QUALITY & SAFETY COMMITTEE. NHS Outcomes Framework responding to feedback to improve services

Transcription

1 1 Trust Patient & Donor Feedback Report 2016/17 QUALITY & SAFETY COMMITTEE NHS Outcomes Framework responding to feedback to improve services Meeting Date: 7 th December 2017 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Lisa Heydon-Mann, Quality & Safety Manager Professor Susan Morgan, Executive Director of Nursing/Service Improvement Jan Pickles, Independent Member Quality & Safety Committee Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Committee are requested to note and endorse the contents of the Quality & Safety Committee Annual Report 2016/17 This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Dignified Care Timely Care Individual Care Page 1

2 2 Trust Patient & Donor Feedback Report 2016/17 1. Introduction / Background As part of the NHS Delivery Framework for the following performance measure has been included under the domain Dignified Care : Performance measure: Evidence of how NHS organisations are responding to patient feedback to improve services. To evidence this, a proforma has been prepared by Welsh Government enabling health boards and trusts to evidence that patient experience feedback is gathered and acted upon in all care settings. 2. Timing: Welsh Government require NHS organisations to submit a report on an annual basis (deadline 29 September 2017) to capture activity undertaken between April 2016 and March Description: The NHS Framework for Assuring Service User Experience was updated in 2015 to include the need to gain feedback from concerns, complaints, compliments and clinical incidents. It is intended to guide and complement service user (patient) feedback strategies in all NHS Wales organisations. It outlines three domains to support the use and design of feedback methods and recommends a four quadrant model to build on existing expertise and resources. NHS organisations are required to evidence that patient experience feedback is gathered and acted upon in all care settings (as applicable). The annual report provides an overview of the main patient and donor feedback activity during the period April 2016 March Financial Impact: Nil identified. 5. Quality, Equality, Safety and Patient Experience Impact: The report provides an overview of service improvement activity as a result of learning from feedback. 6. Considerations for Board / Committee: The Committee are required to note how the service areas of the Trust are responding to patient and donor feedback to improve services 7. Next Steps: Note and Endorse the patient and donor feedback report 2016/17 Page 2

3 Evidence of how NHS Organisations are responding to Patient Feedback to Improve Services NHS Organisation Velindre NHS Trust Date of Report 29 th September 2017 Report Prepared By Lisa Heydon, Quality & Safety Manager Planned Care What has your organisation done to encourage feedback from patients on their experience of care and treatment? Velindre NHS Trust is a nationally recognised specialist centre of excellence for the provision of non-surgical oncology including radiotherapy and chemotherapy; specialist palliative care; blood transfusion; specialist immunohaematology; antenatal blood testing reference work; and transplant immunology. Velindre Cancer Centre (VCC) The Velindre Cancer Centre is a specialist treatment, teaching and research and development centre for non surgical oncology, treating patients with chemotherapy, radiotherapy and related treatments, and caring for patients with specialist palliative care needs. The Welsh Blood Service (WBS) The Welsh Blood Service plays a fundamental role in the delivery of healthcare in Wales. It works to ensure that the donor s gift of blood is transformed The NHS Framework for Assuring Service User Experience was updated in 2015 to include the need to gain feedback from concerns, complaints, compliments and clinical incidents. It is intended to guide and complement service user (patient) feedback strategies in all NHS Wales organisations. It outlines three domains to support the use and design of feedback methods and recommends a four quadrant model to build on existing expertise and resources. NHS organisations are required to evidence that patient experience feedback is gathered and acted upon in all care settings (as applicable). Reporting Schedule: Evidence of how NHS organisations are responding to patient experience feedback to improve services is to be reported annually. This form is to be submitted on 30 September to cover the period April 2016 to March Planned care What has your organisation done to respond to patient feedback in order to improve services? The themes and learning from all complaints are captured centrally through reporting to the Trust Organisational Learning Committee. Within the service divisions, learning is captured via their quality and safety forums. During the period, the following improvements were identified from the investigation of concerns, and implemented to improve services: Velindre Cancer Centre Standards developed for the use of answer machines and suitable timescales within which patients will receive a return telephone call following messages left with medical secretarial teams; Improved arrangements in place for informing ward staff at other hospitals of their inpatient s scheduled appointments at VCC;

4 into safe and effective blood components which allow NHS Wales to improve the quality of life and save the lives of many thousands of people in Wales every year. The Velindre Cancer Centre (VCC) is the only patient facing service provided by Velindre NHS Trust. The VCC has adopted the NHS Wales service user experience framework which identifies the three key determinants of a Good service user experience. 1. First and Lasting Impressions 2. Receiving care in a Safe, Supportive, Healing Environment, 3. Understanding & Involvement in Care These three domains are used to support the use & design of a range of feedback methods to help the organsiation understand the patient experience. Under the framework, the complaints process is an important mechanism for receiving feedback on services and during the report period, a total of 190 complaints were received by the Trust (of which 39 were investigated under the concerns regulations with the remaining 151 managed informally or on the spot). All complaints are investigated and actions are identified to reduce the risk of a repeat in the future. Trend analysis and outcomes of all complaints are reported quarterly to divisonal quality and safety groups and to the Trust Organisational Learning Committee, Trust Quality & Safety Committee and Executive Management Board. It is also important to recognise the patients, relatives, carers and donors contacting us to let us know the good care they have received. The number of formal compliments and those received via social media underestimate the large number of thank you messages and cards received by clinical teams on a day to day basis. We are very grateful to patients, relatives, carers and donors for taking the time and effort to let us know how good their experience of our care has been. Feedback is shared with clinical teams/blood collection teams as appropriate and helps encourage our staff to keep doing the best they A pathway developed to ensure that patients referred for proton beam therapy abroad (and their families/carers and referring clinical teams) are appropriately supported through the process, from the point of referral through to treatment; Improved the process at outreach clinics to conduct daily checks against patient lists and arrival of chemotherapy (to avoid the occurrence of patient arriving for unavailable treatment); Cover arrangements for outreach PICC clinic was reviewed to ensure continuation of service as/when required; Improved 1:1 education sessions with patients making them more individualised, patient led to allow opportunities for concerns to be raised; An organisational review has been set up of how changes are made to patient details within their electronic patient record; A review has been established of the systems and processes in place which support the scheduling of investigations and clinic appointments; All recommendations/improvement actions arising from the investigation of complaints received in respect of VCC are captured and the VCC Concerns Forum (comprising senior clinicians, senior management and concerns colleagues) provides a forum for formally approving recommendations, where appropriate, and ensuring they are completed within their associated timeframes. Welsh Blood Service All feedback from donors is reviewed and, if deemed appropriate, fed into the relevant work stream of our Blood Supply Chain 2020 programme. This also includes suggestions from staff. Examples include: A real time online booking system for donors was introduced. Further Donor feedback is being fed into the next stage of development of the appointment system project. A programme of work was introduced to review clinic accessibility in line with donor demand; i.e. opening times and venues

5 can for our patients and donors, and to receive feedback on what works well. Launch of the PAL Service During the year we launched a new Patient Advice and Liaison Service (PALS) in the Cancer Centre to help patients and their families to resolve nonmedical problems that might be causing concern or confusion when they are visiting the hospital. Our service has been funded for 3 years thanks to the support of charitable donations. Working closely with the Patient Experience Manager, the PALS advisory and advocacy role helps ensure the patient experience goes as well as possible, and problems are resolved before they have a chance to escalate and cause major concern or stress. Last year we said we would increase opportunities for patients and donors to give us feedback about their experience to take this forward, we have used social media platforms to introduce a variety of ways for patients and donors to give us feedback. Someone Else s Shoes The Cancer Centre launched a new audio podcast called Someone Else s Shoes. The podcast aims to increase understanding and enable learning and opportunities for improvement through sharing patient, care and staff stories. In the first podcast David talked about his diagnosis and the importance of his faith. In the second, Linda shared her experience of A&E, radiotherapy at Velindre Cancer Centre, and the Macmillan Activity Programme. Listening and learning from Donor feedback Donor feedback provides the Welsh Blood Service with opportunity to better understand donors experience and to identify opportunities for improvement in services delivered. Donors can feed back via a variety of mediums including: At Clinics Via Social Media Through our Website Donor esurvey Feedback from donors and staff was used to support system updates and improvements since the introduction of changes to the way donors complete their health check questionnaire, reducing waiting times at our clinics; Gluten free post donation snacks was introduced at our clinics; Concerns & feedback trends All donor concerns are reviewed, investigated and where necessary, actions undertaken to avoid recurrence of the issue. Trending and reporting of issues is conduceted and fedback via Operational Service Group meetings to the relevant departments. Monthly reports are also given to the WBS SMT. In May 2016, the Welsh Blood Service undertook a major service transformation with the adoption of the North Wales region, following which, the Welsh Blood Service saw a small rise in complaints resulting from changes North Wales donors had experienced to their online booking process following service transfer. The introduction of the online appointment system in January 2017 has reduced these concern types. There has continued to be a trend in communication and administration concerns in relation to clinic notifications for North Wales donors and this feedback is being used to inform donor engagement work being carried out under the Blood Supply Chain 2020 initiative. There remains low number of complaints received by VCC during Whilst no key continuing or emerging trends in complaint types were identified, a further analysis of formal complaints in recent years has identified some element of communication/issue relating to informed consent, prognosis and/or treatment intent (though it should be noted that not all complaints have, on investigation, been upheld). Work is being taken forward both nationally and within VCC around consent forms and discussions with/amongst clinicians have commenced around some of the general communication issues identified.

6 The Welsh Blood Service undertake a weekly survey of donors who have been invited and/or have attended clinics in the previous week. The survey asks donors for feedback on the full cycle of service provided by the WBS and also invites suggestions for improvements and general feedback. Donor compliment and concern cards are made available at the tea table at all donor clinics for donors to provide feedback of their experience. These are placed in a confidential locked box in the clinic and returned at the end of the working day to head office for analysis. Staff actively invite feedback from donors during their donation session and concerns and feedback are gathered by team staff either on feedback forms or by actively encouraging donors to complete compliment and concern cards at the clinic. Donor feedback has resulted in changes to clinic opening times and appointment systems. We routinely ask our donors to rate their experience of blood donation clinics and every month of the year we exceeded our target of at least 75% of donors rating their satisfaction as 5 and 6 out of 6. The Welsh Blood Service investigated 23 formal complaints during the year. Listening and Learning from patient Experience: We know that we need to make it as easy as possible for patients and their families to feedback on our services. To expand the range of feedback mechanisms we have introduced the following: An online patient survey A snapshot survey A survey for children & young people How Did We Do? feedback stands placed around the Cancer Centre Surveys in our outreach clinics at Prince Charles Hospital and the Tenovus Mobile Unit. We routinely ask our patients to rate their experience of cancer centre services and in 10 out of 12 months of the year we exceeded our target Sharing the Learning The Patient Safety Champion Nurses within the Velindre Cancer Centre continue to play a key role in the investigation and follow-up of complaints. These roles play an important role in sharing learning from complaints and have utilised clinical safety learning days for nursing staff to share learning and feedback from clinical incidents and implementation of 1000 lives plus initiatives. The Significant Clinical Incidents Forum (SCIF) at the Velindre Cancer Centre also has responsibility for identifying lessons learned at a local level. The SCIF group formally reports into the Trust Safety Committee and Trust Organisational Learning Committee. During 2016/17 SCIF has continued to meet and investigate concerns. Action plans and recommendations are developed where appropriate, the approval and monitoring of which will be assigned to the VCC Concerns Forum. Quarterly open SCIF meetings are held to share lessons and learning. The Forum also has a system Speedy Cascade of Important Feedback which is a structured update to appropriate staffing groups raising awareness and reminding everyone of how sometimes simple things can make a big difference. All recommendations/improvement actions arising from the investigation of complaints received in respect of VCC are captured and the VCC Concerns Forum (comprising senior clinicians, senior management and concerns colleagues) provides a forum for formally approving recommendations, where appropriate, and ensuring they are completed within their associated timeframes. Outpatient Learning Collaborative We know that patients are routinely waiting longer than we would like before they are seen for their outpatient appointment. The Cancer Centre Service Improvement Team are working with staff in the Outpatient Department to look at the reasons why individual clinic appointments are delayed, whether clinics are scheduled during the week to best utilise the space and staff available, and the reasons why

7 of at least 80% of patients rating their satisfaction as 9 and 10 out of 10. Patient Liaison Group The Cancer Centre s Patient Liaison Group (PLG) was established in 2002 to provide a listening voice for patients and carers, and over the years the PLG has helped support, inform and develop services at the Cancer Centre. In the coming year the PLGs priorities will be refreshed and developed as part of a wider involvement framework, including launch of the Velindre Involvement Panel which will enable patients and carers to contribute online and help us develop services for the future. Analysing patient feedback The Trust recognises the importance of patient and donor feedback and has also sought to improve the way in which feedback is analysed. During the year the Trust: strengthened links between concerns and patient experience teams and promoted joint working so the full range of patient/donor feedback can be triangulated; reviewed the Trust Organisational Learning Committee, to develop a more dynamic approach to the sharing of learning across the organisation which ensures that learning is not stand alone, isolated or localised but is instead is constant, embedded and showcased throughout and across the organisation; reviewed and prepared processes across the Trust to support the implementation of the national concerns data set pilot aimed at developing a core set of data which will enable consistency of reporting across NHS Wales and provide a framework for measuring/assuring service user experience; further developed the complaints module within our existing patient safety and risk management computer software to enhance complaints reporting and provide some patients do not attend their clinic appointments. Information has been collected and following analysis will be used to make recommendations to the way we currently run Outpatient clinics. Examples of compliments received have included: Velindre Cancer Centre Fabulous hospital staff are always happy helpful, nice & clean hospital You can't love going for Radiotherapy, but the staff are lovely, the facilities are top rate. No complaints with being made to feel welcomed, at ease and extremely well looked after. They re like a tonic. Every department is fantastic. I have a phone call off the doctors and nurses every six months to see how I m doing. The friendliness of staff is second to none. It s quiet and private here, you have adequate equipment. Why would you go anywhere else when you have this on your doorstep. Everyone is so helpful and kind they do their best to try and relieve the boredom. All the staff on the unit are fantastic and do an excellent job. Couldn t get better treatment. Staff are friendly. You can talk to them. It s open and friendly you can ask whatever you need to ask, treated normally as if it s just another illness. Overall atmosphere is perfect, highly professional and caring. We think it s great here, have been coming for three years now and think it s marvellous. Everyone knew my first name, I felt they remembered me, it made me feel more comfortable. The staff were very supportive, friendly, kind, helpful, understanding. Listened to my needs, always there for me. It didn't seem like a hospital, it felt like a five star hotel. Cleanliness was excellent.

8 improved access to complaints data for Managers and Directors; and active promotion of informal resolution of concerns at source and further development of Datix to manage informal complaints. This has provided clarity around the role of Patient Advocacy Liaison, departmental managers and the central concerns team. Doctors all understand what I was going through. Always a good experience. Amazing place. Reflexology Excellent. Excellent! Don't treat you like a patient, treat you like a friend. Chat and laugh with them. Staff always friendly and attentive. Treatment and care has been excellent throughout. A very caring team, you generally feel like they are looking out for you. Being treated and talked to, chatted to, like a normal human being, not a cancer patient by the staff when receiving treatment. I have been overwhelmed by the kindness and quality of care I have received in every part of Velindre. I am 70 years old and never have I received such excellent care anywhere else in my life. A very caring team, you generally feel like they are looking out for you. Welsh Blood Service Always lovely friendly service!! The staff are so kind and happy!! Makes me want me to donate every time they're in town!! As always the whole visit is excellent. I am always treated really well and the staff are well trained and always extremely helpful and pleasant. Well done all!! Brilliant service. Staff superb in all aspects, made me feel at ease, nothing too much trouble and excellent choice of refreshments. Felt valued and contribution makes a difference. Pleasure to donate. Very good service love going there. Feel good after giving. Glad I am well so I can help others. Shame I can only give 3 times a year. A pleasure again!! All staff were polite and helpful and lovely. Sad to be moving back to England and

9 leaving you all behind. Thanks so much. A wonderful team. I was very happy with the service and am happy to say that there has definitely been an improvement in the waiting time when attending I'm always satisfied with the service by all your staff. Everyone is very friendly, and reassuring as I'm always nervous!! My 11-year-old son always comes to watch and the staff are very good in describing each stage and how important it is to give blood to save lives. He now wants to give blood when he's old enough. Completed form to be returned to: hss.performance@gov.wales Appendix 1 identifies the range of feedback mechanisms that VCC currently use Appendix 2 identifies the range of feedback mechanisms that WBS currently use

10 VCC Feedback Mechanisms Appendix 1

11 Appendix 2 WBS Feedback Mechanisms Real Time Retrospective Feedback from donors at clinics either verbally or via compliment and concern cards Donor adverse events process Donor esurvey sent to donors invited to attend donation clinics Service improvement initiatives Service Transformation Programme Quality Safety Standards Board Concerns and Donor Experience Review Collections business meeting and operational review Proactive & Reactive Balancing Postal surveys WBS Twitter feed WBS facebook WEB website Donor concerns process Clinical review of donor adverse events Staff feedback from clinics Working better together

12 Quality & Safety Committee Learning from the KW Review Meeting Date: 7 th December 2017 Authors: Sponsoring Director: Report Presented by: Committee/Group who have received or considered this paper: Jayne Elias, Assistant Director of Nursing & Service Improvement Professor Susan Morgan, Executive Director of Nursing & Service Improvement Professor Susan Morgan, Executive Director of Nursing & Service Improvement Safeguarding Steering Group Executive Management Board Trust Resolution to: (please tick) APPROVE: REVIEW: INFORM: ASSURE: Recommendation: The Quality & Safety Committee is asked to note the key findings of the Desktop Review Lessons Learned Report published by ABMuHB, and to note information about the processes in place within Velindre NHS Trust. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Standard 2.7 Safeguarding Children and Safeguarding Adults at Risk

13 2 [Report Title] 1. Introduction / Background In August 2017 ABMuHB published a redacted report detailing findings of a desktop review of lessons learned following the retrospective review of the management of allegations of sexual assault of patients with a learning disability by a Health Board employee (KW). Whilst suspended from employment in connection with the allegations of sexual assault, KW was arrested and later convicted of murder. The circumstances of his crime were unconnected to his employment but prompted questions about the processes followed by the Health Board when allegations of historical sexual assault were raised by patients. The Health Board review considered: KWs employment history, including potential conflict of interest arising from a familial relationship with a senior manager within the HB at the time of the allegations of sexual assault The management of the allegations made by patients Health Board governance processes Opportunities for learning and improvement 2. Timing: In September 2017 Welsh Government wrote to each of the Health Boards and Trusts in Wales requesting that Chief Executives review the report findings and seek assurance that good governance is in place in relation to incident reporting, safeguarding, employment practices, and that appropriate guidance is followed to protect patients. 3. Financial Impact: There are no specific financial considerations to bring to the attention of the Quality & Safety Committee. 4. Quality, Equality, Safety and Patient Experience Impact: Standard 2.7 of the Health and Care Standards (Safeguarding Children and Safeguarding Adults at Risk) requires health services to promote and protect the welfare and safety of children and adults who become vulnerable or at risk at any time. Section 128 of the Social Services and Wellbeing (Wales) Act 2014 imposes a statutory duty on relevant partners (including Health Boards and Trusts in Wales), to report concerns to a Local Authority in relation to adults at risk Considerations for Board / Committee: 1 An "adult at risk", is an adult who: (a) is experiencing or is at risk of abuse or neglect, (b) has needs for care and support (whether or not the authority is meeting any of those needs), and (c) as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it. Page 2

14 3 [Report Title] The redacted report can be accessed via: s%20learned%20report.pdf The review concluded that: There were a number of process issues regarding the employment and redeployment of KW within the HB. Incident reporting procedures were not robustly followed when serious allegations were raised by service users including a lack of escalation and further exploration resulting in delay in the initiation of Protection of Vulnerable Adult (POVA) processes. All of the allegations were referred to the police who conducted criminal investigations. The Crown Prosecution Service decided not to prosecute following which internal disciplinary proceedings were initiated. Whilst a number of issues relating to governance, adult safeguarding, recruitment, culture and incident reporting were identified, the review did not conclude that KW s future conduct and behaviour outside of his employment could have been predicted. Details of lessons learned and subsequent service improvements are detailed in the report. Welsh Government have been advised in relation to Velindre NHS Trust processes: Incident reporting: The Trust appointed a Senior Nurse for Safeguarding and Public Protection in January The post holder provides advice and guidance to staff in relation to all aspects of the safeguarding portfolio. An automatic alert is sent to the Senior Nurse for Safeguarding and Public Protection when an incident alleging abuse or neglect is reporting via Datix. The Senior Nurse for Safeguarding and Public Protection screens all potential safeguarding incident reports on Datix to ensure appropriate action is taken. A record of all safeguarding enquires and referrals is kept on a secure data base accessible to authorised personnel in the Trust only. Safeguarding practices: The Trust s policy for responding to allegations of abuse (of an adult at risk or child, in or outside of a work context) by a professional/staff member is under review. A revised policy will be issued for wider consultation across the organisation early in October. If an allegation of abuse is made in relation to a member of Trust staff, a Professional Strategy Meeting is convened to consider actions that need to be initiated to potentially safeguard adults and/or children at risk, as well as the individual staff member, whilst investigation processes are in progress. Attendance of Senior HR/workforce and safeguarding colleagues is mandatory. The Professional Strategy Meeting is operated as a parallel process to the safeguarding discussions, safety planning arrangements and investigatory process in relation to the individual adult or child at risk. This is to ensure that each separate aspect of decision making is undertaken robustly. Employment practices: All positions within the Trust have been assessed in relation to the level of Disclosure and Barring (DBS) check required. This process is facilitated on behalf of NHS Wales through NHS Shared Services Partnership. Recruitment processes are undertaken utilising the Trac system, including take up of references and other employment checks. Safeguarding training for HR and workforce colleagues is planned for 27 th November The programme will now be revised to include learning from the KW Review. Page 3

15 4 [Report Title] 6. Next Steps: The Quality & Safety Committee is asked to note the key findings of the Desktop Review Lessons Learned Report published by ABMuHB, and to note information about the processes in place within Velindre NHS Trust. Page 4

16 TRUST QUALITY & SAFETY COMMITTEE PART A RADIATION PROTECTION COMMITTEE HIGHLIGHT REPORT Meeting Date: Author(s): Sponsoring Director: Report Presented by: 7 th December 2017 Matthew Talboys Claire Power Andrea Hague Andrea Hague Trust Resolution to: (please tick) APPROVE REVIEW: INFORM: ASSURE: Recommendation: This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well ACRONYMS This report supports the following Health & Care Standards:

17 2 Highlight Report EXECUTIVE SUMMARY: This paper had been prepared to provide the Board with details of the key issues considered by the Radiation Protection Committee incorporating Medical Exposure Sub- Committee at its meeting on the 27 th October 2017 The Board is requested to NOTE the contents of the report and actions being taken Key highlights from the meeting are reported below: ALERT N/A In the New Year there will be new Ionising Radiations Regulations 2017 and Ionising Radiation (Medical Exposure) Regulations 2018 that the Trust must comply with, including application of a license. ADVISE The process of managing the transition to the new regulations in the Trust is being undertaken by the Radiation Protection Service (RPS). A working group of RPS members have been assembled and guidance documentation issued to all managers and RPS using ionising radiations. The documentation will assist RPS in undertaking the registration and consent(s) required by the HSE in the New Year. Revisions to Trust radiation policy and procedures will also be required in light of the new regulations. New guidance has been issued on Investigation and Notification of medical exposure much greater than intended. These changes may lead to an increase in reportable incident as the criteria for reporting has been amended. Artificial Optical Radiation Safety Policy has been developed to ensure the Trust has a policy to cover its statutory requirements of the Control of Artificial Optical Radiation at Work Regulations ASSURE Natural Resources Wales undertook a regulatory inspection of VCC on the 2nd August The scope of the inspection included the consolidated open and waste permit and concentrated on the Nuclear Medicine and Research Departments. No non-conformances were identified in each area which is an excellent achievement and testament to the good compliance processes in place in each area. INFORM The Terms of Reference for the committee are currently being reviewed.

18 3 Highlight Report Report History The Radiation Protection Committee incorporating Medical Exposure Sub- Committee highlight report is a standing 6 monthly standing agenda item

19 QUALITY & SAFETY COMMITTEE REPORT PART A TRUST RISK REGISTER Meeting Date: 7 th December 2017 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Trust Quality & Safety Coordinator Executive Director of Nursing & Service Improvement Executive Director of Nursing & Service Improvement Executive Management Board Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Committee are asked to DISCUSS and ENDORSE the Trust risk register and the actions status of the Trust register. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well

20 2 December 2017 This report supports the following Health & Care Standards: Governance, Leadership and Accountability Staying Healthy Safe Care Effective Care Dignified Care Timely Care Individual Care Staff and Resources 1. Introduction / Background: The purpose of this report is to present to Committee members the high level organisational risks contained on the Trust Risk Register and the management actions being taken to manage or mitigate these high level risks. The Committee are requested to: 1. Review the Trust risks 2. Provide assurance that Trust risks are being managed/mitigated 3. Endorse the content of the Trust risk register 2. Timing All divisions /departments have a register of risks which are updated and reviewed within the service division. The divisional senior management teams (SMTs) work with their supporting groups/ committees to ensure effective controls are in place for their risks to be managed at a tolerable level. The divisional SMT will determine whether the risk should be escalated onto the Trust risk register. 3. Description: The Executive Director of Nursing & Service Improvement, as the Executive lead on Risk Management, will invite lead Directors, or their nominated representatives, to present and lead a discussion on their areas of identified risk at each meeting in which the Risk Register is presented. Lead Directors are responsible for ensuring that risks are regularly updated and advise the Trust s Quality & Safety Dept that the information contained in the Risk Register is accurate and kept up-to-date. It is the responsibility of lead Directors, or their nominated representatives, to ensure that any changes/updates to risk narrative arising from discussions at meetings are fedback to the Trust s Quality & Safety Department in a timely manner. 4. Financial Impact: Financial risk will vary for each individual risk reported on the Trust Risk Register. 5. Quality, Equality, Safety and Patient Experience Impact. The high risk areas considered to have an impact on quality, equality, safety and patient experience are identified in the Trust Risk Register. Page 2

21 3 December Risk Activity during November 2017 All risks have had the opportunity to be considered by the appropriate Division prior to the risk register being received by the EMB and Trust Board. Due to the scheduling of Trust Committees the risk register for Quarter 3 has not been received by all the appropriate committee/group for consideration or comment. However, the risks were reviewed and approved at EMB on the 15/11/17 and Trust Board 30/11/17. (New Risk Data Integrity Controls in Relation to CANISC) EMB discussed the risk assessment and agreed for it to be received at the next IM&T Management Group to consider and obtain a recommendation. The recommendation is to be received at EMB 13/12/17. Risk 5807 lack of physical space at VCC It was agreed by EMB members that risk 5807 achieved all its actions but was to remain on the risk register for monitoring. The VCC Director will update the risk narrative for EMB 13/12/17. New Risk identified Risk Data Integrity Controls in Relation to CANISC An MHRA inspection finding noted that the safety and integrity of patient data is at risk as the CANISC system is not adequate in providing a protected area for source data storage and a traceable audit trail. VCC SMT requested escalation of the above risk to the Trust Risk Register. De-escalated risks to Divisions Lack of resources and capacity to implement new drugs (SACT's) within the revised timescales of 60 days could prevent the VCC complying with this statutory requirement. Risk reviewed at Planning & Performance Committee and decision made to deescalate to VCC Divisional risk register for monitoring. The following section provides an overview of the committees and groups where each risk has been reviewed during the period November 2017, along with the outcome of any changes/discussions. Risk title Received at Committee and /or Trust Board & outcome of discussion 5807 lack of physical space at VCC EMB P&P Com Trust Board 5808 Availability of sufficient radiotherapy capacity within available financial resource Failure to Deliver the new LIMS for WBMDR Non delivery of expected benefits from the Transforming Cancer Services programme. Page 3 - Status agreed EMB P&P Com Trust Board - Status agreed EMB Trust Board - Status agreed EMB P&P Com Trust Board

22 4 December Status agreed Transforming Cancer Services Infrastructure Project Significant CANISC system failure - Electronic access of patient medical histories would not be available to guide treatment decisions. Closed Risks EMB P&P Com Trust Board - Status agreed EMB Trust Board - Status agreed No risks have been closed. 7. Next Steps The Committee are asked to DISCUSS and ENDORSE the Trust Risk Register and the actions status of the Trust register. Page 4

23 Status of Register: Active November 2017 (Quarter 3) Next review Date: December 2017 Executive Management Board 4.2 Trust Risk Register Datix Risk Ref Risk Statement Date Risk Identified Initial Score based on Impact & Likelihood I L S Date & Rating when last assessed Current Score based on Impact & Likelihood? I L S Action agreed at last risk assessment Progress Target Risk Rating & Target Date Exec Lead for Risk Assuring Com for Risk Dates register reviewed by Committees during the quarter 5807 Currently there is a lack of physical space to accommodate the current requirements for services delivered at VCC. Accommodation Area of the hospital accommodation for both staff and patients is not fully compliant with a number of workplace regulations because of the age of the building and may effect staff and patient wellbeing 01/12/ Date assessed 06/10/17 Amber 12 Due for review 06/04/ Approval of short term Accommodation and implementation Plan from Welsh Government in relation to the ongoing individual accommodation projects for improvement of the current site: Outpatient department, Pharmacy, Mortuary, Rhosyn Ward and Theatre minor repairs. 2. Continue to review best utilization of space and usage: possible increase in the use of outreach clinics, assessment of office areas to ensure compliance to workplace regulations, Managers to document issues related to stress, ill health, occ health or exit interviews, feedback that is directly attributed to the lack of space or current working environment. 1. Accommodation review of prioritised areas within VCC has been completed. The accommodation PBC Interim Service Solution at Velindre Cancer Centre has been presented to Trust Board on 24th November 2016 and was approved for submission to the Welsh Government. Welsh Government have requested that the movement of the mortuary to the main hospital Building and the refurbishment of Pharmacy are progressed to BJC s. The other areas of the PBC will be reviewed at a later time. Work is being progressed to ready the submission of the BJC for Mortuary by December Pharmacy works are being reviewed. 2. Being reviewed and implemented by Velindre Cancer Centre SMT. 3. SMT is working collaboratively with the Transforming Cancer Services team in the delivery of the long term service strategy. Yellow 6 16/03/19 Director VCC Planning & P'mance Committee Divsions Oct 17 P&P Com EMB TB Monitoring of long term plan for new hospital facilities and services Availability of sufficient radiotherapy capacity within available financial resource affects achievement against national cancer standards. Patients may not be treated to optimum treatment timescales, which may affect the overall patient experience and may lead to poorer outcomes. 01/06/ Date Assessed 14/08/17 Red 20 Due for review 14/02/ New Business Case is being developed for commissioners for additional Radiotherapy capacity to meet forecast demand 2. Continue with Efficiency/Service Improvement work to ensure maximum efficiency within Radiotherapy services. 1. Business case for additional radiotherapy capacity has been Yellow 6 submitted to the commissioner group. Initial feedback has been received and there is ongoing dialogue with commissioners re 28/02/18 outstanding queries. However at this stage the Health Boards have not committed funding for this business case in their IMTPs. In addition following the negative decision re arbitration case the service is reviewing the impact of that decision upon capacity that can be provided within commissioned resources. 2. The need for the additional capacity is also outlined in the Trust s IMTP and the radiotherapy objectives have been developed and prioritised to match the business case. Work is in progress to devise a contingency plan for the possibility of no additional funding becoming available for the additional business case but also for the scenario whereby the service has to reduce capacity to core commissioned levels. VCC Director Planning & P'mance Committee Divsions Oct 17 P&P Com EMB TB Regular discussions at EMB and divisional/trust Planning and Performance Committees re:sustainable capacity to meet demand. 1

24 11531 (prev 7025) Failure to Deliver the new LIMS for WBMDR as per project plan. Failure will see a breech of regulation & loss of HTA License which will result in closure of the registry and inability to comply with Single European Code. Originally, the WTAIL requirements were planned to be delivered as part of the main All Wales LIMS implementation (TrakCare Lab) provided by Intersystems (ISC). However this plan was revised in 2013 to integrate two internationally used applications, i.e. Prometheus and Orpheus, developed by Steiner Ltd to provide the functionality required by WTAIL. Steiner will deliver the solution to WTAIL as a third party supplier contracted by ISC. 15/04/ Date Assessed: 19/06/17 Red 15 Due for review 30/12/ WBMDR are currently confirming the April 2017 date. Previous discussions with the HTA have led to an understanding that there is possibility of a deferral period to ensure compliance by the service. 2. Scope timescales for development of current system to identify critical time scales for implementation. 3. Risk under investigation to determine (i) options and (ii) opportunities to reduce cost impact for WBS. 4. Scope timescales for development of current system to identify critical time scales for implementation. Improved ways of working with Steiner, ISC and NWIS. 5. Separate WTAIL Implementation Board established for governance. Improved project management team. Still awaiting consultation and confirmation documents from HTA on Stem Cell exemption. HTA have reviewed responses from Industry and it seems as though comments received from WBMDR have been taken on board. Provisional assurance that Registery will be exempt from Single European Code. The implementation of Prometheus is on track for roll out in January 2018, however a new risk is emerging for the continual delays and slippage in the implementation of Orphesus. Amber 10 31/10/17 WBS Director IM&T Committee Divsions Oct 17 EMB TB Transforming Cancer Services Infrastructure Project. Non delivery of the expected benefits contained within the Transforming Cancer Services Infrastructure Project. There are a wide range of risks associated with the project which include clinical capacity and capability, commercial, governance and financial risks. 30/12/ Date assessed: 09/10/17 Red 16 Due for review 09/01/ Further stakeholder engagement 2. Securing Trust Board, LHB and WG approval for business cases 3. Develop a communication strategy to engage staff 4.Secure support for clinical change across LHBs and 3 rd sector 5. Work with WG to develop a policy framework, project agreement and standard contract 6. Ensure compliance with planning Regulation 7. Make a case for investment for enabling works 8. Secure access to the site 1. Ongoing with a Stakeholder Board scheduled 16th October Amber 8 2. Updated Outline Business Case approved by TB for consideration by our commissioners and a timeline has been 30/11/17 drafted which will be shared at both DOPs and DOFs and includes 'dialogue events' with HBs 3. Comms plan in place. Lunch and Learns ongoing, News letter etc Ongoing meetings with Health boards, draft clinical model in place 5. Work continues to Personalise Project Agreement 6. Outline Planning Application submitted and available on Cardiff Council s website and the CCC planning committee is scheduled for December Draft Outline Business Case prepared and on schedule to be completed for WG initial comments in October Designers and PS identified via Pagabo framework to provide costs for the OBC. 8. Negotiations with ASDA progressing with advanced draft of the HoTs in place 10. Close engagement with Utility companies Director of Planning & Performance and Estates. Planning & P'mance Committee Divsions Oct 17 P&P Com EMB TB Non delivery of expected benefits from the Transforming Cancer Services programme. There is a potential overarching risk of failure to deliver the Transforming Cancer Services program and specific projects. The TCS is a complex program with many projects running individually and concurrently, this may lead to individual projects failing to achieve deadlines, over-running or costs increasing. 27/01/ Date assessed: 09/10/17 Red 16 Due for review 09/01/ Continue stakeholder engagement 2. Approval for Programme Business Case 3. Secure Ministerial approval for long term funding for the programme. 4. LHB approval and support for TCS 5. Continue to strengthen and retain programme team 6. Ensure internal staff 'buy in' to the TCS programme 7. Securing support for clinical change NOTE Programme Issues re. Programme Funding and Recruitment and Retention 1. Ongoing with a Stakeholder Board scheduled 16th October 2. Updated Programme Business Case approved by TB for consideration by our commissioners and a timeline has been drafted which will be shared at both DOPs and DOFs and includes 'dialogue events' with HBs 3. Conversations continue with the WG around funding. Programme currently funded at risk. 4. Due during second phase of approvals HBs scrutiny 02/10/ /12/ Letter submitted to WG seeking longer term support (See Issues) 6. Internal exhibition for the VCC and use of corporate communication mechanisms 7. Feedback from HBs and staff on the service model received and worked into latest version of the BCs + ongoing engagement 8. Overarching Master Programme with key deliverables, dependancies and milestone dates Amber 9 30/11/17 Director of Planning & Performance and Estates. Planning & P'mance Committee Divsions Oct 17 P&P Com EMB TB

25 11199 In the event of a significant CANISC system failure, Velindre Cancer Centre would have no electronic patient record and no chemotherapy or radiotherapy workflow management systems. In this scenario treatment would be seriously compromised, for inpatient admissions and /or outpatient appointments. Electronic access of patient medical histories would not be available to guide treatment decisions. 02/04/ Date assessed 04/09/17 Red 20 Due for review 29/12/ Full Business Case required to support a CANISC Replacement Programme 1. Business Case creation underway for a full Canisc replacement 2. Functionality has been developed to incorporate into the Welsh Clinical Portal for specific tumour sites (aimed to be transferable to other tumour sites) 3. Canisc database migration to new hardware was successfully completed on Sunday 18 June As part of Business Continuity measures the Welsh Clinical Portal was rolled out to all VCC operational areas to enable a seamless view of Pathology Test results 5. Risk assessment reviewed September Due to current Canisc performance issues the impact score remains the same. Yellow 4 30/09/19 Executive Director of Finance IM&T Committee Divsions Oct 17 EMB TB De-escalated risks to Divisions Datix Risk Ref Risk Statement Unknown impact on patient waiting times for SACT due to unprecedented pace and volume of new drugs available in NHS Wales Date Risk Identified & Initial Risk Rating Initial Score based on Impact & Likelihood I L S 14/06/ Date & Rating when last assessed Date assessed 20/07/17 Due for review 30/11/17 Current Score based on Impact & Likelihood? I L S Action agreed at last risk assessment 1. Improved intelligence behind quantifying service impact (modelling using Simul8 and understanding of baseline capacity and demand etc). 2. Development of plans to increase capacity 3. Investment in horizon scanning process 1. SACT plan has been developed and approved by SMTwith agreement to recruit medical and pharmacy staffing in a phased approach with a full complement of nursing staffing in anticipation of anticipated workload demand. 2. SMT have agreed this at financial risk to the organisation and therefore predicted vs actual demand will be monitored at least 6 monthly. 3.Horizon scanning processes and engagement at All Wales level improved and embedded within organisation. 4.Agreement has been gained with commissioners that all future drugs will be funded according to agreed activity costings. However, there is acknowledgement that the financial costing model is likely to be outdated and there is a Finance project ongoing to review. 5.Work is ongoing to identify and utilise sufficient chair capacity prudently to meet anticipated new demand: ie to confirm what capacity exists currently in outreach before opening new chairs at VCC. Paper to SACT SSG Sept SSG to discuss and approve/recommend any additional measures identified within the Capacity Review paper. Until this is undertaken the current risk remains unchanged. Evaluate current risk within 2 months. Target Risk Rating & Target Date Green 2 30/11/17 Exec Lead for Risk Director VCC Assuring Com for Risk Planning & P'mance Committee Dates register reviewed by Committees during the quarter Divsions Oct 17 P&P Com EMB TB Update P&P Com risk assessment delegated to the VCC Divisional Risk Register for ongoing monitoring. EMB agreed action Closed Risks Datix Risk Ref Risk Statement Date Risk Identified & Initial Risk Rating Initial Score based on Impact & Likelihood I L S Date & Rating when last assessed Current Score based on Impact & Likelihood? I L S Action agreed at last risk assessment Progress Target Risk Rating & Target Date Exec Lead for Risk Assuring Com for Risk Dates register reviewed by Committees during the quarter 3

26 QUALITY & SAFETY COMMITTEE TRUST HEALTH & CARE STANDARDS ASSESSMENT 2017/18 Meeting Date: 7 th December 2017 Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Lisa Heydon, Quality & Safety Manager Sian Lewis, Quality & Safety Co-ordinator Sue Morgan, Executive Director of Nursing/Service Improvement Sue Morgan, Executive Director of Nursing/Service Improvement n/a Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Quality & Safety Committee is asked to ENDORSE the self assessment process for the Health & Care Standards 2017/18 This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Governance, Leadership and Accountability Safe Care Effective Care Dignified Care Timely Care Individual Care

27 2 Health & Care Standards 2017/18 1. Introduction / Background: The Health and Care Standards published in April 2015 set out the requirements for the delivery of health care in Wales at every level and in every setting. The onus is on all NHS organisations to demonstrate that the standards are being used and are met on a continuous basis. The standards have been designed to fit the seven themes of the NHS Outcomes and Delivery Framework, which is one of three frameworks published to drive the continual improvements in the health and wellbeing of the people of Wales. The (attached) framework, builds on the previous protocol for the Standards for Health Services, and has been developed to assist all Trust staff involved with the implementation of the Health and Care Standards. 2. Timing The purpose of this report is to seek endorsement of the Trust s approach to undertake a self assessment against the Health & Care Standards by the end of March Description A meeting was held on the 23 rd October 2017 with representatives from the service divisions, corporate department, internal audit and hosted organisations to discuss learning from the assessment process adopted 2016/17, and to agree a process for the 2017/18 assessment against the standards. As part of the discussion the following key points were agreed: The group acknowledged areas for improvement including; Improved integration of the Trust standard leads with the service assessments Avoid duplication of other assessments and the need to link other standards and assessment Sufficient timescales required to undertake assessments Improved integration of HCS with Trust groups The process for 2017/18 Following discussion, it was agreed to adopt the process used last year with a number of enhancements. Those enhancements include; Each standard is to be scoped to identify other standards/audits that affect the area being assessed Page 2

28 3 Trust leads to review the corporate aspects of the standards prior to them being submitted to the service areas Hosted organisations to use the Trust process as a basis for their assessment but retain flexibility to adopt a local assessment process to reflect their needs A number of standards to be identified for testing of the operational requirements of the Standard Standards to be aligned to Trust and divisional groups for ongoing assessment Patient/user involvement to be sought via Trust groups for example, the VCC dignity group 4. Financial Impact: Nil identified 5. Quality, Equality, Safety and Patient Experience Impact: Action plans will be developed in accordance with the assessment and in support of the IMTP. Improvement actions identified from the 2016/17 self assessment will be incorporated into the 2017/18 assessment to reflect progress. 6. Considerations for the Board: Discussions have taken place with Internal Audit with regards to their assurance programme. The number of Standards being audited as part of the assurance process is still to be determined. However, the Trust self assessment will be available for scrutiny and validation by the end of March 2018 to support the Board annual cycle of business. The assessment matrix adopted for the 2016/17 assessment will also be used to complete the 2017/18 assessment (as illustrated below) Compliant Standard is being achieved in over 80% of the relevant areas and services no immediate improvement actions required Partial compliant Non compliant Standard is being achieved in over 30% of the relevant areas and services improvement actions may be required and will be identified on a risk basis Standard is not being achieved across more than 30% of the relevant areas and services improvement actions required The process adopted for 2016/17 received substantial assurance from internal audit. Page 3

29 4 7. Next Steps Timetable to be produced for the process to ensure the assessment is completed by the end of March 2018 Example of a scoping assessment to be circulated to Trust leads A number of standards to be identified to test the operational implementation of the standard Validation process to be developed which includes involvement from Independent Members Internal audit programme to be agreed The Executive Management Board endorsed the proposed process at its meeting on the 15 th November The Quality & Safety Committee is asked to ENDORSE the process for assessment against the Health & Care Standards 2017/18. Page 4

30 Appendix 1 Velindre NHS Trust Framework for the Management of the Health and Care Standards for Wales 2017/2018

31 Contents VELINDRE NHS TRUST... 1 FRAMEWORK FOR THE MANAGEMENT OF THE... 1 HEALTH AND CARE STANDARDS FOR WALES... 1 CONTENTS INTRODUCTION PURPOSE PROPOSED PROCESS Process for Divisions/Hosted Organisations Assurance Process Annual Governance Statement ROLES AND RESPONSIBILITIES Overall Executive Lead for the Health and Care Standards (Executive Director for Nursing and Service Improvement) Independent Members... 6 Independent Members will: Executive Directors... 6 Executive Directors will: Divisions/Hosted Organisations... 6 Service Directors will be responsible for:... 6 Divisional/Hosted Organisation Leads will: Trust Management Lead Corporate Subject Leads NEXT STEPS REFERENCE ASSESSMENT MATRIX DIVISIONAL SELF ASSESSMENT HIGHLIGHT REPORTING TEMPLATE Purpose of Template Improvement Priorities Appendix

32 1 Introduction In 2014 a review of the Doing Well Doing Better Standards for Health Services in Wales and the Fundamentals of Care was undertaken, with the intention of developing an integrated framework, aimed at helping people in Wales to understand what to expect when they access health services. The Health and Care Standards form the cornerstone of the overall quality assurance system within the NHS in Wales. The standards have therefore been designed to fit the seven themes of the NHS Outcomes and Delivery Framework, which is one of three frameworks published to drive the continual improvements in the health and wellbeing of the people of Wales. The Health and Care Standards establish a basis for improving the quality and safety of healthcare services by providing a framework which can be used in identifying strengths and highlighting areas for improvement. The purpose of the Health and Care Standards is to: Embrace the principles of co-production and prudent health care Offer a common language to describe what high quality, safe and reliable healthcare services look like Be used by people of all ages to understand what high quality safe healthcare should be and what they should expect from a well-run service Enable a person-centred approach by focusing on outcomes for service users and driving care which places people at the centre of all that the service does; Create a basis for improving the quality and safety of healthcare services by identifying strengths and highlighting areas for improvement Be used in day-to-day practice to encourage a consistent level of quality and safety across the country and across all services Promote practice that is up to date, effective, and consistent Promote accountability of health services to service users, the public and funding agencies for the quality and safety of services by setting out how providers should organise, deliver and improve services Enable people to contribute fully to their own health and wellbeing Recognise the quality standards for other care and support providers issued under the Social Services Regulation and Inspection. The onus is on the Trust and its service areas to demonstrate that the standards are being used and met on a continuous basis. This will continue to be a key element of the organisation s Board Assurance Framework, its Annual Governance Statement on internal control and its Annual Quality Statement. It is also important that the Health and Care Standards are integrated into the IMTP and Operational Plan for the organisation. This is to ensure that the Date: November 2017 Version: 0a Page: 3 of 13

33 Standards become part of everyday business management within divisions/hosted organisations to drive improvements in quality, rather than seen as a standalone separate activity. 2 Purpose Following the launch of the Health and Care Standards Velindre NHS Trust needs to establish arrangements through which self assessments can be undertaken and action taken to implement improvements and changes required to enable the Trust to deliver the highest quality of services to the people of Wales. The proposed framework has been developed to assist all Trust staff involved with the implementation of the Health and Care Standards. Divisions/hosted organisations and teams should use the standards to self assess at all levels and across all activities to: Map against their own professional standards and operational plans Assess for themselves how well they currently meet the standards Identify what they do well and what could be shared wider Identify what they do less well and what can be done to improve delivery Make changes which contribute to overall quality improvement within their service. Each standard should be assessed to establish if it is applicable, the current level of compliance, determine progress and to identify improvement actions required to meet the standard. 3 Proposed Process 3.1 Process for Divisions/Hosted Organisations The Health and Care Standards will need to be owned by all, with a recognition that quality is at the heart of everything we do. Divisional/hosted organisation directors and their senior management groups will be required to develop and lead arrangements to cascade and embed the Health and Care Standards to ensure compliance against each of the standards that are relevant to their areas of work. To achieve this divisions/hosted organisations are required to identify organisational leads to ensure that the standards are implemented within their area of work. Date: November 2017 Version: 0a Page: 4 of 13

34 Following review, each division and hosted organisation is required to map the Health and Care Standards against their operational plan and its own professional standards and other quality requirements. Divisions are required to complete the Health and Care Standards self assessment via the database provided. Hosted organisations are able to use the database or have their own local arrangements in place to capture the outcome of their assessments. Following the completion of the local self assessments the improvement actions, identified as part of the self assessment audit, should be included within local action plans. Progress against identified improvements should be monitored by the Trust Executive Management Board, service management groups, and where appropriate, the Trust Planning & Performance committee via the IMTP and the Trust Quality & Safety Committee. This is to ensure that the Standards become part of everyday business management within the services to drive improvements in quality, rather than seen as a standalone separate activity. Following the annual assessment, Service Directors are required to provide the Trust Executive Board with a highlight report summarising; The self-assessments undertaken within the service and scores assigned for each Standard relevant to their area of work Improvement priorities for the coming year Governance issues Training needs Good practice 3.2 Assurance Process Following completion of the self assessment process, Independent Members will review the assessments in accordance with the quality assurance process agreed with them. Internal Audit will also undertake a more in depth review of a selection of the Standards and provide an opinion on the assessment approach adopted. This information will be used to inform the Annual Governance Statement. Health Inspectorate Wales (HIW) will continue to use the Standards to undertake a level of testing and validation as part of their public assurance role. 3.3 Annual Governance Statement Assurance for the Annual Governance Statement will be informed from the review by Internal Audit. Date: November 2017 Version: 0a Page: 5 of 13

35 4 Roles and Responsibilities 4.1 Overall Executive Lead for the Health and Care Standards (Executive Director for Nursing and Service Improvement) The overall Executive Lead for the Health and Care Standards will: Provide assurance that the Health and Care Standards are applied across the organisation in an integrated manner Ensure that robust internal procedures for the assessment of the Health and Care Standards exist to ensure that staff and external bodies are informed appropriately 4.2 Independent Members Independent Members will: Undertake a role of overview and review Provide assurance to the relevant Board Committees of compliance with the Health and Care Standards as relevant. 4.3 Executive Directors Executive Directors will: Provide assurance to the Executive Team and the Board in relation to compliance with the Standards Ensure that the Health and Care Standards are incorporated into Trust and Divisional operational plans Ensure that appropriate and effective improvements are in place to address areas of non compliance and resources are agreed and allocated as relevant Ensure appropriate and timely escalation of non compliance with the Health and Care Standards Ensure that identified improvements are monitored regularly throughout the year and escalate issues identified to the risk register as appropriate. 4.4 Divisions/Hosted Organisations Service Directors will be responsible for: Providing compliance assurance to the Executive Board Ensuring that the Health and Care Standards are incorporated into the operational plans Date: November 2017 Version: 0a Page: 6 of 13

36 Ensuring that appropriate and effective improvement actions are in place to address areas of non compliance and resources are agreed and allocated as relevant The appropriate and timely escalation of non compliance with the Health and Care Standards to the Executive Board Ensuring that progress against improvements are monitored regularly throughout the year Quarterly reporting, detailing progress in relation improvement actions, as part of the performance management framework for the operational plan and escalate issues identified to the Risk Register as appropriate. Divisional/Hosted Organisation Leads will: Ensure the completion of the local self assessment, evidence and improvements via their Health and Care Standards database Ensure that all standards are relevant and that the assessment has been agreed as accurate Provide assurance to the service Director and in relation to the compliance with the standards Ensure that progress against improvements is regularly monitored throughout the year Present final assessments to the service Director Raise awareness of the Health and Care Standards and ensure that their integration into operational plans. 4.5 Trust Management Lead The Trust lead will: Establish procedures and systems to assist with the self assessment and improvement planning process at executive and service level Establish and monitor systems to integrate the Health and Care Standards across the organisation and escalate issues identified to the risk register as appropriate Assist the Executive Lead, Independent Members, Executive Directors and Service Directors as required Ensure that reviews are undertaken to comply with the timescales for the Annual Governance Statement. 4.6 Corporate Subject Leads Corporate subject leads will be identified against each Standard and will provide guidance to Services as requested. The Leads will support the assessment process by providing corporate input and oversight to their standards. Date: November 2017 Version: 0a Page: 7 of 13

37 5 Next Steps The framework should be adopted for 2017/2018 to avoid any delays to the assessment of the Health and Care Standards. 6 Reference Welsh Government: Health and Care Standards (April 2015) Date: November 2017 Version: 0a Page: 8 of 13

38 7 Assessment Matrix Compliant Standard is being achieved in over 80% of the relevant areas and services no immediate improvement actions required Partial compliant Standard is being achieved in over 30% of the relevant areas and services improvement actions may be required and will be identified on a risk basis Non compliant Standard is not being achieved across more than 30% of the relevant areas and services improvement actions required

39 8 Divisional Self Assessment Highlight Reporting Template EXECUTIVE MANAGEMENT BOARD Divisional Self Assessment Highlight Report Meeting Date: Author: Sponsoring Executive Director: Report Presented by: Committee/Group who have received or considered this paper: Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well

40 Highlight 11 Report 1. INTRODUCTION / BACKGROUND: 2. TIMING 3. CONSIDERATIONS FOR BOARD / COMMITTEE Overall Compliance: (as detailed on Appendix 1) Areas of Good Practice: Less than Optimal Practice / Governance Issues: Training Needs: Actions Identified: (as detailed on Appendix 2) 4. NEXT STEPS The Board should; NOTE the overall compliance of the divisional self assessment against the Health and Care Standards Any queries on information contained within this report can be directed to Director Page 11

41 Appendix 1 Overall compliance with the standards for health services Purpose of Template Provide an overall assessment of how your Division has been assessed against each standard using the assessment matrix Health and Care Standards Overall Divisional Assessment Against the Matrix Governance, Leadership and Accountability 1.1 Health Promotion, Protection 1: Staying Healthy and Improvement 2.1 Managing Risk and Promoting 2: Safe Care Health and Safety 2.2 Preventing Pressure and Tissue Damage 2.3 Falls Prevention 2.4 Infection, Prevention and Control (IPC) and Decontamination 2.5 Nutrition and Hydration 2.6 Medicines Management 2.7 Safeguarding Children and Safeguarding Adults at Risk 2.8 Blood Management 2.9 Medical Devices, Equipment and Diagnostic Systems 3.1 Safe and Clinically Effective 3: Effective Care Care 3.2 Communicating Effectively 3.3 Quality Improvement, Research and Innovation 3.4 Information Governance and Communications Technology 3.5 Record Keeping 4.1 Dignified Care 4: Dignified Care 4.2 Patient Information 5.1 Timely Access 5: Timely Care 6.1 Planning Care to Promote 6: Individual Care Independence 6.2 Peoples Rights 6.3 Listening and Learning from Feedback 7.1 Workforce 7: Workforce

42 Improvement Priorities Appendix 2 What needs to be addressed/ what are we not doing? Priority level for inclusion in improvement plan Improvements Identified Identified improvements need to be annotated within the Improvement Plan along with actions to address them and timescales. HIGH (Immediate/3 months) Medium (Within 1 Year) Low IMTP reference

43 QUALITY & SAFETY COMMITTEE Management of Patient Safety Incidents related to NWIS Meeting Date: 7 th December 2017 Authors: Sponsoring Director: Report Presented by: Committee/Group who have received or considered this paper: Lisa Heydon Quality & Safety Manager Professor Susan Morgan, Executive Director of Nursing & Service Improvement Professor Susan Morgan, Executive Director of Nursing & Service Improvement N/A Trust Resolution to: (please tick) APPROVE: REVIEW: INFORM: ASSURE: Recommendation: The Quality & Safety Committee is asked to receive for ASSURANCE the actions taken to improve the management of patient safety incidents related to NWIS. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well ACRONYMS This report supports the following Health & Care Standards: Managing Risk and Promoting Health & Safety 3.4 information Governance and Communications Technology

44 2 [NWIS patient safety incidents November 2017] 1. Introduction / Background The Delivery Unit was commissioned by Welsh Government to undertake a whole system review of the management of Serious Incidents (SI s) involving NWIS. The final report was issued on 19 th April 2017, and was considered by the Executive Management Board in June 2017 and Trust Board in July The Executive Director of Nursing & Service Improvement was identified as the Trust lead for implementing recommendations relevant for the Trust, in partnership with Andrew Griffiths Director NWIS. 2. Timing: This report provides the Quality & Safety Committee with an update on progress made to date, and presents the actions to develop an all Wales process for the effective management of patient safety incidents related to NWIS and other organisations within NHS Wales. 3. Financial Impact: There are no specific financial considerations to bring to the attention of the Quality & Safety Committee 4. Quality, Equality, Safety and Patient Experience Impact: Patient safety incidents related to NWIS may have an impact on the quality and safety of care delivered to patients by individual Health Boards and Trusts. This paper supports adherence to standards 2.1 (Managing Risk and Promoting Health & Safety) and 3.4 (Information Governance and Communications Technology) of the Health and Care Standards Considerations for Board / Committee: Activity to date includes; Formal assurance that work to address the recommendations set out in the Delivery Unit report and to ensure compliance with the Putting Things Right Regulations (2011) was provided to Welsh Government in June Lead officers within NWIS (Head of Clinical Informatics Assurance) and the Trust (Quality & Safety Manager) have initiated work to review internal policies and procedures. The key processes for the effective management of patient safety incidents related to NWIS and other organisations within NHS Wales have been considered following a joint NWIS/Trust meeting of lead officers. A working group has been established with representation from all health bodies across Wales to develop an all Wales process for the management of NWIS related incidents. 6. Next Steps: The Quality & Safety Committee is asked to receive and note the contents of this report and the action plan outlining the steps to enable wider consultation and sign up within NHS Wales. Page 2

45 3 [NWIS patient safety incidents November 2017] Appendix 1: Management of Patient Safety Incidents related to NWIS (Action Plan) Action Lead Target Date Status Update Establish a reporting and escalation process for SI s between NWIS and VNHST. Establish a Task and Finish Group for the development of an All Wales Process for the management of SI s involving NWIS and other Health Bodies. Develop Terms of Reference for the Task to Finish Group. Raise awareness of the DU Report at the All Wales Senior Investigation Manager Network Meeting. Develop a joint understanding of NWIS detected incidents that would be considered as SI s and No Surprises. Review open SI s and identify actions to help bring these incidents to a closure. Develop an all Wales Process to inform a VNHST procedure for the management of NWIS detected SI s and No Surprises. LH/PE October 2017 Completed Monthly meetings are held between VNHST and NWIS to discuss SI s. Quarterly SI reports received from NWIS for the Trust EMB LH November 2017 Completed All Wales Group established and first meeting scheduled for December LH/PE November 2017 On Target Draft completed 23/11/17 to be approved by all Wales Group at first meeting LH/PE November 2017 Completed Discussions held with SIM network November Recommendation from the Group to include the Nurse Directors in all NWIS SI notifications Group January 2018 On Target Discussions held with SIM network November 2017 of the need to define SI s and No Surprises. This will be taken forward at the January SIM network meeting PE/LH January 2018 On Target Meeting scheduled with NWIS and VHNST December 4 th 2017 Group March 2018 On Target Working group established draft process already scoped for further discussion with the working group Page 3

46 4 [NWIS patient safety incidents November 2017] Develop a process to facilitate and enable learning from NWIS SI s. Identify risks and issues for the on-going management of NWIS detected SI s and No Surprises generate recommendations for consideration by the Health Bodies. Group March 2018 On Target Dependent on WG feedback on governance arrangements Group March 2018 On Target Working group established risk will be identified as part of the development of an all Wales process Page 4

47 Quality & Safety Committee PART A Delivering Excellence - Performance Report Meeting Date: 7 th December 2017 Author: Sponsoring Executive Director: Report Presented by: Jeff O Sullivan, Planning and Service Development Manager Professor Sue Morgan, Executive Director of Nursing & Service Improvement Andrea Hague, Divisional Director VCC Cath O Brien, Divisional Director WBS Trust Resolution to: (please tick) Approve: Endorse: Discuss: Note: Recommendation: The Committee is asked to DISCUSS the contents of this report. This report supports the following Trust objectives as set out in the Integrated Medium Term Plan: (please tick) Equitable and timely services Providing evidence based care and research which is clinically effective Supporting our staff to excel Safe and reliable services First class patient /donor experience Spending every pound well This report supports the following Health & Care Standards: Standard 2.2 Preventing Pressure and Tissue Damage Standard 2.8 Blood Management Standard 3.1 Safe and Clinically Effective Care Standard 6.1 Planning Care to Promote Independence

48 1. Introduction / Background 1.1 This report provides an update to the Quality & Safety Committee with respect to performance against Trust wide key performance metrics. 2. Timing: 2.1 Reporting period to September Description: 3.1 The Performance Report has been developed and produced by the Trust Planning & Performance team and provides a summary of progress against the Level 1 & 2 objectives and performance metrics in the three year plan which fall under the remit of the Quality & Safety Committee. Definitions of the priority levels are shown below: 4. Financial Impact: 4.1 There are no direct financial implications contained within this report and delivery of the performance metrics presented in the report and work associated with delivering improved performance supports sound financial governance across the Trust. 5. Quality, Equality, Safety and Patient Experience Impact: 5.1 The current performance reporting and monitoring system is predicated upon identifying performance issues and supporting effective decision making at service and operational levels to drive forward continuous improvement in the quality, equality, safety and experience for our patients. 6. Considerations for Board / Committee: 6.1 Performance measures in Table 1, below, that have fallen below the agreed level and are reported as Red. These are highlighted to the committee as requiring further discussion. 7. Next Steps: 7.1 The Committee to discuss the content of this paper, and where required, identify additional mitigating actions to support continuous improvement. Page 2

49 Table 1: Performance overview Performance Metric Reference Issues: Rationale for highlighting to Committee Performance in September 2017 Associated Trust Risk register: Datix Risk Ref The data shows 6 pressure ulcers for this period: No grade 1's 5 grade 2 pressure ulcers 1 unstageable pressure ulcer Number of Velindre Acquired Preventable Pressure Ulcers The data appears to show a rise Pressure Ulcer incidents in comparison to previous data however this is likely due to increased reporting and greater focus on Pressure Ulcer management. 6 reported pressure ulcers n/a Actions: The pressure ulcer reduction group continue to meet monthly to focus on the prevention and management of pressure damage. The group has prioritised the implementation of the revised SKIN bundle to reduce and manage Velindre acquired pressure ulcers. Issues: Number of Velindre Acquired Infections There was one MSSA bacteraemia in September. Action: 1 acquired MSSA infection n/a Page 3

50 Root cause analysis is in progress. There have been three cases since April all patients had a PICC insitu but follow up results have proved to be negative so source not identified. Page 4

51 Welsh Blood Service Monthly Report September 2017 At a Glance highlights Positive month for number of new apheresis donors bled, supported by high perfomance in number of successful apheresis assessments completed during the period. Continual strong perfomance in antenatal and reference serology turnaround times, well above target position. Following the successful implementation of the replacement irradiator, platelet wastage has reduced significantly in line with normal service provision. Spike in total number of red cells due to failure of Temperature Controlled Vehicle (TCV), (twice during September) accounting for 1.4% of total losses. This has been fully investigated and repairs Overall Performance September KPI Progress %Target Not % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0 % 27 % 73 % %Target Achieved Achieved 1

52 Equitable and Timely Access to Services Sep-17 Monthly Target: 333 SMT Lead: Tracey Rees What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date New BMV Registrations September recruitment was just shy of target position and the second month in succession showing good progress. High profile social media activity during The engagement team have awarded a contract to deliver a six to eight month BMV recruitment campaign. The campaign will seek to increase the number of new blood donors and the number of BMV recruits. The campaign activity will attempt to connect with existing blood Campaign live OctoberMarch September promoting a recent bone marrowdonors within the eligible age range to encourage them donor experience is likely to have had a to attend a blood clinic and sign up to the positive impact on overall position. registry. The campaign will also target non donors within the age bracket to encourage them to become blood donors and to join the registry. New Bone Marrow Registry Members Target Not Achieved Equitable and Timely Access to Services Sep-17 2

53 Monthly Target: 2750 SMT Lead: Paul Wilkins What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Quarterly Metric Whole Blood New Donors Dec-16 Sep-17 Target Not Achieved Equitable and Timely Access to Services Sep-17 The number of donors bled during the quarter was lower than the target of This was partly due to a poor performing month in August where only 657 new donors were bled. However, August was a productive month for new prospects. Activity is still focused on targeting new donors who have signed up through What's My Type but have not yet been bled. New donor recruitment will also be supported by the forthcoming bone marrow recruitment campaign which will aim to drive new donors into the service. The engagement team has undertaken a piece of work to identify clinics in the next 16 weeks where a high number of new donors are expected. The strategy will focus on having a visible presence at these clinics (possibly What's My Type) and attempting to increase the number of new donors through the doors. The rationale is that clinics with typically high levels of new donors are likely to be in transient locations (hospitals, retail centres, universities, etc.) with high footfall and greater potential for new donor recruitment. End of January 2018 Quarterly Target: 14 SMT Lead: Paul Wilkins What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date 3

54 This quarter saw 21 new apheresis donors being bled, which was above the target of 14. This increase was prompted by a positive period of recruitment in previous months. Encouragingly, there were 76 successful apheresis assessments completed in the period - making it the best performing quarter for successful assessments in the rollinmg 12 month period. Many of these donors who were added to the panel will not have been bled in the period therefore it is hoped that forthcoming months will see the benefit of this recruitment. A continued focus for the next period will be to ensure those donors who have recently been added to the clinic to be bled. Efforts to attract new donors for assessments at Talbot Green will continue with additional support offered by a dedicated recruiter. Ongoing Dec Sep-17 Quarterly Metric Apheresis New Donors 4

55 6 Target Achieved Monthly Target: N/A SMT Lead: Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date All blood groups over 3 days stock during this period. We will continue to actively monitor stock levels. Ongoing Safe and Reliable service Sep-17 Number of days when red cell stock level is below 3 days for blood groups O, A and B

56 Monthly Target: 100% SMT Lead: Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date All clinical demand was met during September. O negative issue and collection remains fragile with additional recruitment activity targeted to improve stock position. We will continue to monitor stock levels going forward. Daily resilience with collections informing of stocks and collecion positions with which to adjust and amend collection targets on a real time basis. Ongoing Safe and Reliable service Sep-17 % Red Cell Demand Met % 6

57 Monthly Target: 100% SMT Lead: Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date The replacement of the clinical irradiator has seen a return to normal platelet production and recovery of this performance indicator. Pooled and apheresis platelets are produced to meet All Wales demand. However, we still have the North Wales factor where we cannot utilise platelets for their full lifespan which has an adverse effect on wastage. address wastage levels in North Wales % Platelets Demand Met Safe and Reliable service Sep-17 Platelets Demand Being Met 140% 120% 100% 80% 60% 19%40% 20% 0% 7

58 Safe and Reliable service Sep Monthly Target: 40% SMT Lead: Paul Wilkins/Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date 41% of platelets produced were derived from apheresis production in September. Following consultation there has been steady improvement in target achievement. The operational management team are working closely with the department and engagement teams to maximise appointment utilisation. A performance moniotoring group has been set up to review and manage service delivery and performance of this area. We will be reviewing the assumptions made in setting the current target through the autumn. We will be reviewing the assumptions made in setting the current target through the autumn. 8

59 Safe and Reliable service Sep-17 Monthly Target: 65% SMT Lead: Tracey Rees What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date months Good performance against target. Ongoing review to improve further. The WBMDR are researching ways to engage and recommit donors on the panel to encourage donors to update their details effectively to cleanse the donor panel and improve these figures even more. Target Achieved Monthly Target: N/A SMT Lead: Tracey Rees What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Currently below forecast position due to lower than anticipated requests from transplant centres. Natural peaks and troughs are evident each year, more data is required to accurately predict 12 month out turn. Demand is dependent on requirements from transplant centres. Continue to progress work on increasing donor recruitment and retention. Matching of donors and recipients is highly complex although there is a correlation with the number of donors on the register and the availability and willingness of donors, there will inevitably be a period of time required to allow impact of these campaigns to results in increased requests months for campaign to demonstrate improvement Safe and Reliable service Sep-17 Stem Cell Collections 9

60 -5 4 Quarterly Metric Deceased Donor Typing/Cross matching Safe and Reliable service Sep-17 Quarterly Target: 80% SMT Lead: Tracey Rees What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date 13 The target turnaround time for this critical service which is delivered 24/7 was decreased from 6 to 4 hours with effect from April The new target was met in quarter 1 and quarter 2. None required, we will continue to actively monitor this revised target N/A Target Achieved Safe and Reliable service Sep-17 Quarterly Target: 90% SMT Lead: Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date 10

61 Quarterly Metric Anti D & -c Quantitation -1 Turnaround times for September 98%. Continued monitoring and active management is in place. N/A Target Achieved Quarterly Target: 90% SMT Lead: Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Turnaround times for routine antenatal samples remain on track for September Continued monitoring and active management is in (99%) and above targeted performance level place. of 90% in 3 working days N/A Safe and Reliable service Sep-17 11

62 Antenatal Turnaround Times Safe and Reliable service Sep- 17 Quarterly Target: 80% SMT Lead: Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Turnaround times for September remain on track at 85%. Continued monitoring and active management is in place. N/A References Serology Turnaround Times Safe and Reliable service Sep Quarterly Target: 90% SMT Lead: Andy Ellis What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Rather than take an isolated month it has been determined that a rolling 3 month review will provide a more meaningful indication of performance. 152 incidents in rolling period (43 September) with 28 still open & overdue. Monthly reports and dashboards are generated for departmental Operational Service Groups to ensure visibility of incident management. Quality team staff are working with Departmental leads to undertake reviews of open items to ensure timely action taken. MHRA action group setup and this forms part of the action plan. Ongoing 12

63 Target Not Achieved 0 CRITICAL FINDINGS 0 Target: N/A SMT Lead: Andy Ellis What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date No major or critical findings by external regulators in month. N/A N/A and Reliable service INCIDENTS REPORTED TO 11% REGULATOR/ LICENSING 0 Safe Sep-17 Target: N/A SMT Lead: Andy Ellis What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date There were no reportable adverse events in September. N/A N/A 13

64 Spending Every Pound Well Sep-17 Monthly Tolerance: 3% SMT Lead: Joan Jones What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date This was over the 3% tolerance level set for Part Bags again this month. These figures are further broken down by team so that areas with consistently high levels can be targeted. Several new venepuncturists are currently in training and will impact on this figure.the reasons for Part Bags across all teams for Sept 17 are as follows:- Slow bleed 74%, Bruise/Discomfort 16%, Vasovagal 8%, Equipment fail 2%. Higher levels of Vaso vagal events on trailers which influences part bags has been identified. Various improvements have been implemented on trailers to improve this, for example consistent angle of donation/recovery. Some improvement has been realised. Further work will continue to improve this issue. Several new venepuncturists are now in post and will be provided with support over the coming months. Business Intelligence (BI) team is currently working with collections to support a move away from manual based system to electronic data capture for this KPI, this will require engagement with MAK-systems to support required system update. February/March 2018 Ongoing scoping work. Monthly Tolerance: 2% SMT Lead: Joan Jones What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date 14

65 Spending Every Pound Well Sep-17 The FVP rate is calculated in the context of donors bled and not donors attended. This remains within set tolerance for Sept Continue to monitor and provide support as required. Maintaining this performance for successful venepuncture is essential in ensuring sufficient blood is delivered to meet service need. February/March 2018 Spending Every Pound Well Sep-17 Monthly Target: 1.25 SMT Lead: Paul Wilkins What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Target Not Achieved The collections department have had a number of operational constraints, combined with staff training which have resulted in the unusually high efficiency (1.24) score for the month of September and has not been the result of a process change as yet. The collections team model workstream has now formed and in the early stages of engaging with the teams to establish representation across Wales. Work will begin on reviewing staffing skill mix and requirements as the structure is further developed within collections. The team representation has still not been confirmed. Timelines will be set when the team is formed. Spending Every Pound Well Sep-17 15

66 Spending Every Pound Well Sep-17 Monthly Tolerance: 6% SMT Lead: Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Laboratory processing losses account for 2.8% of the total losses. Of this 1.4% was due to TCV failure twice this month which is unusually high and the other discards were a combination of team and lab issues. Continue to monitor losses and seek reductions in loss figures across both departments. The two TCV events were fully investigated under Datix frozen filter has been identified and repairs undertaken. Ongoing Target Achieved Monthly Tolerance: 10% SMT Lead: Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Time expiry on platelets was within target in September following the successful implementation of the replacement irradiator. WBS will continue to monitor this metric and to monitor expiry figures following implementation of the reduction in the apherisis target. A move from 5 to 7 day shelf life for platelets will improve wastage rates with improved stock management. 16

67 Spending Every Pound Well Sep Target Not Achieved Spending Every Pound Well Sep-17 2 Monthly Tolerance: 1% SMT Lead: Ian Reynolds What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Wastage levels remained within target with 0.29% this identifies good stock management. WBS will continue to monitor this metric and to monitor expiry figures. Ongoing Target Achieved 20 Series1 17

68 02 Series1 First Class Donor Experience Sep Scored 5_6 out of 6 NW Scored 5_6 out of 6 SW Target Achieved Monthly Tolerance: 71% SMT Lead: Paul Wilkins What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date Donor satisfaction was again above target for September at 94%. 2,224 esurveys were sent in September with 684 responses(31%) n.b. The metric has been adapted to only include responses to the associated question when measuring the percentage of satisfaction. Previously the metric also included respondents who did not provide an answer to the associated question. Visible management within teams and focussing on donor satisfaction at all touch remains a daily action for all involved. Ongoing 20 Series1 First Class Donor Experience Sep Number of Concerns Received Monthly Target: N/A SMT Lead: Andy Ellis What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date concerns were received in Sept - 9 'On the Spot' and 2 Formal. Both formals were related to donors being turned away (for valid reasons). All 'On the Spot' were collection team / DCC related and were effectively managed. No identified trends All outcomes of investigations are fedback to the relevant department and staff involved. Reports are being produced for inclusion into Operational Service Groups. Timescales for internal investigations are being shortened to alow more time for review prior to response to donor. Ongoing Series1 02 Series1 First Class Donor Experience 02 18

69 % Responses to Concerns within 30 Working Sep-17 Monthly Target: 100% SMT Lead: Andy Ellis What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date 0 All concerns were responded to within 30 working days. Including 1 requiring Welsh Translation. N/A N/A Days Target Achieved 02 Series1 First Class Donor Experience Sep Monthly Target: 100% SMT Lead: Andy Ellis What are the reasons performance? Actions(s) being take to improve performance Expected Completion Date All formal concerns were acknowledged within 2 day timeframe. Concerns process is being reviewed The process of how concerns are reported and investigated is under review and will be completed by February Target Achieved 16 19

70 17

71 At a Glance Highlights Velindre Cancer Centre Monthly Report September 2017 The target was met for emergency radiotherapy waiting times performance in September. Radical radiotherapy performance was 97% in September (98% target) Palliative radiotherapy performance was 96% in September (target 98%). SACT waiting times data has not been submitted for the August and September- an updated exception report will be submitted at EMB. The DNA percentage was 6% in September against the 5% target. There were no cases of Velindre aquired C.Diff, MRSA or E.Coli in September. There was one case of Velindre acquired MSSA in September. There were 6 Velindre acquired pressure ulcers in September. PADR compliance was 66% for September (target of 85%).

72 Sep-17 Equitable and Timely Access to Services - Radiotherapy 100 % 90 % % % % % % 30 % 20 % 10 % 0 % 100 % 90 % % % % % % 30 % 20 % 10 % 0 % Patients receiving radical radiotherapy within 28 days % in 28 days Target % in 28 days Patients receiving palliative radiotherapy treated within 14 days Target: 98% Why is performance off track? There were 9 breaches in September. Of the 9 breaches: 5 breaches were due to DIBH. 1 breach was due to a doctor being on annual leave. 1 breach was due to the need to re-plan. 1 breach was due to the patient not receiving the appointment letter. 1 breach was due to a clinical decision being taken by the Doctor to treat a patient on a specific day. SMT lead: TBC Actions being taken to improve performance: Local review of breaches continues to occur weekly- patient waits are minimised where possible Breaches for DIBH are anticipated to decrease through Nov and Dec as the next phase of DIBH implementation is undertaken. The next stage of breach review will involve a closer look at the delays in plan approval and the subsequent impact on the pre treatment pathway and the patient s start date Expected completion date: RDG will meet on the 17th November to confirm next steps/timings of the above actions % in 14 days Target % in 14 days

73 Sep-17 Equitable and Timely Access to Services - Radiotherapy (Cont.) 100 % 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0 % Patients receiving emergency radiotherapy treated within 2 days Target: Why is performance off track? Not applicable - performance on track SMT lead: TBC Actions being taken to improve performance: Expected completion date: % in 2 days Target % in 2 days

74 Sep-17 Equitable and Timely Access to Services - Chemotherapy 100 % 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0 % Non - emergency chemotherapy patients treated within 21 days Target: Why is performance off track? Chemotherapy waiting times data has not been available since July. Please see exception report for more information. SMT lead: TBC Actions being taken to improve performance: Waiting list management meetings are in place, providing assurance at an operational level that waiting times are being managed. Exception report due which will give us actions with timescales Expected completion date: % in 21 days Target % in 21 days Emergency chemotherapy patients treated within 5 days 100 % 90 % 80 % 70 % 60 % % % % % % % % in 5 days Target % in 5 days

75 Sep-17 Equitable and Timely Access to Services - Therapies (Inpatients) 100 % 80 % 60 % 40 % 20 % 0 % % of OT patients seen within 2 working days 100 % 80 % 60 % 40 % 20 % 0 % % of Dietetics patients seen within 2 working days 100 % 80 % 60 % 40 % 20 % 0 % % of PT patients seen within 2 working days % of OT patients Target % % of CT patients Target % % of PT patients Target % 100 % 80 % 60 % 40 % 20 % 0 % % of SLT patients seen within 2 working days % of SLT patients Target % Target: 100% Why is performance off track? Dietetics and Occupational therapy achieved 86% and 83% compliance respectively due to the clinical team having to dedicate time to inducting a new staff member. Each team has 3 qualified professionals therefore any clinical capacity lost will have an impact upon clinical delivery. SMT lead: TBC Actions being taken to improve performance: Therapy manager attending capacity and demand training day in November to support development of a capacity and demand model. Data being closely monitored and reviewed to ensure the appropriate resources are being utilised efficiently. Time/activity analysis is also being carried out across therapies in November to support this. Expected completion date: Capacity & demand training 22nd November. Monthly RV & submission of data. Time/activity analysis to be completed by 17th November and submitted for analysis w/c 20th November

76 Sep-17

77 Equitable and Timely Access to Services - Outpatient Waiting Times Sep % 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0 % % of patients seen within 20 minutes Target: <20 minutes Why is performance off track? The main reasons for these delays were: Co-ordination of Annual leave Members of the Site Specific Team team absent due to, annual leave, study leave, sick leave and the clinic numbers not being adjusted to support this. Clinic delays Chemotherapy Assessment appointments taking longer than their scheduled start time which results in delays to the next patient on the list. Blood Results - A key issue in the waiting times is the time it takes for the patients blood test results to be available. A high proportion of patients coming through Outpatients are required to have their bloods taken before clinic. More often than not a patient s blood results are not available at the time of their clinic appointment. SMT lead: TBC Actions being taken to improve performance: New Administration Handbook being developed to guide clerical staff on booking processes. Booking templates for all clinics being reviewed. Canisc clinic codes being cleansed Blood process being reviewed and tested in Gynae Chemo Assessment Clinic Expected completion date: Administration Handbook: First draft to be available by 31st January 2018 Clinic Templates: Review of the Gynaecology clinic templates to be completed by 31st January Blood Process Test starting booking patients in for their blood appointments 1 hour before clinic from 14/11/17 for a period of 8 weeks. The VCC blood process is being specified and will be completed by March 2018.

78 Sep-17

79 Outpatients - DNA Rates Outpatients - New to Follow up Ratio Sep % 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0 % DNA % 8 % 7 % 6 % 7 % 6 % 7 % 7 % 7 % 7 % 6 % 5 % 6 % Target: <5% Why is performance off track? September DNA 6% spread over all clinics. The clinic type with the highest number of DNA s during September is follow-up appointments. Data collected for the financial year so far show the Testicular clinic codes have the highest proportion of DNA s- they are usually young, fit men who are on long term follow up. SMT lead: TBC Actions being taken to improve performance: Review of follow up protocols Review of different ways we can offer follow up clinic appointments. Text reminder working with the Information team to see if we could develop a report which would enable a text reminder service Expected completion date: A review of the follow up protocols is on track to be completed by 31st November we will then have an understanding of how long it will take to implement changes to practice. Implementing a temporary text reminder system for patients in the Testicular clinics is being explored by the service improvement team and informatics. A decision on whether a pilot project is feasible with the current IT system will confirmed by 31st November We are also scoping new methods of follow up more suited to different groups of patients to see if this impacts upon compliance.

80 Sep New to follow up ratio Target: Why is performance off track? The new to follow up ratio for September 2017 was 0.9 and remains fairly standard each month. This means that for every 1 new patient this is 8/9 follow up appointments. We are currently undertaking a review of the European Oncology Practice guidelines to determine how each SST's practice compares and to understand if we are following up patients appropriately. SMT lead: TBC Actions being taken to improve performance: The Gynaecology SST has identified a need to reduce the number of chemotherapy assessment follow ups undertaken for appropriate patients. This work is being progressed through the Gynaecology Service Improvement Project and a service implementation plan is being developed with the team. A demand and capacity modelling exercise is being undertaken by the Business Support Manager for Outpatients which will highlight follow up capacity and identify opportunities to explore alternative follow up methods. Expected completion date: The service implementation plan will be written and discussed with the Gynaecology team by 30th November The review of European Guidelines will be completed by 30th November The demand and capacity exercise for each SST will be completed by March 2018.

81 Safe and Reliable Services - Hospital Acquired Thrombosis Sep Number of Velindre acquired preventable HATs Target: 0 Why is performance off track? Not applicable - performance on track. SMT lead: TBC Actions being taken to improve performance: Expected completion date: Count Target

82 Safe and Reliable Services - Velindre Acquired Pressure Ulcers Sep Number of Velindre acquired preventable pressure ulcers Count Target Target: 0 Why is performance off track? The data shows 6 pressure ulcers for this period: No grade 1's 5 grade 2 pressure ulcers 1 unstageable pressure ulcer The data appears to show a rise Pressure Ulcer incidents in comparison to previous data however this is likely due to increased reporting and greater focus on Pressure Ulcer management. There have been no Velindre acquired grade 3-4, pressure ulcers reported for this period. SMT lead: TBC Actions being taken to improve performance: The unstageable pressure damage has been reported to Welsh Government in accordance with Putting Things Right regulations. The pressure ulcer reduction group continue to meet monthly to focus on the prevention and management of pressure damage. The group has prioritised the implementation of the revised SKIN bundle to reduce and manage Velindre acquired pressure ulcers. Findings of the RCA s undertaken have identified areas of patient care that require improvement resulting in the following being implemented: Individualised Prescribed Nursing Care Plan for pressure ulcer care and management Expected completion date: The above actions have been implemented and are ongoing Daily Waterlow risk assessment Repositioning to relieve pressure Discussions with patients and carers about the risk of pressure damage and individualised care plans. Review the SKIN bundle audit tool. Implementation of further air relieving equipment, i.e. wedge.

83 Safe and Reliable Services - Healthcare Associated Infections Number of Velindre acquired infections: Velindre acquired C.diff infections = 0 Velindre acquired MRSA infections = 0 Velindre acquired MSSA infections = 1 Velindre acquired E.coli infections = 0 Target: 0 Why is performance off track? C difficile- There were no cases in September There have been no MRSA bacteraemias since There was one MSSA bacteraemia in September, and root cause analysis is in progress. There have been three cases since April all patients had a PICC insitu but follow up results have proved to be negative so source not identified. There has been one E. coli bacteraemia in September, rootcause analysis is in progress. There have been 7 cases since April 2017, 4 of which had a E.coli UTI prior to onset of the bacteraemia (therefore the patient is more susceptible to contracting e.coli bacteraemia). SMT lead: TBC Actions being taken to improve performance: Routine monitoring and preventative actions continue each month for all infections. Aseptic Non Touch Technique (infection prevention competency) implementation progressing well across the Trust to ensure optimal clinical IV management. Urinary Tract Infection management group established on 11/09/17 and will meet monthly to review the management & treatment of urinary tract infections. Expected completion date: There will be a rolling programme with ongoing elements and a 3 yearly competency assessment and new starters/staff changeover.

84 Sep-17 Safe and Reliable Services - Death within 30 days of chemotherapy Sep-17 Percentage of deaths by quarter: Percentage deaths by Cancer Site