audiology Individual Changes in location of two of the community clinics and Management Plan (IMP) removal of noise source in another clinic have provided some Standard 4 Implementing an Audiology Individual improvement in the acoustical conditions of the clinic rooms Management Plan used for hearing assessment. Standard 5 Outcomes Standard 5: Standard 7 Information Provision and Communication Improvements to staff qualifications improved with Band 7 with Children, Young People and Families audiologist having completed M module training. Standard 8 Multi-Agency Working Process in now in place for completion of peer review Standard 9 Service Effectiveness and Improvement competency checks for all required appointment types. Actions for Adult Rehabilitation from 2015/16 audit: Action plan covering individual criteria identified by external audit as low scoring: Standard 2: Information provision & Communication with individual patients Criteria 2a.13 Up-to-date technology (e.g. video clips, website) used following appointments to support self management of technological interventions and communication needs. Standard 5: Implementing an Individual Management Plan Criteria 5d.3 - Patients offered reassessment every 3 years. Date form completed: Progress against action plan for the 2016/17 report is underway. Completed actions include: - Standard 2, criteria 2a.13 Audiology IT team set up and storyboard in progress to create new website, including aspects to support selfmanagement following appointments. Standard 5, criteria 5d.13 Plan to work towards increased capacity to consider 3 year review of patients. Form completed by (PRINT NAME): Updated by Sarah Bent (Lead for Clinical Improvement, Adult Audiology) Updated by Georgina Parry (Paediatiric Audiology Operational Lead)

36 Page 28 of 57

37 Older People: Page 29 of 57 Title of Clinical Audit: National Audit of Sentinel Stroke National Audit Programme (SSNAP) Host Organisation: Royal College of Physicians Date of last National report: Continuous data collection. Results sent out quarterly. Project Background and Aims: SSNAP measures the entire patient care pathway, from admission to hospital through to six months poststroke; hospitals are compared against evidence based standards and the national average. There were 63, 005 records included in SSNAP (from January October 2013) and 100% of teams in hospitals who directly admit stroke patients in England are registered to take part in the audit. Huge improvements have been made in the quality of stroke care and services over the past years as measured by previous national stroke audits and it is anticipated that similar improvements will be demonstrated through future SSNAP quarterly reports. BCUHB-wide lead: Dr Krishnamurthy Ganeshram (Consultant Physician) Judith Rees, Area Operational Manager East lead: Dr Walee Sayed (Consultant Physician) & Lynne Hughes (Stoke Coordinator) Central lead: Dr Krishnamurthy Ganeshram (Consultant Physician) & Karen Roberts (Stroke Co-Coordinator) West lead: Dr Salah Elghenzai (Consultant Physician) & Rhian Owen (Stroke Coordinator) Recommendations of last National report: There are a number of specifically focused forums which include monthly site-based and weekly multidisciplinary meetings. These meetings are occurring on all sites and review the key performance indicators. Specific issues of note for BCUHB: In addition to the reference to meeting structures above, an issue of note for BCUHB relates to further improvement activity surrounding Peer Review. There was also a Peer Review performed by the Royal College of Physicians at the invitation of BCUHB which took place on all three Acute sites in January There was a Peer Review report received from the Royal College. An action plan in response to the report is currently being agreed. BCUHB actions agreed: Monthly site based meetings to be in place to discuss key performance indicators. Weekly multidisciplinary meetings to be in place. Invite Royal College of Physicians Peer Review visits on all three Acute sites. Agree a BCUHB action plan in response to the recommendations of the Royal College of Physicians Peer Review visits Date form completed: Progress with agreed actions: Monthly meetings in place. Weekly meetings in place. Royal College of Physicians Peer Review visits occurred in January Please see Action Plan at Appendix 1 Form completed by (PRINT NAME): Trevor Smith, Head of Clinical Audit & Effectiveness (Acting). Title of Clinical Audit: National Hip Fracture Database (Falls & Fragility Fractures Programme) Host Organisation: Date of last National report: Royal College of Physicians September 2017 Project Background and Aims: The Falls and Fragility Fracture Audit Programme (FFFAP) is designed to audit the care that patients with fragility fractures and inpatient falls receive in hospital and to facilitate quality improvement initiatives. The care that patients receive is measured through a number of elements that run in parallel within the programme. Hip fracture is an ideal marker condition with which to examine and challenge the quality and outcome of the care offered to frail and older patients by the modern NHS. Hip fracture is a clearly defined diagnosis, generally made very soon after a patient presents to accident and emergency (A&E) or the hospital trauma team. This makes it suitable for direct comparisons between hospitals that provide care.

38 Page 30 of 57 Hip fracture is common, with 65,000 such injuries each year leading to the occupation of over 4,000 inpatient beds at any one time across England, Wales and Northern Ireland. Hip fracture management takes a frail patient through a complex clinical pathway involving a wide range of specialists, clinical teams, departments and agencies. Hip fracture patients face a significant risk of dying or of losing their independence, and prognosis is dependent on how well hospital and community services work together. The National Hip Fracture Database (NHFD) is managed by the Clinical Effectiveness and Evaluation Unit (CEEU) of the Royal College of Physicians (RCP) and grew out of the 2007 collaboration between the British Orthopaedic Association and the British Geriatrics Society. Its development has been described in annual reports which, with additional reports on anaesthetic care, casemix-adjusted outcome and length of hospital stay, can be found on the NHFD website: BCUHBwide lead: To be confirmed East lead: Mr Ian Starks (Consultant Surgeon) Specific issues of note for BCUHB: Ysbyty Glan Clwyd: Response from YGC trauma unit: Central lead: Dr Swapna Alexander (Consultant Geriatrician). Mr Paramasivam Sathyamoorthy (Consultant Surgeon) West lead: Dr Alan Bates (Consultant Geriatrician) 1. Leadership Six weekly clinical governance meetings are central to any hip fracture programme. The existing team discuss issues in the monthly governance meeting which is attended by the members of the team. The NHFD figures are presented and action plans are made. YGC has a dedicated clinical lead for the NHFD in post. There is also a senior nurse who collects and inputs the data. Need: To establish a clinical MDT team led by surgeon/geriatrician/anaesthetist. 2. Inpatient falls Rate of IP fractures: This has shown a definite decreasing trend with the rates falling from 6.8 to 5.64 in December. Measures implemented to decrease falls are as below Initiatives in YGC Implementation of the Inpatient Falls Prevention Strategy board within BCUHB to develop a robust policy and structure regarding the prevention and management of adult inpatient falls. The policy The Prevention and Management of Adult in-patient Falls was activated on 19/12/2016 and sets out to o Ensure the Health Board delivers its aims, objectives, responsibilities and legal requirements to ensure that the risk of harm to adult patients caused by falls is minimised. o This policy describes what must be done for the assessment and management of patients at risk of falling or who have fallen in hospital. Within the policy, a pathway was developed and supporting assessment documents will be utilised in the assessment of those at risk of falling and also for those who have sustained a fall as an in-patient. An E-Learning package was added as a mandatory training module for all ward staff who have the possibility of working with those at risk of falling. A time frame for compliance to this training was set out per ward with the aim that all staff were to have completed the training by December 2017 (a one year period from the launch). An appropriate evaluation was completed six months after the launch of the policy and pathway of which the results are still being analysed. The evaluation included: o Audit of all Falls documentation on all BCUHB sites (compliance and competence) o Audit of staff views on the Falls Prevention Pathway o Audit of staff views on the Falls Prevention E-Learning package Instigation of Falls Prevention Quality and safety meetings per acute hospital site with a Multi- Disciplinary team approach. 3. Prompt surgery Figures from 2016 show that the time to theatre was consistently above the national average.

39 Page 31 of 57 Prompt surgery is being achieved in about 60-68% of patients. The figures were low from May to September (40-55%) but slowly rose at the end of the year. 4. Time to theatre Time to theatre has been a multifactorial issue. As per the NICE guidelines and the Welsh Frailty Fracture Network (WFFN), we are committed to reducing the time to theatre to less than 36 hours in all cases where the patient is medically fit. Efforts have been made via inter- and intra-departmental discussion as well as measures to improve pre-operative optimisation, thereby improving efficiency of preparation and ensuring patients are ready for theatre. Progress has been made with the introduction of a new pathway document, via its various draft stages. A snapshot audit of time from admission to theatre carried out over two weeks in March 2017 showed that out of 14 patients, 10 were operated on within 36 hours of admission, seven of which were operated on within 24 hours of admission. Of the remaining four patients, two needed significant medical management which could not be expedited in less than 48 hours, and the remaining two needed surgery for injuries sustained after falls in hospital, but not immediately recognised. These latter two had their fixation surgery within 24 hours of diagnosis. Indeed if time of diagnosis to surgery is counted, the overall figures would be better. It is accepted that this snapshot may not be representative of the whole year, and work is in progress to develop a real-time run chart of this data. Other measures have included prioritisation (where possible) of patients with hip fracture or similar fragility fracture on the trauma list, after children and life / limb threatening trauma and before less urgent subspecialty work. Additionally work has been done to develop efficiency and throughput in the trauma theatre, reducing the likelihood of hip fracture surgery being carried over to the next working day. Nonetheless it is recognised that there is still much to improve and other recommendations brought via the WFFN are in progress to reduce unnecessary delay to theatre. 5. Fracture management Nerve block: YGC performs nerve block routinely in the ED. This is an area in which YGC performs very well, with almost 90% of patients receiving a nerve block (fascia iliaca compartment block or femoral nerve block) as primary mode of analgesia in the pre-operative setting in a local audit This audit has not yet been repeated but anecdotal evidence would suggest that the block rate is still high in the pre-operative setting as most patients brought to theatre are found to have a puncture site and dressing in place from the block, with documentation in the notes to corroborate this. Future work will involve developing the use of ultrasound-guided block by interested practitioners. There is no outcome evidence for general anaesthesia versus spinal anaesthesia, despite large scale data collection such as the Anaesthetic Sprint Audit of Practice (ASAP). The NICE recommendation that where appropriate, patients are offered spinal anaesthesia is not based on outcome data. It is for individual anaesthetists to choose with the patient which is the most appropriate mode of anaesthetic, based on clinical needs and the patient s preference as far as possible. Variance from other regions may reflect the patient population as well as previous experience and training of the local body of anaesthetists. In some centres, general anaesthesia is chosen for expediency, as time in the anaesthetic room is often less with a general anaesthetic than with a spinal, especially when time for positioning for spinal is considered. Where there is lack of robust data to suggest outcome improvement with spinal anaesthesia, some anaesthetists may have a tendency towards choosing general anaesthesia in order to achieve a better throughput, thereby reducing the likelihood of a cancellation resulting from lack of theatre time. With regards to the low numbers of perioperative blocks recorded, again these are multifactorial. Part of this will lie in data capture and work is being done to ensure that all blocks are documented in a way that the data is captured and coded. A current issue relates to the high number of blocks performed in ED, which when combined with a number of patients being operated on within 12 hours of receiving the block, is not repeated in theatre for fear of local anaesthetic toxicity. Other issues relate to a significant number of patients receiving Local Anaesthetic Infiltration techniques by the surgeon, thereby precluding a block by the anaesthetist. However, local infiltration techniques in hip fracture are not evidence-based, so we are moving away from this as an option and we encourage the use of perioperative nerve blocks for both general and spinal anaesthetic when the previous block is not within 12 hours. Hip fracture surgeries Proportion of arthroplasties which are cemented:

40 Page 32 of 57 Our results are below the national average. We are addressing this with internal discussions and measures have been put in place to avoid cement related complications. Eligible displaced intra-capsular fractures treated with THR: Our results are above national average. The number of total hip replacements for intracapsular fractures is increasing in the unit. We have audited our performance recently and this was presented in the orthopedic clinical governance meeting on the The audit conclusion was that the barriers to performing THRs in the eligible patients were the nonavailability of a hip specialist when required and the cost implications. We have discussed dedicated neck of femur lists supervised by hip surgeons but recognise the difficulty in achieving this due to the constraints in space and personnel. Inter trochanteric fractures treated with SHS: Our results are below national average. This is possibly due to coding of these fractures. An intramedullary nail is inserted for intertrochanteric fractures that have extension below lesser trochanter [as guided by NICE]. These fractures are coded as intertrochanteric fractures although they are eligible for intramedullary nail. This coding issue is to be addressed. Sub-trochanteric fractures treated with an IM nail: Our figures are above national average 6. Rehabilitation Comprehensive geriatric assessment has been carried out in less than 10% of cases in a few months of the year. The end of the year shows that the number of patients being assessed by an orthogeriatrician is between 5-10%. The unit appointed two Physician Liaison Consultants in 2017 to improve the medical care of the patients. 7. Time to ward: Varied from 9-17 hours which is well above the national average. This reflects the pressure on ED beds and patient flow. The four-hour performance of the Emergency Department is about 80% in terms of achieving a four-hour discharge or transfer to ward areas. There have been a significant number of in-patient bed reductions in recent years in the unit, including on the trauma ward, with an expectation that community services and enhanced home care would compensate for this. At the same time the acuity and complexity of our in-patients has risen. This has resulted in intermittent challenges to flow. The ED staff are trained to take care of hip fracture patients and the site management team move the patients as soon as possible to either the trauma ward or the surgical assessment unit. Intentional rounding, harm reduction strategies and widespread adoption of nerve blocks in the ED contribute to the patients experience being reasonable. Although we acknowledge that an in-patient environment is infinitely preferable. 8. Physiotherapy assessment after surgery: The department recognises the need for early mobilisation after surgery. There is a sticker system introduced in the notes wherein the physiotherapist writes on the sticker/in the notes whenever they see a patient in order to provide contemporaneous evidence of care. 9. Pressure ulcers: These has been increasing significantly and there are measures being put in place to decrease the incidence Staffing on the ward has improved which has led to better patient care and should decrease the incidence of pressure ulcers. The data captured records patients who are admitted with pressure ulcers and does not reflect the number of pressure ulcers developing on the ward. The local information system is more uptodate and reflects much better figures. 10. Follow up: YGC has a dedicated senior nurse who follows up patients after discharge. 11. Bone health medication: 60% of patients are assessed which has decreased from last year. This is partly due to data entry. The FLS service is working on improving this figure further. 12. Length of stay:

41 Page 33 of 57 Length of stay has been decreasing. The LOS in the acute ward is less than 15 days and the total length of stay is less than 30 days and remains consistent in spite of the pressures of the decrease in number of beds, availability of community beds and beds in care homes. 13. Mortality: 30 day mortality is up to 10%. The reasons are being addressed. For the period this report covers there was no dedicated orthogeriatrician to support the care of these patients. In 2017 two consultants were appointed to deliver a total of four sessions per week to the ward over four days. The department regularly reviews their mortality cases at the six-weekly governance meeting. 14. Improving patient care: The health board has also introduced a new proforma that contains all the elements of good care and is regularly auditing the proforma to improve practice. There is one nurse for each bay of six patients in the YGC trauma unit There is open visiting to enable patient s relatives to come in and assist patients to eat/stay with the patient and to discuss any issues they may have with the medical/nursing staff. This also helps patients to participate in therapy to a greater extent. Daily board rounds with the MDT have improved communication and MDT patient care Presence of a junior doctor on the ward ensures that there is a presence on the ward to manage any medical problems and aid discharge. There is a dementia support worker who works with the therapists in delivering care Re-operation rates: Within accepted limits Overall assessment: Red: Time to ward Pressure ulcers Mortality Bone health Amber: Hours to theatre Green: Length of stay IP fractures BCUHB actions agreed: Central Action plan for 2017: Leadership: Formation of a #NOF working group involving all members of the MDT including anaesthetist and ED staff. IP falls: Shows a decreasing trend. Measures in place to prevent IP falls Time to theatre: Needs to improve. Measures in place - new pathway document to improve patient flow, prioritisation of lists. Fracture management: Nerve blocks 90% of patients are receiving nerve blocks. GA/SA- depends on individual performance and priority is to decrease time to surgery. Perioperative nerve blocks- low numbers probably because of high number of nerve blocks in ED and surgeons are using local infiltration in surgery. Need to optimise nerve blocks by changing practice Surgery; Proportion of arthroplasties which are cemented below national average. Internal discussions put in place to avoid cement related complications. Eligible displaced intra-capsular fractures treated with THR: good results but figures could improve with dedicated hip fracture surgeons being available and improved investment. Intertrochanteric fractures treated with SHS: below national figures. Problems with coding to be addressed Subtrochanteric fractures treated with IM nail: above national average Rehabilitation: good service from the local geriatric department to assess patients for discharge to local rehabilitation services. Good MDT and board rounds facilitate better patient management. Comprehensive geriatric assessment: The trust has appointed one geriatrician (2 sessions) and 1 consultant

42 Page 34 of 57 (2 sessions) to improve patient assessment and care). Time to ward: Problems with beds due to decreased number of trauma beds. ED staff trained to look after patients in ED though this is not a preferable situation. Physiotherapy assessment day after surgery: new documentation should provide correct capture. Pressure ulcers: above national average- measures put in place to decrease them. Bone health medication: lower than national average better data capture and new FLS nurse appointed. Length of stay: average figures need to work on decreasing figures by improving patient flow. Mortality: higher than national average already discussed in mortality meetings, appointment of physician liaison service to assist the department for 4 sessions a week. Date form completed: Form completed by: Dr Swapna Alexander (Consultant Geriatrician). Title of Clinical Audit: National Audit of Inpatient Falls (Falls & Fragility Fractures Programme) Host Organisation: Royal College of Physicians Date of last National report: Round 1 October Round 2 report is expected November Project Background and Aims: The Falls and Fragility Fracture Audit Programme (FFFAP) is designed to audit the care that patients with fragility fractures and inpatient falls receive in hospital and to facilitate quality improvement initiatives. It has four overarching aims to: Improve outcomes and efficiency of care after hip fracture. Improve services in acute and primary care to respond to first fracture and prevent second fracture. Improve early intervention to restore independence. Work in partnership to prevent frailty, preserve bone health and prevent accidents in older people. The care that patients receive is measured through a number of elements that run in parallel within the programme. The audit is comprised of three work-streams: National Hip Fracture Database (NHFD). Fracture Liaison Service Database (FLS-DB) Assessment and treatment for osteoporosis. Inpatient Falls Audit. Round 1 of the National Audit of Inpatient Falls took place in The first report showed data on nearly 5,000 patients aged 65 years or older across 170 hospitals, and reviewed how well hospital trusts and local health boards prevent inpatient falls in England and Wales, which are set against the NICE guideline (CG161) on falls assessment and prevention. Round 2 took place in May The audit report is expected to be published in November BCUHB-wide lead: To be confirmed East lead: Dr Sara Gerrie (Consultant Geriatrician) Central lead: Dr Gerallt Owen (Consultant Physician: Care of the Elderly) West lead: Dr Alan Bates (Consultant Physician) Recommendations of last National report: Key recommendations : Recommendations for trusts and local Health Boards: Falls steering group We recommend that all trusts and health boards have a board-level falls steering group that has representation from and reports to the organisation s board. This group should regularly review their data on falls and moderate harm, severe harm and deaths per 1,000 occupied bed days (OBDs) and assess the success of their practice against trends in these figures. Falls multidisciplinary working group We recommend that all trusts and health boards have a falls multidisciplinary working group that meets regularly, and that they review the activities of this group to ensure it is fit for purpose and functioning appropriately. This group should monitor interventions to improve prevention of falls in hospital and use proven methods to embed these changes. Do not use a fall risk prediction tool We recommend that trusts and health boards review their falls pathway to see whether they are still using a fall risk prediction tool. If they are, they should stop using it with immediate effect, regard the following groups of inpatients as being at risk of falling in hospital, and manage their care accordingly as per NICE CG161:

43 Page 35 of 57 All patients aged 65 years or older Patients aged years who are judged by a clinician to be at higher risk of falling because of an underlying condition.* Audit bed rail use We recommend that trusts and health boards regularly audit the use of bed rails against their policy and embed changes to ensure appropriate use. Review multifactorial falls risk assessments (MFRAs) We recommend that all trusts and health boards review their MFRA and associated interventions to include all the domains in this audit. This will then need to be linked to quality improvement projects to ensure that what is included in the policy actually translates into what happens on the ward. Key indicator recommendations: Dementia and delirium We recommend that all trusts and health boards review their dementia and delirium policies to embed the use of standardised tools and documented relevant care plans. Falls teams should work closely with dementia and delirium teams (if present) to ensure team working for these high-risk patients. Blood pressure We recommend that all patients aged over 65 years have a lying and standing blood pressure performed as soon as practicable, and that actions are taken if there is a substantial drop in blood pressure on standing. Medication review We recommend that all patients aged over 65 years have a medication review, looking particularly for medications that are likely to increase risks of falling. Visual impairment We recommend that all patients aged over 65 years are assessed for visual impairment and, if present, that their care plan takes this into account. Walking aids We recommend that trusts and health boards develop a workable policy to ensure that all patients who need walking aids have access to the most appropriate walking aid from the time of admission. Regular audits should be undertaken to assess whether the policy is working and whether mobility aids are within the patient s reach, if they are needed. Continence care plan We recommend that all patients aged over 65 years have a continence care plan developed if there are continence issues, and that the care plan takes into account and mitigates against the risks of falling. Call bells We recommend that all trusts and health boards regularly audit whether the call bell is within reach of the patient and embed change in practice if needed. *Please note that only patients aged 65 or over were included in this audit. However, NICE CG161 also applies to people aged 50 to 64 who are admitted to hospital and are judged by a clinician to be at higher risk of falling because of an underlying condition, and all patients aged 65 and over. BCUHB actions agreed: Progress with agreed actions: Agree appropriate BCUHB Committee that would oversee Agreement achieved that the engagement with the engagement with the In-patient Falls action plan. this National audit and associated action planning of recommendations would sit within Ensure full participation with the Round 2 data collection BCUHB-wide. Date form completed: the Inpatient Falls Prevention Strategic Board. Full participation with Round 2 achieved with good engagement in Community Hospitals alongside all three Acute sites. Full report is awaited in November Form completed by: Trevor Smith (Head of Clinical Audit & Effectiveness, Acting). Title of Clinical Audit: Fracture Liaison Service Database (FLS-DB) Falls & Fragility Fractures Programme Host Organisation: Royal College of Physicians Date of last National report: Facilities Audit : May 2016 Second report due to be published in October Project Background and Aims: The Fracture Liaison Service Database (FLS-DB) is a new clinically led web-based national audit of secondary fracture prevention in England and Wales commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the Falls and Fragility Fracture Audit Programme (FFFAP). The FLS-DB patient audit is now live and collecting information on fragility fracture diagnosed from 1 January 2016.

44 The first FLS-DB audit report on patient data was published in Spring The second FLS-DB report is due to be published in October Page 36 of 57 BCUHB-wide lead: Awaiting confirmation East lead: No Fracture liaison service at present Central lead: Dr Swapna Alexander (Consultant Physician) Llandudno Hospital West lead: Dr Swapna Alexander (Consultant Physician) Llandudno Hospital Recommendations of last National report: FLSs that participated in the report should: Be congratulated for their wish to evaluate and improve the patient service that they offer. Review their own service s performance within this report and develop effective quality improvement plans to improve quality and efficiency of patient care or of service. Ensure that patients presenting with a hip fracture are included in the FLS-DB, as they are at very high risk of another fracture and current audits have limited measures for the quality of bone assessment 9. Develop closer working between primary, community and secondary care services to help facilitate effective management plans and to support patients to understand the importance of ongoing steps to minimise fracture risk, including adherence to anti-osteoporosis medication. Review their performance using their own live run charts, which are available on the FLS-DB webtool. Participate in the FLS-DB audit continuously to measure key quality aspects of their service. Provide constructive feedback to the FLS-DB audit team by at flsdb@rcplondon.ac.uk, so that we can improve the audit over the years to come. Ensure that, as a minimum, they collect the audit dataset within their local pathway and then work to improve FLS-DB data submission by the next data cut-off of June FLSs that did not participate in the report and services without an FLS should: Review opportunities regarding data entry options, and discuss approaches with other, well-performing fracture liaison services. Contact FLSs that did participate and NOS for advice on how to develop and improve the services offered by an fracture liaison services. Chief executives and hospital trust boards should: Support their FLS s work for quality improvement to develop and improve the FLS s services and engagement with the audit Recognise that secondary fracture prevention provides a great opportunity to improve integration across clinical service areas to provide a genuinely patient-centred approach. Commissioners and local health boards should: Review the audit s findings. Those clinical commissioning groups (CCGs) without an FLS should actively support a project plan so that they can implement a service in 2017/18 Contact other CCGs with effective fracture liaison services and the NOS for support in developing strategies to establish new FLSs Consider aligning the key performance indicators for their fracture liaison service(s) with those of the audit run charts to reduce duplication and improve transparency. Specific issues of note for BCUHB: Feedback from Dr Swapna Alexander has highlighted an administrative support resource shortage that is preventing participation with the Fracture Liaison Service Database currently. Dr Alexander has stated that the fields that have to be inputted are ongoing and would need dedicated staff to fill up the patient s journey as the investigations, recommendations and follow up proceed. It would not be possible with the clinical and administrative staff as currently in place at the moment. Dr Alexander is to create a business case for an admin staff preferably based at LLGH to pull out the information (including DXA scans etc) to ensure that any robust data could be generated. BCUHB actions agreed: Business case required in relation to need for administrative support to facilitate participation with the Fracture Liaison Service Database. Date form completed: Progress with agreed actions: Business case required. Form completed by: Trevor Smith (Head of Clinical audit & Effectiveness, Acting)

45 Page 37 of 57 Title of Clinical Audit: National Audit of Dementia 3 rd Round Host Organisation: Date of last National report: Royal College of Psychiatrists 13 th July 2017 Project Background and Aims: The National Audit of Dementia (care in general hospitals) measures the performance of general hospitals against criteria relating to care delivery which are known to impact upon people with dementia in hospitals. The third round of the audit collected data between April & November hospitals in England and Wales took part and were asked to complete 4 elements; A hospital level organisational checklist A retrospective casenote audit with a target of a minimum of 50 sets of patients notes A survey of carer experience of quality of care A staff questionnaire on providing care and support to people with dementia The staff and carer questionnaires were newly created for round 3 and the casenote and organisational checklist were altered from their Round 2 format. 98% (199/203) of hospitals eligible to participate across England and Wales submitted data for all or part of the audit. In total, the audit received 199 organisational checklists, casenote submissions, staff questionnaires and 4664 carer questionnaires. BCUHB-wide lead: Sean Page (Consultant Nurse: Dementia) East lead: Professor Anthony White (Consultant Physician in Medicine for Elderly) Central lead: Dr Indrajit Chatterjee (Consultant Physician: Care of the Elderly) West lead: Dr Sion Jones (Consultant Physician: Care of the Elderly) Delyth Thomas (Acute Dementia CNS) Recommendations of last National report: Delirium: Medical and Nursing Directors should: Ensure that hospitals have robust mechanisms in place for assessing delirium in people with dementia including: At admission, a full clinical delirium assessment, whenever indicators of delirium are identified. Cognitive tests administered on admission and again before discharge Delirium screening and assessment fully documented in the patients notes (regardless of the outcome) Care offered in concordance with the delirium evidence-base recommendations when the assessment indicates symptoms of delirium Results recorded on the electronic discharge summary Ensure staff receive training in delirium and its relationship to dementia, manifestations of pain, and behavioural and psychological symptoms of dementia Personal information use: National commissioners (Welsh Government, NHS England) should propose a nationally backed monitoring programme aimed at embedding the collection, sharing and use of person centred information. This should include a clear expectation that once gathered, this information will follow the patient between providers and this will be monitored. Ward Managers: should audit implementation/use of personal information collected to improve care for patients (e.g. This is me or other locally developed document). The result of the audit should be fed back to the dementia champions/dementia lead and ward staff. Nutrition: Clinical Commissioning Groups and Health Board Commissioning Services should ensure that tenders let by Trusts for new catering contracts always specify provision of finger foods for main meals and access to a range of snacks 24 hours a day. Medical and Nursing Directors should promote the attendance of key carers to support care, but ensure that this is complementary to, and not instead of, care delivered by staff. The level of input by carers, and how carers and how carers feel about the level of input they have been asked to deliver should be monitored through carer feedback, complaints and PALS enquires. Carer satisfaction should be seen as a marker of good care. Ward managers should be supported to ensure carers supporting patients should

46 Page 38 of 57 not be asked to leave at mealtimes/stopped from helping with meals (this excludes emergency and urgent care and treatment) Dementia Champions The Chief Executive Officer should ensure that there is a dementia champion available to support staff 24 hours per day, 7 days per week. This could be achieved through ensuring that people in roles such as Site Nurse Practitioners and Bed Managers have expertise in dementia care. Decision making The Safeguarding Lead should ensure that staff are trained in the Mental Capacity Act, including consent, appropriate use of best interests decision making, the use of Last Power of Attorney and Advance Decision Making. Training should cover supportive communication with family members/carers on these topics Specific issues of note for BCUHB: See BCUHB Actions & Progress agreed below. BCUHB actions agreed: Progress with agreed BCUHB-wide: Welsh Government Part B assurance pro-forma was discussed at the last Dementia Clinical Audit Group (October 2017) and is currently being finalised. The actions within this BCUHB plan will inform our response to the All-Wales action planning process. Sean Page is linking in with the All-Wales group regarding this. Wrexham Maelor Management of Delirium: BCUHB already have delirium assessment and management guidelines in place. Further improvement is needed to improve compliance which could be done after sufficient data collection and participation in the spotlight delirium audit. Hospital to take forward actions based on spotlight audit. Personal information use: Ongoing work with regard to personal data collection such as This is me and What matters discussion and documentation. What is not clear is whether such a unified assessment document or trusted assessor report which follows the patient between providers. Clarity regarding this is required and audit of such documentation would be useful. Nutrition: A measurable progress has been made with regards to assessment of nutrition. Good record keeping using MUST score and weight monitoring. Continue ongoing work with carer support and dementia support worker. The Health Board has a willingness to support ongoing work to improve nutritional standards. To engage in carer satisfaction audit annually. Dementia Champions: The hospital has been proactive in promoting dementia champions and this is fairly well established. However supportive educational programme for promoting this role should be continued. Mental Capacity and Decision Making: The Health Board already has a safe Guarding Lead and Medical Director for Law & Ethics. There is a good support mechanism in place to promote good clinical practice; however we recognise ongoing need for further staff training. Further assurance regarding this from Medical Director for Law & Ethics Governance: There is ongoing work with regard to SAFER working implementation across the hospital. Data regarding falls, readmissions and delayed transfer of care of dementia patients is to be discussed with dementia lead/working group with a view to make further improvements. Clinical Audit Dementia Group to inform hospital management team and area team about audit findings and outcomes actions: The WG Part B assurance pro-form will outline actions in full. In addition: See comments above. Participate in the NAD Spotlight audit which will focus upon Delirium in a further case-note sample. Prof White has replied to Royal College to state that additional review of the sample case-notes regarding nutrition has been undertaken. Promotion of dementia Champions continues. Mental Capacity and consent training issues currently under discussion at the Consent, Capacity and Strategic Working Group.

47 Ysbyty Gwynedd: Delirium Assessment: Currently there is no formal Delirium Pathway within the medical documentation, however we will introduce the recognized 4AT assessment in order for a formal delirium assessment to be undertaken. Our intention following further discussion with the Clinical Medical Director is to incorporate the assessment to be undertaken it has been identified that the medical staff will require additional education regarding the formal assessment process. Delirium 10 Nursing assessment in-situ, not highlighted in audit. In order to learn from areas of good practice we will be visiting Wrexham Maelor in order to identify how their Delirium Pathways have been implemented and develop consistency for patients within BCUHB. A spotlight audit will be undertaken which will hopefully support an appropriate Delirium Pathway being integrated within the documentation. Discharge Summary: The evidence suggests that Delirium assessments are not being recorded on the discharge summaries, therefore our colleagues within primary care have no/very little information in relation to Delirium. Work will be undertaken to establish how we can encourage / implement this function within our MTED system in order to capture the relevant information and share with primary care. Delirium Training: Delirium awareness sessions already in-situ since 2014 and its relationship to dementia. Currently there is only one trainer. Action: train the trainer and delirium champions. Dementia Champions: Ysbyty Gwynedd have no dementia champions other than 4 dementia support workers during the day. Evidence suggests from the audit that support for staff out of office hours is poor. Out of hours support will be achieved through ensuring that people in roles such as site nurse practitioners and bed managers have expertise in dementia care. Personal Information: Person centred information gathered will be followed with the patient between providers. Ward Managers: should audit implementation/use of personal information collected to improve care for patients (e.g. This is me or other locally developed document such as the About Me). The results of the audit should be fed back to the dementia champions/dementia lead and ward staff. Promote awareness of delirium 10 in 24 hour observation chart: Ysbyty Gwynedd has introduced in 2017 a new 24hr chart but it is not being fully implemented, awaiting staff feedback, may resort to a modified more usable version in order to improve compliance. Nutrition: Increase awareness of staff re availability of snacks and finger food menu:- Orange finger food menu is already in-situ and was being piloted on 2 wards during the NAD2016. Re publicise the importance of finger food/snack menu via BCUHB social media. Matron meeting, ward manager meeting and patient safety meeting. Commit to annual stall to raise awareness. Mental Capacity and Decision Making: The Safeguarding Lead to ensure that staff are trained in the Mental Capacity Act including consent, appropriate use of best interests decision making, the use of Lasting Power of Attorney and Advance Decision Making. Training will also cover supportive communication with family Page 39 of 57 Work ongoing through SAFER. Work ongoing through Dementia Clinical Audit Group. See comments above. Awareness sessions have been in place since 2014.

48 members/carers on these topics Ysbyty Glan Clwyd Management of Delirium: Ysbyty Glan Clwyd above average for assessment & discharge planning. BCUHB guidelines on delirium are in place. However delirium assessment by AMT score on admission, discharge and the documentation on discharge notifications needs to be promoted more through education of junior & senior doctors in all major departments. We are also participating in the National Delirium Spotlight audit Personal information use: This is me document completion for Glan Clwyd site was at par with national audit figures however there is scope for improvement. Further emphasis also needs to be given on how to use the personal information for benefit of the patient in the ward. Plans are in progress to pilot Dementia rounds this is to ensure completion of This is me or equivalent documentation and also patient needs are addressed and met. Nutrition: There is a need to improve the variety of finger food / snacks for dementia patients 24 hrs a day however, this is applicable for all 3 acute sites across BCUHB. Staff awareness needs to be improved regarding access to 24hr snack / finger food that is already available. Dementia Champions: The Dementia Support Workers and Named Nurses in Care of the Elderly wards in Glan Clwyd work as Dementia Champions however, ongoing work is in progress to review the job description and update the list of named Dementia Champions. Governance: Data regarding falls, readmissions and delayed transfer of care of dementia patients are now discussed at the Clinical Quality & Safety Governance meetings; important governance related matters are also discussed in the COTE departmental business & governance meetings also attended by multidisciplinary professionals & nursing representatives from community hospitals across the central area. Clinical Audit Dementia Group to inform hospital management team and area management team about audit findings and outcome measures. Date form completed: 25/10/2017 Page 40 of 57 See comments above. Form completed by (PRINT NAME): Sue Yorwerth (Clinical Audit & Effectiveness Facilitator) Trevor Smith (Head of Clinical Audit & Effectiveness, Acting) Heart:

49 Title of Clinical Audit: National Audit of Heart Failure Host Organisation: National Institute for Cardiovascular Outcomes Research (NICOR) Page 41 of 57 Date of last National report: 10 th August 2017 Project Background and Aims: The National Heart Failure Audit provides national comparative data about individuals with a coded primary diagnosis of heart failure in secondary care. Capturing this data helps clinicians and managers measure care bundles of clinical indicators with a proven link to improve outcomes for these individuals. The audit is managed by NICOR with specialist knowledge provided by the British Society for Heart Failure. While the audit dataset aims to capture all primary coded heart failure admissions, the annual NICOR report focuses specifically on management and treatment of those with left ventricular systolic dysfunction (HFrEF); the evidence-base for treatment is strongest in this subset, who therefore, are the focus of the specialist nursing teams attention. Heart failure affects around 900,000 people in the UK, and this number is rising, due to an ageing population, more effective treatments, and improved survival rates after a heart attack. Heart failure is a large burden on the NHS, accounting for 1 million bed days per year, 2% of the NHS total, and 5% of all emergency admissions to hospital. The BCUHB North Wales Sp HF Service launched in BCUHB-wide lead: Dr Graham Thomas (GP Special Interest: Cardiology) East lead: Dr Jenny Welstand (Lead Sp HF Nurse: East) Central lead: Andy Bennett (Lead Sp HF Nurse: Central) West lead: Nia Coster (Lead Sp HF Nurse: West) Recommendations of last National report: Report which covers the period 2015 to 2016 again demonstrates better outcomes for patients under management of HF specialist teams, therefore those on cardiology wards fair better as seen by cardiologists. Improved prescribing, particularly triple therapy substantially improves both morbidity and mortality outcomes. Specific issues of note for BCUHB: It was noted that in all areas of BCUHB higher percentages of patients are prescribed the three key disease modifying medicines and received care from Heart Failure specialists than those recorded nationally. Specific issues of note for BCUHB EAST In East Division the number of admissions now reflects the PDWR coded numbers as in the data reflected the secondary admissions data audit project that we undertook. The east echo data is inaccurate as we have accepted that we tick yes to this standard, even when not undertaken, provided we have had a previous echo at some point showing LVSD. If we accurately complete this we will have minimal data: - Q: Has the patient had an echo within a 12-month period of his admission? Under this section it is then recorded what the echo shows: normal, LVSD, LVH, valve disease, diastolic dysfunction, increased LA, other, unknown, no echo. All those recorded with LVSD are then used to complete the information on the medication for the audit, e.g. how many on ACE, BB, MRA etc. A need has been identified for a discussion with audit, operational management, cardiology and the HF team. With respect to place of care, and s/b specialist only half of patients are in a cardiology bed, and only 59.7% see a cardiologist which is poorer than the national average. The HF team do manage to get round the medical/cote wards as best as possible ; we don t have a dedicated HF inpt nurse like the other two sites, we see a total of 89.2% according to this report. The nurses (as I expect happens at the other two sites) see an equal number of patients with HF as a secondary reason for their admission; these patients often require even higher amount of input and their bundles of care are challenging because of other pathology/comorbidity etc. These patients are often frequent readmission cases. In respect to prescribing, there has been an overall increase in the prescribing or consideration of ACE/ARB, B Blockers and particularly MRA. Our medical teams are poor at discharge planning in a manner effective for the GP; we see a decline in numbers of EPOC d/c planning which I suspect will further deteriorate next report. The numbers with LVSD receiving HF nurse follow up increases but again Cardiology follow up is poor at less than 30%. This reflects the lack of cardiologist with interest in HF and HF clinic f/u seen in many other hospitals in Wales and UK. Coding continues to be problematic in that patients are frequently mis-coded which thereby affects access to HF specialist care and accurate recording of Heart Failure as the primary cause of admission. The NWIS data for east seems to include those with box changes/a&e admissions who are not supposed to be included in the

50 Page 42 of 57 figures. Many with LVSD as primary reason for admission are not coded. Actions and progress Mis-coded patients notes are corrected and returned to the coding manager. The coding manager is due to meet with the team to discuss use of a diagnosis sticky label he HF can use to flag to coding those with primary admission LVSD as many are missed despite being identified prospectively. The problem with incorrect data about A&E admissions/box changes is currently being investigated, it is not clear how many cases this is, and if this is a minor or bigger issue. Very brief data is kept on secondary admission cases to ascertain numbers; it is not possible to review bundles of care. The HF team have highlighted to one of the consultant cardiologists about the need for supported specialist input and if this might be included as a consideration in job planning reviews for 2017/18. A discussion about the echocardiogram problem would be welcomed. Dr Jenny Welstand Heart Failure service update for NICOR report - WEST April 2015-March 2016 Specific issues of note for BCUHB WEST Comparing data from April 2014-March2015 with April 2015-March 2016 there has been a steady increase in the cases entered onto the data base and a positive improvement in HF care received with an overall increase in the prescribing of Ace/ARB, B Blockers and MRA as well as the numbers receiving discharge planning, HF nurse follow up and Cardiology follow up. This clearly indicates the improvement in our data collection and HF management following the appointment of a HF specialist nurse within the secondary care setting and the appointment of admin support to input data and assist with all aspects of data collection. There is some concern regarding the accuracy of some of the NICOR data and how % are calculated, namely the % of patients referred to Cardiac Rehab appears to be a little high. We have contacted NICOR to enquire how data is calculated but it is all computer generated and difficult to break down. Coding continues to be problematic in that patients are frequently miss coded which may potentially affect access to HF specialist care and accurate recording of Heart Failure as the primary cause of admission. Actions and progress Details of miss coded patients have been recorded for Ysbyty Gwynedd admissions during the period April with the purpose of trying to update and correct coding errors but the whole process is very time consuming and has therefore been impossible to maintain. Further discussions and education with coding needs to be implemented to improve accurate coding of patients. Specific issues of note for BCUHB - Central Area Background: The national HF audit is completed on annual basis. In 2014/2015 due to the lack of specialist HF clinicians the national HF audit was not fully completed with only 83 records being submitted. In April 2015 significant investment was made by BCUHB into local HF specialist services including an increase in specialist nurses and administrative support. Part of this investment was directed to improving compliance with the national audit. Key local findings from the 2015/2016 report (central area) The 2015/2016 audit has had 245 records submitted - a significant improvement. Local provision of inpatient echocardiogram remains high and above national average. Although a greater number of patients admitted with heart failure received cardiology inpatient care; this figure remains low with 47% of patients admitted with heart failure being cared for on a nonspecialist ward. The national report makes reference that a reduction in mortality is seen for those patients cared for on a specialist ward. A significant improvement has been seen in specialist inpatient input (this includes nursing and medical input) with nearly 80% of patients being seen by a specialist (primarily a nurse). This improvement can be attributed to the increase in specialist nurses being available to see patients. Improvements can be seen in discharge planning for patients. The number of patients referred to a HF nurse specialists has risen by nearly 50% in the last 2 yrs. This is due to a greater emphasis being made by the HF nursing team on seeing patients admitted with heart failure on non-specialist wards. A greater number of patients are being followed up by the heart failure nursing team after being discharged from hospital. There have been some minor local reduction seen in the prescribing rates of some key HF medications, although the prescribing rates remain above the national average. Local HF team action plan:

51 Page 43 of 57 The local HF team plan to analyse the data around the prescribing of recommended. treatments for inpatients to develop an understanding of the issues and formulate a plan of action. Continued focus on outreach liaison work with the aim of improving heart failure inpatient care for those patients on non specialist wards. Date form completed: Form completed by (PRINT NAME): Dr Jenny Welstand, Heart Failure Specialist Nurse. Catrin Hanks, Cardiac Network Manager. Project update (include date of update): : The expanded fully trained staff are in post working in an integrated fashion across community and the acute sector addressing the key clinical interventions which will see improvements to the HF service and will be reflected in the next NICOR report. Title of Clinical Audit: National Audit of Cardiac Rhythm Management Host Organisation: Date of last National report: Royal College of CCAD/NICOR/UCL February 2017 Project Background and Aims: The National Audit of Cardiac Rhythm Management (CRM) collects procedure information on all patients with implanted devices or receiving interventional procedures for management of cardiac rhythm disorders. It was established as the National Pacemaker Database (NPDB) in the late 1970s by a forward thinking cardiologist, Dr Anthony Rickards. The database now contains close to 1,000,000 records, and is one of the largest and longest running in modern cardiology. The project was currently commissioned until March 2016 NICOR/UCL have been given a 1 year extension (March 2017) and have put in a 5 year bid to commission the new contract(2022) Aims and objectives to improve the care of patients who undergo pacemaker, ICD, CRT and cardiac ablation procedures in the UK to look at activity, trends and outcomes in pacing, ICD, CRT and cardiac ablation practice in UK hospitals to provide assessment of treatments, evaluate associated risk factors and measure long term survival rates of patients who undergo pacemaker, ICD, CRT and cardiac ablation procedures in the UK to continue to collect and develop the presentation of data from pacemaker, ICD, CRT and electrophysiology centre s in the United Kingdom to explore the usage of new software technologies to undertake rapid linkage and analysis of data to provide new analyses and outputs of the data as defined by the clinical group to receive process and present performance management of audit data BCUHB-wide lead: Dr Richard Cowell (Consultant Cardiologist) East lead: Dr Rajesh Thaman (Consultant Cardiologist) Central lead: Dr Chris Bellamy (Consultant Cardiologist) West lead: Dr Mark Payne (Consultant Cardiologist) Recommendations of last National report: See issues highlighted by leads and actions in response below. Specific issues of note for BCUHB: Ysbyty Gwynedd: Now that the Cardiology Day Unit has been returned to Cardiology we are able to admit our pacemaker and complex device patients in a timely fashion. As of June 2017 there has been a revision of services relating to unscheduled care and this has presented challenges which have impacted upon the Cardiology Day Unit. In relation to pre-assessment and post implant follow-up, BCUHB faces challenges in their delivery of care for Complex device patients across N Wales as compared to LHCH (Liverpool Heart and Chest Hospital) patients. A business case for one additional arrhythmia specialist nurse and on cardiac physiologist on each site is in preparation. Wrexham also have capacity issues for CRT implants that will be addressed in the same business case. The first scheduled meeting regarding this since May will take place on 14/07/17. Ysbyty Glan Clwyd: At Glan Clwyd we only implant Bradycardia Devices, not bivent pacemakers or ICD s. Those are done at Wrexham Maelor Hospital, Ysbyty Gwynedd or Liverpool Heart & Chest Hospital. According to the report we meet BHRS minimum implant guidance. Wrexham Maelor: Incomplete data on physiological pacing in this report we have since improved data capture. We currently have two half day Brady pacing sessions a week. Urgent cases are accommodated during but not always in a

52 Page 44 of 57 timely manner and can lead to prolonged inpatient stay. A solution to this would be to have a system for out of hours pacing. This would require funding for the lab and lab staff, operator, physiologist and nurse. However, this cost would be met by the saving made on reduced hospital stay. We have met with management who are looking into the costing. We currently have one half day session for CRT and ICD implants a week. We take all elective and emergency referrals from YGC as they do not implant CRT or ICD s. We have submitted a business case to support an additional half day session at YWM to avoid delays in implant and also to avoid sending patients to LHCH for implants at an additional cost of 8000 pounds on the tariff. As well as additional lab time and lab staff the business case addresses the need for an additional Band 7 cardiac physiologist and additional arrhythmia nurse specialist to provide pre counselling and post implant counselling and support. BCUHB actions agreed: Progress with agreed actions: BCUHB: BCU Ensure GMC Numbers are assigned to implant procedures and ensure latest software is being used. Ysbyty Gwynedd: A business case for one additional arrhythmia specialist nurse and on cardiac physiologist on each site is in preparation. Wrexham also have capacity issues for CRT implants and have requested second list (see Wrexham entry) this will form part of the overall business case but it is hoped that this aspect can be fast tracked and has been presented to the Management Team in Wrexham. Wrexham Maelor: Business case being written to support the North Wales Complex Device Service which will address implantation capacity issues, physiologist staffing issues and nursing support for pre and post implantation care. Following first meeting more details have been requested regarding the need for 3 arrhythmia nurses and psychology sessions - see below. Currently, Wrexham have not been able to submit any data due to there being problems with the format it is being extracted in. There has been liaison with NICOR to solve this problem however once we are up and running on the new CCW reporting system the issue should be resolved. Date form completed: Business Case in preparation. Regarding second list proposal in Wrexham - presented to Management Team (see Wrexham BCUHB actions agreed summary). See above. Form completed by (PRINT NAME): Angela Taylor (Clinical Audit & Effectiveness Facilitator). Trevor Smith (Head of Clinical Audit & Effectiveness - Acting). Liaising with NICOR. Title of Clinical Audit: National Audit of Percutaneous Coronary Interventional Procedures Host Organisation: Date of last National report: Royal College of NICOR/UCL 14 th September 2017 Project Background and Aims: The National Audit of Percutaneous Coronary Intervention (PCI) provides comparative data on the provision of PCI in the UK. The aim of the audit is to describe the quality and patterns of care, the process of care and outcomes for patients. Expansion in the use of Percutaneous Coronary Intervention (PCI) - the minimally invasive surgery performed on heart patients instead of using drugs - is seeing more patients with acute coronary syndromes treated more quickly, according to the latest National Audit of PCI. PCI mechanically improves blood flow to the heart using stents and can be used to relieve the symptoms of angina, prevent and treat heart attacks. When used to treat heart attack patients, the procedure is called primary PCI. BCUHB-wide lead: Dr Paul Das (Consultant Interventional Cardiologist) East lead: N/A Central lead: Dr Paul Das (Consultant Interventional Cardiologist) West lead: N/A

53 Page 45 of 57 Recommendations of last National report for 2014: National: PCI centres, Strategic Clinical networks and Commissioners should work to improve treatment times for patients receiving urgent and emergency care, especially when an inter-hospital transfer is required. Adults who are unconscious after cardiac arrest caused by suspected acute ST segment elevation myocardial I infarction (STEMI) are not excluded from having coronary angiography (with follow on primary percutaneous coronary intervention [PCI] if indicated). Coronary angiography and PCI is performed within 72 hours for patients with NSTEMI or unstable angina Specific issues of note for BCUHB: Rate of PCI per pmp appears as the lowest in the country however this is an error. 803 PCIs were performed in 2015 for a total population of 694,000 the pmp correctly calculated is 1,156 pmp. If correctly presented in the chart on page 11 NWCC would appear on a similar level with eight other hospitals. This has been reported to NICOR audit enquiries. BCUHB actions agreed: Progress with agreed actions: Work to improve treatment times for PPCI Call to balloon and Door to Balloon times are monitored and patients receiving urgent and emergency reported regularly to the PPCI board meeting. Extra training has care, especially when an inter-hospital been provided to members of staff where necessary transfer is required. Clinical Lead: Dr Paul Das Coronary angiography and PCI is performed within 72 hours for patients with NSTEMI or unstable angina Date form completed: Referral to treatment times for?proceed referrals are now monitored on a monthly basis. Form completed by (PRINT NAME): Angela Taylor (Clinical Audit & Effectiveness Facilitator). Title of Clinical Audit: National Audit of Myocardial Ischaemia National Audit Project (MINAP) Host Organisation: Date of last two National reports: National Institute for Cardiovascular Outcomes Research 31 st Jan 2017 (2014/15) (NICOR) / University College of London (UCL) 27 th June 2017 (2015/16) Project Background and Aims: The Myocardial Ischaemia National Audit Project (MINAP) is a national clinical audit of the management of heart attack. It supplies participating hospitals and ambulance services in England, Wales and Northern Ireland with a record of their management and compares this with nationally and internationally agreed standards. MINAP provides comparative data to help clinicians and managers to monitor and improve the quality and outcomes of their local services. Its findings have been made public since 2003 via annual public reports when all eligible hospitals signed up to participate in the clinical audit. The Myocardial Ischaemia National Audit Project (MINAP) began in late 1998 when a broadly based Steering Group developed a dataset for acute coronary syndromes. The Steering Group represents key stakeholders including professional bodies, national government and patient representation in conjunction with the British Cardiovascular Society. It is the long term aim of the project to continue to provide, for all interested groups, including patients, commissioning bodies, cardiac networks of care, and academic researchers, first class data on the care for acute coronary syndromes within England and Wales. BCUHB-wide East lead: lead: Dr Richard Cowell (Consultant To be confirmed Cardiologist) Central lead: Dr Chris Bellamy (Consultant Cardiologist) West lead: Dr Mark Payne (Consultant Cardiologist) Lucy Trent (Clinical Nurse Specialist) Recommendations of last National report: 1. Continue working closely with those that deliver care to ensure provision of the most accurate data. 2. Raise public awareness of the risk factors known to increase the chance of heart attack including: obesity, type 2 diabetes, hypertension, tobacco smoking & hyperlipidaemia. 3. Support initiatives to: mitigate known risk factors, publicise the signs and symptoms of heart attack and encourage prompt responses at onset of symptoms. 4. Work with service providers and centres more clearly to understand how they can provide better care. This might include facilitating meetings between neighbouring hospitals and Ambulance Trusts to share best

54 practice and to consider reconfiguration of services. Page 46 of 57 Specific issues of note for BCUHB: West (Bangor): There are clearly some reporting issues that are generating aberrant percentages for secondary prevention drugs and length of stay. The Chest pain team will investigate these technical issues with the MINAP team to ensure future accuracy. East (Wrexham): Call to needle times do not meet target of 70% treated within 60 minutes (62.2%). This is likely due to the gradual introduction of 24/7. PPCI This should be addressed with the phasing out of thrombolysis therapy as PPCI takes over as treatment of choice Central (YGC): Call to needle times do not meet target of 70% treated within 60 minutes (66.7%). This is likely due to the gradual introduction of 24/7. PPCI This should be addressed with the phasing out of thrombolysis therapy as PPCI 24/7 is established. Primary PCI 24/7 service began on 03/04/2017. MINAP administration post has been recently filled. BCUHB actions agreed: Progress with agreed actions: There are clearly some reporting issues that are generating aberrant percentages for secondary prevention drugs and length of stay. The Chest pain team will investigate these technical issues with the MINAP team to ensure future accuracy. Call to needle times do not meet target of 70% treated within 60 minutes (66.7%). This is likely due to the gradual introduction of 24/7 PPCI. This should be addressed for the whole of BCUHB with the phasing out of thrombolysis therapy as PPCI 24/7 is established (National recommendation for Clinical staff and audit leads). Interrogate the data on a regular basis, and use the data to facilitate quality improvement initiatives aimed at targeting MINAP identified limitations in the care provision of people with STEMI and nstemi. Call to needle times do not meet target of 70% treated within 60 minutes (62.2%) in East division. This is likely due to the gradual introduction of 24/7. PPCI This should be addressed with the phasing out of thrombolysis therapy as PPCI takes over as treatment of choice. This should be addressed for the whole of BCUHB with the phasing out of thrombolysis therapy as PPCI 24/7 is established Date form completed: Issue has been discussed (August 2017) and data is collected correctly by current MINAP team. Clinical Lead Dr M Payne (West) PPCI 24/7 was established in April Clinical Lead Dr C Bellamy (Central). Appointment of Cardiology Data Co-ordinator this Autumn to continue this role. Clinical Lead Dr C Bellamy (Central). PPCI 24/7 was established in April Clinical Lead Dr Richard Cowell (East). Form completed by (PRINT NAME): Angela Taylor (Clinical Audit & Effectiveness Facilitator). Title of Clinical Audit: National Audit of Cardiac Rehabilitation Host Organisation: Date of last National report:

55 Page 47 of 57 NHS Digital & British Heart Foundation 02/12/2016 Project Background and Aims: The NACR is funded by the British Heart Foundation (BHF) and is hosted by the University of York in collaboration with the NHS Digital ( In its role as the official audit for NHS cardiac rehabilitation programmes in the UK) the NACR aims to: Map the extent of cardiac rehabilitation provision across the UK. Report annually, at clinical commissioning group level and Health Boards, on uptake and clinical outcomes for over 300 programmes in the UK. Define the typical gains for patients to expect from top performing programmes. Highlight and reduce inequalities in provision and outcome. Disseminate audit findings to service providers and the public. Inform clinical guidance, policy, commissioners and practice standards. Drive up quality and facilitate service improvement locally, nationally and internationally. Including new in 2015 the Joint BACPR-NACR Certification Programme. Implement observational research to determine the effectiveness of routinely delivered services. Produces online supplements for key service indicators at programme level. Seeks feedback on the physical activity supplement to help inform reporting of other patient outcomes in the future. BCUHB-wide East lead: Central lead: West lead: lead: Jacqueline Cliff Catrin Warren (Cardiac Rehabilitation Dale Macey (Cardiology To be (Cardiac Liaison Physiotherapist) & Rehab Specialist Nurse) & confirmed Nurse) Juliet Tobler (Cardiology Rehab Specialist Iowerth Jones (Smoking Nurse) Cessation Specialist) Recommendations of last National report: Most CR programmes need to recruit a greater proportion of eligible female patients. Heart Failure (HF) patients should be seen as a priority group for CR. The mode of delivery of CR should be broader than just group based approaches. CR should start earlier for all patient groups. The frequency and quality of patient assessment before and after CR needs to improve. Specific issues of note for BCUHB: (local issues from Part A) CR should start within 28 days: West 32. Within 42 days post CABG West 75. East no Action required, West We were using phases and not commissioning packs in Due to the geography of the west area phase III is only delivered in Bangor and Holyhead by our team. Exercise in all other areas is delivered by leisure services. % of patients with initiating event and assessment: East & Central need to increase completion of all appropriate fields of minimum assessment pre cardiac rehabilitation. % Starting CR with a record of Pre and Post Assessment : East 29%, Central 10%, West 5%. East & Central - Need to increase completion of post cardiac rehabilitation assessment, mainly to add in a post CR functional exercise assessment. West Because of geographical issues many of our patients go straight into community programs which are run by leisure services, so we don t deliver the re-test (patients are re-assessed by leisure service). Median wait time from IE to pre CR assessment: East No data available presently, Central No longer recorded, West MI/PCI 46. Duration of CR (NICE says 84 days / 12 weeks): East median , East need to provide earlier end assessment. Smoking cessation: East - 96% stopped pre and same post, Central & West Not enough data collected. East need to continue to strive for improved smoking cessation & long-term smoking cessation. Exercise-recorded as achieving 150 mins per week: East pre 22% East post 72% Central & West not enough data collected. East to concentrate on helping people achieve 150 mins exercise per week. Central More assessment data needs collecting. West Not enough data collected. BMI <30: East pre 53% East post 56%, Central & West not enough data collected. East need to improve reaching BMI <30. Anxiety: East Pre CR - Normal 70%, Borderline 15%, Clinically anxious 15%. East Post CR - Normal 70%,

56 Page 48 of 57 Borderline 10%, Clinically anxious 0%. Central & West not enough data collected. Depression: East Pre CR - Normal 85%, Borderline 10%, Clinically depressed 5%. East Post CR - Normal 85%, Borderline 15%, Clinically depressed 0%. Central & West not enough data collected. East need to produce a business case for psychological therapies in cardiac rehabilitation. Normal health related QOL: East & Central Improvement in all areas except Pain & Social Support. All Welsh CR Services to meet BACPR accreditation: (Heart Conditions Delivery Plan by WG 2017). BCUHB actions agreed: Progress with agreed actions: Heart Failure patients are being identified, Jan 2018 update on numbers coming through. assessed and attending Cardiac Rehab Catrin Warren, Specialist Physiotherapist. Exercise Programmes. Data collection on numbers of referrals, waiting times, assessments and numbers attending Cardiac Rehab Programme now being collected on WPAS. Quarterly Reports to be developed. Date form completed: Oct 2017 First Quarterly Reports expected. Juliet Tobler, Cardiac Rehab Nurse. Form completed by (PRINT NAME): Angela Taylor (Clinical Audit & Effectiveness Facilitator). Title of Clinical Audit: National Vascular Registry (NVR) Host Organisation: Royal College of Surgeons Vascular Society Date of last National report: November 2016 Annual Report Project Background and Aims: The NVR was formed in January 2013 by the amalgamation of the National Vascular Database and the UK Carotid Interventions Audit projects. The National Vascular Registry (NVR) aims to provide comparative information on the performance of NHS vascular units and so support local quality improvement. It also aims to inform patients about major vascular interventions delivered in the NHS. All NHS hospitals in England, Wales, Scotland and Northern Ireland are encouraged to participate in the Registry. This report provides a description of the care provided by NHS vascular units, and contains information on the process and outcomes of care for: (i) patients undergoing carotid endarterectomy, (ii) patients undergoing abdominal aortic aneurysm (AAA) repair, (iii) patients undergoing a revascularisation procedure (angioplasty/stent or bypass) or major amputation for lower limb peripheral arterial disease (PAD). BCUHB-wide lead: To be confirmed East lead: Mr Tony DaSilva (Consultant Surgeon) Central lead: To be confirmed West lead: To be confirmed Points raised from last National report: Key recommendations: Vascular units within NHS trusts / Health Boards: Vascular units should review the results for their organisation to ensure care is consistent with the recommendations in national clinical guidance on patients requiring major arterial surgery with vascular conditions. There remain considerable variations between NHS vascular units with regard to the provision of carotid endarterectomy within 14 days of symptoms. NHS trusts should optimise referral pathways within their networks and implement improvements to drive down the waiting times All staff involved in organising and delivering care to patients who require carotid surgery need to examine their data and assess their performance against standards within NICE Guideline CG68 Vascular units are encouraged to adopt the care pathway and standards outlined in the Vascular Society s AAA quality improvement programme. This can be accessed at the Vascular Society s website. A clinical lead should be nominated to monitor and report on the adoption of the pathway and this should be reflected in their job planning There is wide variation in the time patients take from vascular assessment to elective AAA repair. The

57 Page 49 of 57 National AAA Screening Programme has set a target of 8 weeks and, for non-complex aneurysms, this should be a target for all units for both screen and non-screen detected AAA The mortality rates for emergency repair of ruptured aneurysms remain high. One factor might be the lack of availability of endovascular repair out of hours. We recommend NHS vascular units examine their local practice to determine reasons behind the low proportion of endovascular cases The case-ascertainment for major amputation and endovascular procedures needs to be improved. All clinicians within vascular units (surgeons and interventional radiologists) should review how data can be routinely entered into the NVR Vascular units should undertake a detailed analysis of the pathways of care and outcomes for lower limb amputation, and are encouraged to adopt the care pathway and standards outlined in the Vascular Society s Quality Improvement Framework. Specific issues of note for BCUHB: There is no identified BCUHB-wide audit lead or agreed leads for Central and West Areas. BCUHB actions agreed: Progress with agreed actions: Identification of lead roles required. Confirmation of lead roles sought by Clinical audit & Effectiveness Department. Date form completed: Form completed by (PRINT NAME): Trevor Smith (Head of clinical audit & Effectiveness, Acting)

58 Page 50 of 57 Cancer: Title of Clinical Audit: National Bowel Cancer Audit Host Organisation: Health & Social Care Information Centre (Project Management) & Association of Coloproctology of Great Date of last National report: December 2016 Britain & Ireland (Clinical Leadership) Project Background and Aims: The National Bowel Cancer Audit is a high-profile, collaborative, national clinical audit for bowel cancer, including colon and rectal cancer. The audit aims to improve the quality of care and survival of patients with bowel cancer, and meets the requirements as set out in the NHS cancer plan, NICE guidelines and the report of the Bristol Royal Infirmary inquiry BCUHB-wide lead: Mr Andrew Maw, Consultant Surgeon East lead: Mr Palanichamy Chandran, Consultant Surgeon Central lead: Mr Andrew Maw, Consultant Surgeon West lead: Dr Catherine Bale, Consultant Oncologist & Mr Anil Lala, Consultant Surgeon Recommendations of last National report: The 2016 Annual report s recommendations focussed on: Care pathways The contribution of the NHS bowel cancer screening programme to the diagnosis of patients with early bowel cancer is demonstrated. All health professionals should be encouraged to actively promote participation in this service to increase service uptake. Clinicians and data managers should prioritise data completeness for: reason for no treatment, performance status, care plan intent and pre-treatment M-stage. This will reduce the proportion of patients who do not undergo a major resection who are unassigned to a treatment pathway and therefore better describe the care and outcomes in this cohort. Surgical care Improving the post-operative survival in patients undergoing emergency or urgent bowel cancer resection should remain a clinical priority. The provision of pre-operative resuscitation, adequate theatre access, postoperative critical care, and early colorectal team involvement, including full radiological support and facilities for colonic stenting as a bridge to curative surgery or expediting palliative chemotherapy, is likely to improve survival. Efforts to reduce long length of stay may need to be more focused on improving the provision of, and reducing any regional disparity in, community and primary care services (as described in the length of stay short report). Potential delays to discharge, particularly in the elderly population, should be considered pre-operatively, to allow for the provision of community services if required, to reduce the risk of prolonged length of hospital stay Survival Further work is required into investigating regional variation in rates of two-year survival. This is a priority for the audit moving forward and access to the chemotherapy dataset and cause of death data will facilitate this. Patients presenting with stage IV bowel cancer should be referred to multi-disciplinary teams (MDTs) to optimise timing of resection of both the primary tumour and metastases as well as advising on neo-adjuvant and adjuvant treatment. Specific issues of note for BCUHB: BCUHB was not considered an outlier on any of the indicators There were data completeness issues in YGC and YG in relation to pre-treatment staging which may have

59 Page 51 of 57 affected other indicators Positive margins following rectal surgery were higher in YG The rate of urgent/emergency surgery at YGC and YG is high but has decreased from previous years where YGC was the highest in Wales BCUHB actions agreed: Progress with agreed actions: Full report to be discussed at next Colorectal Cancer Clinical Advisory Completed Group and actions agreed Data completeness in YGC and YG has already improved (this data is from Completed 2014/15); further improvements are expected with the introduction of validation meetings and use of MDM module in MDTs with effect from 2017 Data re rectal cancer surgery in YG to be reviewed by clinical team Completed Audit of emergency surgery and admissions in YGC commenced in 2016 Completed and will complete in 2017 (to include comparison with YG and Wxm) Date form completed: Form completed by (PRINT NAME): 26/01/2017 CAROLINE WILLIAMS, Performance Lead, Cancer Services Project update (include date of update): 16/10/2017 Update received from Caroline Williams confirming all actions complete. Title of Clinical Audit: National Lung Cancer Audit Host Organisation: Royal College of Physicians Date of last National report: January 2017 Project Background and Aims: The National Lung Cancer Audit looks at the care delivered during referral, diagnosis, treatment and outcomes for people diagnosed with lung cancer and mesothelioma. The audit was set up in response to The NHS Cancer Plan, to monitor the introduction and effectiveness of cancer services. BCUHB-wide lead: Dr C Sakkarai Ambalavanan, Consultant Respiratory Physician East lead: Dr Neil McAndrew, Consultant Respiratory Physician Central lead: Dr Sakkarai Ambalavanan, Consultant Physician West lead: Dr Ali Thahseen, Consultant Physician Recommendations of last National report: The 2016 Annual report s recommendations focussed on: Data Completeness Case ascertainment of at 95% or more. Valid performance status (PS) and stage recorded in at least 90% of cases. Patients with stage I II and PS 0 1, completeness for FEV1 and FEV1% should exceed 75%. Process At least 90% of patients seen by lung CNS. At least 80% of patients should have a lung CNS present for diagnosis. Pathological confirmation rates of lung cancer below 80% should be reviewed. NSCLC-NOS rates more than 15% should be reviewed. Proportion of patients receiving PET-CT scan before surgery or radical radiotherapy in at least 90% of cases. Proportion of patients receiving chemotherapy for SCLC starting treatment within 2 weeks of pathological diagnosis in at least 80% of cases Treatment and Outcome The casemix-adjusted ratio to be used to determine outlier status but organizations can use the 2015 mean results (shown below) as a guide to performance. Activeanticancer treatment rates for patients- (60%) Surgical resection rates for NSCLC patients - (17%) Radical treatment rates for patients with stage I/II NSCLC- (70%) Chemotherapy rates for SCLC - (>69%) Systematic anticancer treatment rates for PS (0-1) stage IIIB/IV NSCLC - (64%)

60 Page 52 of 57 1 year survival - (38%) Specific issues of note for BCUHB: Pathological confirmation rates of lung cancer below 80% should be reviewed BCUHB is below 80% but is improving year on year and under review. Proportion of patients receiving chemotherapy for SCLC starting treatment within 2 weeks of pathological diagnosis in at least 80% of cases a review of cases of SCLC has been undertaken and SCLC pathway is an agenda item for discussion at the next Lung CAG meeting. Active anticancer treatment rates for patients - (60%) data is being reviewed in East Surgical resection rates for NSCLC patients - (17%) resection rates in Central had been low. Now in place is a high risk MDT, weekly attendance by the surgeon at MDT, use of CPEX in borderline cases, access to second opinion, discussions regarding the low rate raised with Thoracic surgical services managers BCUHB actions agreed: Progress with agreed actions: Pathological confirmation rates data is Data has been recently reviewed and although improving year continually reviewed and improving year on on year, continues to be below 80% for each location. To be year reviewed at the February 2018 Lung Clinical Advisory Group A review of SCLC patients is underway and a new process for monitoring SCLC pathway was discussed and agreed at the Lung CAG 24 th March 17 meeting. A review of BCUHB SCLC patients receiving chemotherapy within 2 weeks has been performed and further work on the new process, agreed with Pathology managers, is required to work towards future compliance. To be reviewed at the February 2018 Lung Clinical Advisory Group meeting. Data on Active anticancer treatment rates for To be reviewed at the February 2018 Lung Clinical Advisory patients to be reviewed in the East area Group meeting. Review of the data for surgical resection rates Review of data planned following improvements in the pathway for NSCLC patients planned following and audit results to be reviewed at the February 2018 Lung improvements in the pathway Clinical Advisory Group meeting. Date form completed: Form completed by (PRINT NAME): 24/02/17 Helen Lawrence, Administration & Information Manager Project update (include date of update): 04/10/2017 Update on agreed actions provided following discussion at the Lung Clinical Advisory Group in September Title of Clinical Audit: National Oesophago-gastric Cancer Audit Host Organisation: Health & Social Care Information Centre (Project Management) &The Association of Upper Gastrointestinal Surgeons of Great Britain & Ireland (AUGIS), British Society of Gastroenterologists (BSG) & The Clinical Effectiveness Unit at the Royal College of Surgeons of England. Date of last National report: September 2016 Project Background and Aims: The National Oesophago-Gastric Cancer Audit covers the quality of care given to patients with Oesophago-Gastric (OG) cancer. The audit evaluates the process of care and the outcomes of treatment for all OG cancer patients, both curative and palliative. BCUHB-wide lead: Mr Andrew Baker, Consultant Surgeon East lead: Mr Andrew Baker, Consultant Surgeon /Dr Thiriloganathan Mathialahan, Consultant Gastroenterologist Central lead: Mr Richard Morgan, Consultant Surgeon West lead: Dr Rachel Williams, Associate Specialist, Oncology Chester Lead: Mr David Monk, Consultant Surgeon Recommendations of last National report: The 2016 Annual report s recommendations focussed on: Case ascertainment of OG cancer patients within England has stabilised at around 80 per cent (Chapter 3). While MDTs are commended for their effort in submitting data for this group of patients, steps should be taken to identify the missing 20 per cent of patients to ensure their details are submitted in the future.

61 Page 53 of 57 There has been a sizeable fall in the annual number of patients with HGD reported to the NOGCA since 2012 (Chapter 4). Local MDTs need to ensure that they have clear protocols in place to ensure all cases of HGD are discussed at their OG cancer MDTs, and the details of each case are submitted to the Audit. Only 65.7 per cent of patients with HGD had their disease treated endoscopically, despite the BSG recommending that all patients should be considered for this treatment (Chapter 4). MDTs should prospectively monitor their management of HGD, and ensure there is access to endoscopic treatment of Barrett s HGD. A significant proportion of cases of OG cancer are diagnosed after an emergency admission (Chapter 6). It is important that NHS trusts/nhs boards monitor these rates and take steps at a local level to identify possible reasons where levels are high. UK guidelines recommend that all patients with a new diagnosis of OG cancer have a staging CT scan. Reported rates are very variable across NHS trusts/health boards, which may reflect poor reporting of staging investigations to the Audit (Chapter 7). It is important that NHS organisations monitor their use of staging investigations and investigate reasons for low use. Where this is due to poor reporting, mechanisms should be put in place to improve reporting in future to ensure this information is captured (e.g. at the time of MDT meetings). There is variation in the planned use of palliative treatment modalities among patients unsuitable for treatment with curative intent (Chapter 8). MDTs should review the way in which patients are offered palliative treatment options and examine whether more patients would benefit from active treatment. Cancer centres performing curative surgery should regularly monitor the number of lymph nodes resected and proportion of patients with positive resection margins (Chapter 9). There was variation across NHS providers in the choice of palliative radiotherapy regimens for oesophageal tumours (Chapter 10). Providers should keep their current regimens under review and evaluate their practice when new guidance on radiotherapy is published by the Royal College of Radiologists. Specific issues of note for BCUHB: Report to be discussed at Upper GI Clinical Advisory Group in February but no specific issues of note identified for BCUHB by BCUHB lead, Mr Andrew Baker and Helen Lawrence, Administration & Information Manager. BCUHB actions agreed: Progress with agreed actions: N/a N/a Date form completed: 26/01/2017 Form completed by (PRINT NAME): Helen Lawrence, Administration & Information Manager & Mr Andrew Baker, BCUHB Lead / Consultant Surgeon Project update (include date of update): 13/04/2016 Report taken to the February Upper GI Clinical Advisory Group but no additional comments made Title of Clinical Audit: National Prostate Cancer Audit Host Organisation: Royal College of Surgeons Clinical Effectiveness Unit (CEU) Date of last National report: 14 th December rd Annual Report Project Background and Aims: NPCA is the first national clinical audit of the care that men receive following a diagnosis of prostate cancer. It is designed to collect information about the diagnosis, management and treatment of every patient newly diagnosed with prostate cancer in England and Wales, and their outcomes. The findings from the audit will contribute to changes in clinical practice ensuring that patients receive the best care possible and experience an improved quality of life. BCUHB-wide lead: Mr Ernest Ahiaku (Consultant Urologist) East lead: Mr. Iqbal Shergill (Consultant Urologist) Central lead: Mr. Ross Knight (Consultant Urologist) West lead: Mr Ernest Ahiaku (Consultant Urologist) Recommendations of last National report: Implication for practices highlighted in the report : - Improvements in data quality and completeness of each section of the NPCA minimum dataset in order to enable the rigorous risk-adjustment required to identify outlying performance of providers.

62 Page 54 of 57 Providers should consider if and when (before or after biopsy) to use multiparametric MRI for the diagnosis of prostate cancer. The trend seen towards a reduction in the potential under-treatment of locally advanced prostate cancer is encouraging and is in line with current guidelines. In future reports, the NPCA will provide more detailed information on the types of multi-modal treatments received by these men in line with current recommendations. The proportion of men with low-risk disease being potentially over-treated is stable at about one in eight men. This level of over-treatment of low-risk localized disease still remains an area of concern and further work is required to evaluate treatment pathways for these men and whether active surveillance is being offered appropriately in line with current standards. The high response rate for the NPCA patient survey indicated the successful engagement of patients in the collection of NPCA PROMs and PREMs and we hope this is repeated with the next patient survey which will include all men who are candidates for radical treatment. Overall, men report a good experience of care and our preliminary results demonstrate that there is limited variation in the experience that patients reported across specialist MDTs. In some specialist MDTs the provision of information about treatment options and the making of decisions about treatment may need further improvement Specific issues of note for BCUHB: Improvements in data quality and completeness of each section of the NPCA minimum dataset in order to enable the rigorous risk-adjustment required to identify outlying performance of providers. Providers should consider if and when (before or after biopsy) to use multiparametric MRI for the diagnosis of prostate cancer. The proportion of men with low-risk disease being potentially over-treated is stable at about one in eight men. This level of over-treatment of low-risk localized disease still remains an area of concern and further work is required to evaluate treatment pathways for these men and whether active surveillance is being offered appropriately in line with current standards. BCUHB actions agreed: Progress with agreed actions: The Multi Disciplinary Module within Canisc will be piloted for Pilot to run Feb April Further Rollout Glan Clwyd patients commencing , this will allow the live to other areas to follow capture and validation of NPCA data during the MDT meeting. The Consultant sign off of the NPCA patient case will continue outside of the meeting. The pilot will take place for 6 weeks when progress and rollout for Wrexham and Bangor patient cases will be assessed. The benefits of Multiparametric MRI before or after biopsy has been discussed within the MDT meeting. The ability and feasibility to provide this service across the 3 hospital sites is listed within the Operational Plan for Radiology The MDT will be updated via the Consultant Radiologist member. Over treatment of Low risk localised disease is listed as an agenda item at the Urology CAG A review of patients having had radical treatment will take place to establish and agree the pathway Discussed at Clinical Advisory Group - September 2017 Discussed at Clinical Advisory Group September 2017 Date form completed: Form completed by (PRINT NAME): 10/01/2017 Nikki Andrews (Project Lead Cancer Services) Project update (include date of update): 27/09/2017 Action plan discussed at Urology MDT on 27 th Sept 2017, Update on agreed actions to follow

63 Page 55 of 57 Women s and Children s Health: Title of Clinical Audit: National Neonatal Audit Programme Host Organisation: Date of last National report: Royal College of Paediatrics & Child Health September 2017 Project Background and Aims: NNAP was established in January 2006 and is currently commissioned until March 2014 by the Healthcare Quality Improvement Partnership (HQIP). The audit addresses eleven questions and collects data on every baby admitted to a neonatal unit. From October 2008 units are named in all NNAP reports. The overall aims of the audit are: To assess whether babies requiring specialist neonatal care receive consistent high quality care across England and Wales in relation to the audit questions; To identify areas for improvement in relation to service delivery and the outcomes of care. BCUHB-wide lead: Dr Geedi Farah (Consultant Neonatologist) East lead: Dr Brendan Harrington (Consultant Paediatrician) Recommendations of last National report: Consultation with parents. Clinical follow up at 2yrs. Rates of babies receiving mother s milk at discharge. Mothers given Magnesium Sulphate. BCUHB actions agreed: Consultation with parents: Highlight the importance of documentation. Clinical follow up at 2yrs: Establish 2 year follow up clinics. Rates of babies receiving mother s milk at discharge: 20 unprotected hours dedicated for advice/education. Sign up for UNICEF breastfeeding initiative. Work towards BLISS charter certification. Central lead: Dr Geedi Farah (Consultant Neonatologist) Dr Mohammed Sakheer Kunnath (Consultant Paediatrician) Dr Ian Barnard (Consultant Paediatrician) West lead: Dr Michael Cronin (Consultant Paediatrician) Progress with agreed actions: We are working to improve on this and hope that we will have better results next year by raising awareness among colleagues about the importance of documenting their communication with parents with the first 24hrs of their baby s admission. The communication is actually taking place, but we have issues around the documentation not being completed. An has been sent to all concerned with the neonatal unit highlighting the importance of this, and plans are in place for regular reminders to be sent to consultants, advance nurse practitioners and other members of the team. We have set up a 2 year developmental follow up clinic which started running in March 2017 and I am confident that our data will be much better next year. From the beginning of this year, we have a senior nurse who has 20 unprotected hours dedicated for breast feeding advice to parents and educating staff about breastfeeding. We expect better results next year, but the overall rates of breastfeeding are low in Wales compared to England. An organisational focus on this will be of most help to us. We are signing up for UNICEF breast feeding initiative and working towards accreditation for this. This is also part of BLISS baby charter certification work which we are working towards.

64 Mothers given Magnesium Sulphate: Check data validity. Improve education/awareness. Page 56 of 57 Our rates for mothers who are given Magnesium Sulphate are very low and there are questioning whether the results reflect the true data that we have inputted in to BadgerNet. We plan to pull all the relevant notes and check. We have already taken measures such as educational sessions both within the neonatal team and obstetric team in order to raise awareness and our expectation is that we will have better data results next year. Form completed by (PRINT NAME): Alison Smith Clinical Audit and Effectiveness Facilitator Date form completed: 09/10/2017 Project update (include date of update): 05/10/17 - Information around actions was provided by the lead Dr Geedi Farah Consultant Neonatologist. Title of Clinical Audit: MBRRACE-UK. Perinatal Mortality Surveillance Report. UK Perinatal Deaths for Births from January to December Host Organisation: Date of last National report: NPEU/University of Oxford June 2017 Project Background and Aims: MBRRACE-UK is a collaboration led from the National Perinatal Epidemiology Unit (NPEU) at the University of Oxford. MBRRACE-UK' is the collaboration appointed by the Healthcare Quality Improvement Partnership (HQIP) to continue the national programme of work investigating maternal deaths, stillbirths and infant deaths, including the Confidential Enquiry into Maternal Deaths (CEMD). The programme of work is now called the Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP). The aim of MBRRACE-UK is to provide robust information to support the delivery of safe, equitable, high quality, patient-centred maternal, newborn and infant health services. The current programme, called the Maternal Newborn and Infant Clinical Outcome Review Programme, is provided by the MBRRACE-UK collaboration. MBRRACE-UK stands for Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK. BCUHB-wide lead: Fiona Giraud Maureen Wolfe (Matron Clinical Risk & Governance) East lead: Bethan Evans (Ward Sister) Central lead: Lynne Clayton (Community Midwife) Debbie Edwards West lead: Sali Williams (Labour Ward Shift Leader) Recommendations of last National report: Close monitoring of mortality rates. Renewed focus on neonatal deaths to achieve a significant reduction in numbers. Identify the extent to which deaths before 32 weeks gestation are avoidable. A national forum to be established in Wales to agree best approach to reporting. High quality data submission to MBRRACE. Completeness of data submission to MBRRACE. Placental histology should be undertaken for all stillbirths, preferably by a perinatal pathologist. Systems are in place to implement appropriate guidance related to monitoring fetal growth. All stillbirths and neonatal deaths to be investigated using a standardised process and independent multidisciplinary peer review. Specific issues of note for BCUHB: Development of a local plan to action national recommendations. See actions agreed section below: BCUHB actions agreed: Progress with Public health awareness to be raised with regards to: Smoking cessation. Healthy diet. Referral pathways to be monitored for those women with medical disorders: Diabetes Mental health issues. Effective communications with external providers of neonatal care to ensure neonatal death reviews held in external organisations are shared with BCUHB. agreed actions: Agreed timescale: December 2017 December 2017 Ongoing

65 Page 57 of 57 Data to be completed in full before submission to MBRRACE: women s details and booking July 2017 information. Ultrasound capacity issues to fully meet GROW recommendations therefore entered as a Ongoing risk on the Women s Directorate Risk Register. Issues with GROW documentation and growth trajectory. A task and finish group has been Sept 2017 set up to address the concerns identified. Further work has commenced to collect information from neonatal death reviews held by Ongoing external providers to improve communication and data collection. Date form completed: Form completed by: Maureen Wolfe (Matron Clinical Risk & Governance) Trevor Smith (Head of Clinical Audit & Effectiveness, Acting)

66 1 JAQS17_5c Appendix 1 Stroke Action Plan.doc 1 Joint Peer Review of Stroke Services at BCUHB January 2017 Appendix 1 Action Plan Peer Review Recommendation Pan BCU/Site Specific Action Required Action Lead Timescale Expected Impact Progress September Improving the delivery of emergency stroke treatments (several issues of clinical practice should be addressed to improve thrombolysis treatment rates and door-to-needle times) a The current thrombolysis protocol should be updated with regards to the exclusion criteria (e.g. excluding patients with diabetes and previous stroke). The newly amended protocol seen by the Review Team should be brought up to date, formally ratified and visible in the Emergency Department to promote decision making for all clinicians involved in thrombolysis. PAN BCU Review and updating of existing protocol with ratification by BCU Secondary Care Q&S Committee Lynne Hughes, Stroke Coordinator East, Dr Sayed and Dr Ganeshram, Stroke Physicians November 2017 Increase in number of patients receiving Thrombolysis Protocol updated, awaiting final comments from Stroke Clinicians and for submission to Secondary Care Q&S November 2017 meeting Agreement reached with WAST to provide specific patient detail and Onset time as part of ASCHICE and pre alert to improve decision making earlier in the pathway b Although the door to needle times for thrombolysis reached acceptable standards during the daytime on weekdays, similar PAN BCU Protocol needs to be reviewed for telemedicine and agreement on best practice. This must include decision on Dr Ganeshram and Dr Sayed November 2017 Quicker access to brain imaging and facilitate timely assessment to stroke patients Protocol updated and awaiting comments from Stroke Physicians which will enable decision on type of Home connections

67 2 performance metrics may also be achievable throughout the whole week if a fully functional and resourced telemedicine system was operational.. need to view the CT images only or the need to view the patient for assessment from home. Reporting mechanism and timescales also to be included Access to home telemedicine to be reviewed again with the costs of being able to view/talk to the patient and also costs for viewing CT only. Judith Rees, DGM East December 2017 and speed up decision making out of hours and over the weekend Increase in number of patients receiving Thrombolysis Improved Door to Needle Times needed to be made. Initial scoping of Broadband availability undertaken currently being reviewed with B.T. and BCU I.T. department. Built in floor scales at entrance to Resus in Wrexham installed. Already in place in YGC c It is important that stroke clinicians receive training and engage in the reporting of brain imaging for thrombolysis decisions rather than operate via the remote outsourcing system, which leads to unacceptable delays in reporting. PAN BCU List of Clinicians who have received ASTRACAT training to be updated. Training sessions to be implemented where required Judith Rees, DGM East October 2017 As Training available Faster decision making Potential Increase in number of patients receiving Thrombolysis No progress made

68 3 d Implementation of small changes in the pathway to achieve marginal gains in the delivery of CT scanning generally and for administration of thrombolyis to patients more quickly There needs to be a formal policy and pathway developed with the nearest Neuroscience Centre (Walton Centre) for the delivery of mechanical thrombectomy for those patients with large vessel occlusion PAN BCU PAN BCU Review of the patient pathway on each Site to consider improvements that can be made in DTN times e.g. Direct to C.T, on arrival; Thrombolysis given in CT; Fast pre- Alert to Stroke Team ahead Review of latest national guidelines for implementation of agreed protocol for access to CT brain imaging by non-medical staff Review of Neuroscience centre being used and protocol currently in place for the Walton centre. Stroke Co- Ordinators on each Site Lead Stroke Physician on each Site Dr Ganeshram as Stroke Lead and Lead Consultant Radiologist Director of Neurosciences November 2017 December 2017 December 2017 Improved DTN times Improved CT scanning timescales and decision making Agreement in principle reached with Radiology department in Wrexham to support administration of alteplase bolus in CT providing there is guidance relating to the treatment of anaphylaxis. Consultant, Dr Curran, is currently writing this and has had discussions with pharmacy with regards to provision of the required drugs. This will then be shared across BCU. Patients over the age of 80 considered for thrombolysis up to 4.5 hours. Scheduled for Neurosciences Board meeting on the 12 th December 2017

69 4 identified by CT angiography. Planning for this service (in anticipation of a commissioning framework for English centres providing this service) should include the Welsh Ambulance Service. e Although staff were aware of National Clinical Guidelines for Stroke there was no evidence of these being translated into clinical Guidelines with a need to more appropriate supervision of patients by a Stroke Physician YGC 2 Sustainability of services, including workforce Produce guidelines on the management of stroke to include typical complications of stroke. Dr Ganeshram November 2017 Improved clinical outcomes In process of being written a b In patients stroke care should be concentrated in fewer locations two or at most three out of the existing number of community hospital beds All sites caring for stroke in-patients (or PAN BCU PAN BCU Capacity modelling across inpatient facilities and development of Services on reduces number of Sites Work with information Asst. Area Director Community Services, Eleri Roberts/Dr S Elghenzai DGMs Jan 2018 October 2017 Improved skill mix and specialist staff on all inpatient facilities Accurate data and Capacity modelling being undertaken as part of HASU options appraisal MDT workshop set up for Nov. to confirm model as part of Living Healthy Staying Well Strategy All sites input to the SNAPPS audit.

70 5 services providing early supported discharge) should be registered with the national audit to provide overall data about the quality of the patient pathway. department to ensure that entire episode of care is recorded appropriately and reflected in the national audit performance information c d Training programmes should be reorganised so that staff working in units with smaller numbers of stroke patients (in-patient or community-based) can maintain their skills and receive regular contact with centrally-based clinicians with a broader range of stroke skills and experience; Particular consideration should be given to the development of nonmedical clinical leadership e.g. nurse or therapy consultant roles. These roles should take responsibility for clinical care in nonacute settings, potentially reducing the PAN BCU PAN BCU Refresh the training programme for all staff involved in stroke care in both the acute and community setting Feasibility of role development to be undertaken Clinical and Operational Leads across individual Secondary Care and Area Director of Therapy Services, Gareth Evans/Nursing Lead to be agreed Jan 2018 March 2018 Appropriately trained staff with outcomes for all patients More flexible workforce addressing the future recruitment challenges of medical staff Under discussion and part of MDT workshop on the future rehabilitation model of care

71 6 e f g commitments for medical consultants and enabling them to devote more time to areas where medical responsibility is essential; Medical workforce numbers and qualifications should reflect the recommendations of the British Association of Stroke Physicians Workforce Standards The HB should reconsider what other incentives (e.g. rebanding of hard-to-fill posts) may help recruitment and retention if these issues are holding up service development or quality improvement. Fit for Purpose, appropriately staffed Early Supported Discharge (ESD) Services should be implemented across North Wales. This should reflect the rurality of some parts of North Wales and PAN BCU PAN BCU PAN BCU Workforce planning review to be undertaken Feasibility of role development to be undertaken Business Case for the development of the Service to be undertaken for further discussion with the Health Board DGMs Area Directors and Director of Therapy Services Director of Therapy Services December 2017 March 2018 November 2017 Appropriately resourced and qualified medical workforce Appropriately trained staff with improved therapeutic interventions ESD Service in place, reduced Length of stay Workforce review commenced as part of HASU Options appraisal Continued discussion Therapy-led Scoping work commenced as part of Living Healthy Staying Well option appraisal. For inclusion in Board papers in October with more detailed report Jan 2018

72 7 h i j well as Service the more urban areas. Therapists should not be moved from provision of ESD Service to Acute Services to support improved performance compliance Adequate administrative and ward clerk support should be available to the Stroke Team to reduce the time spent on inappropriate duties and increase the time spent on clinical duties In clinical or geographical areas where the numbers of stroke patients alone are insufficient to sustain a specialist stroke-skilled workforce, teams should be reorganised wherever possible into hybrid stroke/neuro or stroke/frail elderly teams, aiming for stroke to be at least 50% of the workload Provision of the principal therapies PAN BCU YG YG Review of admin support on each site and business case developed to increase where needed Review of workforce model to rural areas Undertake establishment DGMs Asst. Area Director Community Services, Eleri Roberts/Dr S Elghenzai November 2017 Jan 2018 Increased clinical time for clinical staff More robust community Services Stuart Harmes Jan 2018 Appropriate staffing levels Some additional support in place in Wrexham with further review to take place across BCU Work is in progress to reconfigure COTE into locality areas to cover COTE/Frailty and will also include Stroke. This will be carried out in partnership with Community Resource Teams within the localities which include nursing, therapies as well as social service colleagues. Request for additional OT staff has gone to

73 8 k (physio, OT, SALT) should be increased on Prysor ward to allow treatment to take place, as opposed to only assessment. Regular multidisciplinary training (one of the defining hallmarks of specialist stroke care) should be reintroduced on the stroke unit. Staff of all disciplines should be supported to further develop their strokespecific skills YG review for therapies in order to provide at least an additional 45 minutes of each relevant therapy Development of innovative practices to increase face-toface therapy time Refresh the training programme for all staff involved in stroke care in both the acute and community setting 3 Rurality, access and the particular needs of Welsh speakers Dr Elghenzai/ Sian Hughes Jones, Lowri Welnitschuk Stuart Harmes March 2018 for therapeutic interventions Appropriately trained staff with improved therapeutic interventions vacancy control panel for consideration. Physio- fully established SALT currently no week-end cover VCP approved recruitment to vacant posts within bottom line budget w/c , in the interim priority being given to cover on the stroke ward while recruitment takes place Plans underway for staff to attend the Stroke Forum 2017 in November Training opportunities identified and will be delivered Q3 & Q4 Staff training sessions taking place on Mondays a HB should persist in their efforts to prevent non-welsh speaking acting as a barrier to the influx of staff from elsewhere, by offering support in learning Welsh and providing PAN BCU Continue efforts to recruit from non welsh-speaking areas Health Board Continuous Care provided to patients in their language of Choice with improved clinical outcomes Ongoing

74 9 b c the time for staff to learn the language; Even if the reconfiguration of hyperacute stroke services across Wales results in their relocation to somewhere other than Ysbyty Gwynedd, the needs of the local population for emergency diagnostic assessment under a drip-and-ship model of stroke care, and for locally-based services to be maintained in the West Area. The uncertainty over the future of hyperacute stroke care (and the uncertain timescale for such changes) should not prevent urgent efforts being made to improve all aspects of the stroke service for the area. Irrespective of the options appraisal for location of the Hyper- Acute Stroke Unit(s) (HASU) in North Wales (i.e. if Wrexham is not YG YWM Review of Hyper Acute Service Model Review of Hyper Acute Service Model Health Board Health Board November 2017 November 2017 Improved clinical outcomes Improved clinical outcomes Under discussion as part of the HASU Options appraisal. The initial views of the stakeholder group are not supportive of this. Under discussion as part of the HASU Options appraisal The underlying principle of this work is that continuous

75 10 designated as a HASU centre), it is important to acknowledge that post-acute and rehabilitation stroke services will still need to be provided in the East area. The uncertainty should not act as a justification not to further enhance and deliver high quality stroke services in the locality. 4 Support for quality improvement in the service, and preparedness for future developments improvement of existing services, addressing the Peer review outcomes needs to continue irrespective of any future changes in service model of delivery. Quality improvement within the service needs to be at the forefront of core business under the aegis of clinical governance. A quality and safety committee needs to be established and focus the application of national audit metrics along the whole stroke pathway. There needs to be a clear pathway for reporting key performance indicators through the hospital s governance structure, PAN BCU Establishment of BCU Stroke Governance meeting with local Stroke Quality and Safety meetings on each site with agreed Terms of Reference that are consistent across the Service Clear reporting mechanism established within HB Rob Smith, Area Director and Lead for Stroke for BCU wide group DGMs for local groups Jill Newman, Director of Performance Established Established Established Improved Clinical Governance processes, communication and leadership BCU Stroke Collaborative established July 2017 and meets monthly Local Q&S groups established in YGC and Wrexham with YG to be established October 2017 Mortality Review processes in place at all Sites Policy approval process now confirmed in Wrexham and already in

76 11 with agreed action plans delivered to realistic timescales. The strategic direction should be underpinned by the recent RCP Clinical Guidelines and the NICE Quality Standard for Stroke, prioritising the key evidence based interventions that reduce disability, mortality and institutionalisation. Clinical and Managerial Leadership needs to be confirmed across the Service PAN BCU Review of Job Plans for Consultants to ensure Stroke responsibilities are reflected. BCU Executive Lead to be identified BCU Operational Lead to be confirmed Job Planning Leads for COTE medical staff Chief Operating Officer Director of Secondary Care December 2017 In Place Clear Clinical and Managerial Leadership with improved Service development place in YG and YGC Job Planning being reviewed Rob Smith, East Area Director identified Judith Rees, East DGM identified Dr Ganeshram, Central Consultant identified BCU Clinical Lead to be confirmed Medical Director Visits to other Beacon Sites should take place PAN BCU Opportunities for visiting and DGMs August 2017 Best practice to be identified Wrexham Team visited Salford in the Summer.

77 12 to understand what a comprehensive Stroke Service looks like and facilitate the development of Services networking across other Sites to be explored YGC reviewing options to visit other Sites

78 1 JAQS17_5d Clinical Audit Report corporate.doc Page 1 of 2 BCUHB Corporate Clinical Audit Update: October /17 BCUHB Corporate Clinical Audits: Title Driver Project Lead Scope / Aim of Audit Audit Date Consent Putting things Right Dr Ben Thomas Consultant in Acute Medicine (and Interim Associate Medical Director - Clinical Law and Ethics) Healthcare professionals must ensure that patients know enough to enable them to decide about their treatment. BCUHB has an agreed policy in order to outline the best practice when obtaining consent which states; Valid consent to treatment is absolutely central in all forms of healthcare, from providing personal care to undertaking major surgery. Seeking consent is not only a legal obligation but also a matter of common courtesy between health professionals and patients. Discussions continue regarding an All-Wales audit tool. Within BCUHB it was decided to complete a retrospective case-note audit of consent process and the report was launched December July 2016 Record Keeping Putting things Right BCUHB Health Records Group Poor record keeping is often identified in patient concerns, risk incidents and Ombudsman s reports. Two rounds of data collection have been completed in the West Area which has involved direct involvement of Assistant Medical Director (AMD) alongside junior doctor participation in order to maximise the opportunity for training and accountability. FY1 And FY2 training has been provided by AMD. Central and East data collection is to be scheduled. This audit will aim to determine compliance against agreed national standards (Royal College of Physicians and the Nursing and Midwifery Council Guidelines). Based on these national standards, a template had been devised and agreed by the BCUHB Health Records Group to facilitate a standardised approach to record keeping audit. In West area, reaudit completed in (May 2017) and further re-audit scheduled for November 2017 Central and East Area audits to be scheduled. Discharge Planning Putting things Right Awaiting notification of new lead or overseeing committee An audit of the BCUHB Discharge policy is currently in the planning and consultation stage. Date of re-audit to be confirmed. BCUHB Corporate Clinical Audit Update: October 2017

79 Page 2 of 2 Informing GP s of discharge within 48 hours Primary Care Support Unit Dr Mark Walker The re-audit has been requested by the Deputy Medical Director. Data has been collected and is currently in the analysis stage. Report to be circulated in November BCUHB Corporate Clinical Audit Update: October 2017

80 6 JAQS17/6 Clinical Audit Plan 2017/18 - Mr Adrian Thomas 1 JAQS17_6a Clinical Audit Plan coversheet.docx 1 Joint Audit and Quality, Safety & Experience Committees To improve health and provide excellent care Title: Clinical Audit Plan for Author: Responsible Director: Public or In Committee Strategic Goals Mr Adrian Thomas (Executive Director of Therapies & Health Sciences) Mr Trevor Smith (Head of Clinical Audit & Effectiveness, Acting) Mr Adrian Thomas (Executive Director of Therapies & Health Science) Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks Special Measures Improvement Framework Paper requested by the Audit Committee as part of the Cycle of Business Audit Committee and Quality, Safety and Experience Committee to receive and approve the programme These papers highlight the ongoing work and participation with these streams of audit & effectiveness activity from a wide range of BCUHB multidisciplinary staff and where this is linked with local improvement activity. Also highlighted is ongoing activity towards achievement of full participation with these prioritised projects in relation to all aspects of the audit cycle; including areas where engagement needs to be strengthened with data submission, allocation of lead roles, assurance of local implementation of national recommendations. Due to the scope and breadth of the topics included in the Clinical Audit Plan work-streams all of the themes are of relevance.

81 2 Theme/ Expectation addressed by this paper Equality Impact Assessment Recommendation/ Action required by the Committee NA. The Joint Committee is asked to receive and approve the Plan for 2017/18 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board Committee Coversheet v11 June 2017

82 1 JAQS17_6b Clinical Audit Plan v1.2.docx Page 1 of 6 Betsi Cadwaldr University Health Board Clinical Audit Plan 2017/18 Betsi Cadwaldr University Health Board 2017/18 Clinical Audit Plan (Oct 2017)

83 Page 2 of 6 Clinical Audit Plan 2017/18 1. Introduction: The Betsi Cadwaladr University Health Board (the Health Board) 2017/18 Clinical Audit Plan (the Plan) includes the NHS Wales National Clinical Audit and Outcome Review Annual Plan 2017/18 and the Health Board Corporate Clinical Audit priorities. The Plan provides opportunities for all services to be engaged in prioritised clinical audit and although challenging, clearly identifies the Health Board s commitment to delivering safe, high quality care which is evidence based. The Plan and the clinical audit projects contained within it provide a framework on which to audit and benchmark local services to ensure they meet national and local standards. 2. Development of the Clinical Audit Plan 2.1 NHS Wales Plan The comprehensive programme of national clinical audit projects adopted by the Welsh Government, the NHS Wales National Clinical Audit and Outcome Review Annual Plan 2017/18 as determined by the National Clinical Audit & Outcome Review Advisory Committee is shown at Appendix 1. This is the 6th annual National Clinical Audit and Outcomes Review Plan confirming the list of National Clinical Audits and Outcome Reviews in which all health boards and trusts are expected to participate when they provide the service. National Clinical Audit and Outcome Reviews (formally Confidential Enquiries) provide valuable comparative information at national and local level enabling organisations and clinicians to compare achievements and share experiences with peers. Topics contained within the NCAORP are overseen by the Healthcare Quality Improvement Partnership (HQIP). The audits included in the National Clinical Audit & Outcome Review Plan which are not applicable to BCUHB are: National Adult Cardiac Surgery Audit National Audit of Congenital Heart Disease (due to care provided in Manchester) Paediatric Intensive Care (PICaNet) Betsi Cadwaldr University Health Board 2017/18 Clinical Audit Plan (Oct 2017)

84 Page 3 of 6 Additional projects that have been added to the 2017/18 National Clinical Audit & Outcome Review Plan include: National Breast Cancer Audit Epilepsy 12 National Maternity and Perinatal Audit National Audit of Psychosis 2.2 BCUHB Corporate Clinical Audit Plan 2016/17 This outlines Corporate Clinical Audit priorities agreed by the Clinical Audit and Effectiveness Sub Group and the Quality and Safety Group identified as being of importance across the Health Board. They have been included as a result of local and national triggers such as recommendations within Ombudsman Reports, from concerns and risks, or as a directive on an All Wales level. It is fully anticipated that the Corporate Clinical Audit section will need to be flexible and adapt to the changing needs of the Health Board as a result of national or local influences such as adverse clinical events, critical incidents and breaches in patient safety or external reports. Therefore there may be changes to the Plan as the year progresses. This Section also shows additional Health Board wide projects that are being performed. BCUHB Corporate Clinical Audit Plan: 2017/ /18 BCUHB Corporate Clinical Audits: Title Driver Project Lead Scope / Aim of Audit Re-audit Date Consent Putting things Right Dr Ben Thomas Consultant in Acute Medicine (and Interim Associate Medical Director - Clinical Law and Ethics) Healthcare professionals must ensure that patients know enough to enable them to decide about their treatment. BCUHB has an agreed policy in order to outline the best practice when obtaining consent which states; Valid consent to treatment is absolutely central in all forms of healthcare, from providing personal care to undertaking major surgery. Seeking consent is not only a legal obligation but also a matter of common courtesy between health professionals and patients. The Consent and Capacity Strategic Working Group will consider inclusion of the further elements of Treatment in Best Interests (Form 4) and Material Risk in the June / July 2018 re-audit. Work also continues through the Consent and Capacity Strategic Working Group in relation to the Procedure-specific consent forms and also education. Re-audit June / July Betsi Cadwaldr University Health Board 2017/18 Clinical Audit Plan (Oct 2017)

85 Page 4 of 6 Record Keeping Putting things Right BCUHB Health Records Group Poor record keeping is often identified in patient concerns, risk incidents and Ombudsman s reports. Two rounds of data collection have been completed in the West Area which has involved direct involvement of Assistant Medical Director (AMD) alongside junior doctor participation in order to maximise the opportunity for training and accountability. FY1 And FY2 training has been provided by AMD. Central and East data collection to be scheduled. This audit will aim to determine compliance against agreed national standards (Royal College of Physicians and the Nursing and Midwifery Council Guidelines). Based on these national standards, a template had been devised and agreed by the BCUHB Health Records Group to facilitate a standardised approach to record keeping audit. In West area, reaudit completed in (May 2017) and further re-audit scheduled for November 2017 Central and East Area audits to be scheduled. Other local team record keeping audits are requested to be registered with the CA&E Dept. Discharge Planning Informing GP s of discharge within 48 hours Putting things Right Primary Care Support Unit Awaiting notification of new lead or overseeing committee Dr Mark Walker An audit of the BCUHB Discharge policy is currently in the planning and consultation stage. There are currently a number of work-streams which overlap and have impact upon discharge and patient flow; such as SAFER ; in particular the Safety Huddle and Bundle (Red to Green) activity. It had therefore been decided to continue to gain feedback from key colleagues and identify the most effective audit standards to incorporate. The re-audit has been requested by the Deputy Medical Director. Data has been collected and is currently in the analysis stage. The report will be circulated in November Date of re-audit to be confirmed. Anticipated to be February 2018 To be decided by Deputy Medical Director Betsi Cadwaldr University Health Board 2017/18 Clinical Audit Plan (Oct 2017)

86 Page 5 of 6 Additional BCUHB-wide projects Title Driver Project Lead Scope / Aim of Audit Re-audit Date Hospital Acquired Thrombosis Patient Safety Group Office of the Medical Director A work-stream for HAT audit and improvement intervention is led by the Clinical Nurse Specialists and managed by the Office of the Medical Director (OMD). Dates scheduled by OMD Rapid Response to Acute Illness (RRAILS) Putting things Right Office of the Medical Director (OMD) A work-stream for RRAILS audit and improvement intervention is managed by the Office of the Medical Director (OMD). Dates scheduled by OMD Ward Quality & Safety Audit Health & Care Standards Diane Read (Head of Transforming Care) Information Reporting Intelligence System (IRIS) linked in with the Health & Care Standards Audit (previously referred to as Fundamentals of Care Audit). Ongoing HARM Dashboard Health & Care Standards Diane Read (Head of Transforming Care) Collecting existing data from various streams e.g. DATIX, ESR, etc. Ongoing Antimicrobial Audit Infection Prevention & Control Office of the Medical Director Monthly antimicrobial ward-based data collection. Ongoing Prescription Chart Audit (including antibiotic, O2, medication errors, VTE) Infection Control All Wales Pharmacy Group Strategic Infection Prevention & Control Group Pharmacy (sitebased leads) Strategic Infection Prevention & Control Group Point prevalence study driven by All Wales Pharmacy Group. Three data collection points that focus upon Prescription Chart Audit (including antibiotic, O2, medication errors, VTE). Collaboration between Pharmacy and Ysbyty Gwynedd doctor, Dr Bedwell. This activity relates to the on-going audits overseen by the Strategic Infection Prevention & Control Group and also reported through the Quality, Safety & Experience Groups. Point prevalence due to complete in January 2018 On-going data collection. Betsi Cadwaldr University Health Board 2017/18 Clinical Audit Plan (Oct 2017)

87 Page 6 of 6 Appendix 1 NHS Wales National Clinical Audit and Outcome Review Annual Plan 2017/18 The programme is shown on pages 8-15 of the attached document (also available as a Welsh language version) Betsi Cadwaldr University Health Board 2017/18 Clinical Audit Plan (Oct 2017)

88 1 JAQS17_6c Clinical Audit Plan Appendix 1 NHS Wales National Clinical Audit and Outcome Review Plan-2017_18.pdf National Clinical Audit and Outcome Review Annual Plan 2017/18 Crown copyright 2017 WG ISBN Mae r ddogfen yma hefyd ar gael yn Gymraeg. / This document is also available in Welsh.