Annual Quality Report 2009/10

Transcription

1 Annual Quality Report 2009/10 The Cheshire and Merseyside NHS Treatment Centre

2 Part 1 - Introduction Statement on Quality from the Chief Executive The Members of the board of Interhealth Canada (UK) Ltd have received and approved this Quality account in June. The management philosophy of the company is centered on putting the patient first and this shapes our view of quality taking it beyond clinical outcomes to encompass every element of the patient pathway patient satisfaction, and reliability. Our parent Company Medical Director Eric Parsons, as a Director of Interhealth Canada (UK) Ltd is directly involved in our quality programme. He has been a director of our parent company for15 years. When discussing the approach to quality he said In all my years with Interhealth I have never seen quality compromised for profit. In fact profit has at times been forgone to ensure quality Whilst we are very proud of the quality of services we deliver at the Cheshire and Merseyside NHS Treatment Centre we continue to build and improve on this. In the report you will find details of our quality initiatives split by the three domains of quality for the coming year: To improve customer satisfaction by listening and learning from our customers especially when they express concerns and improving our services through enabling some of our patients and careers to participate with us in experience based design To improve the quality of care delivered by our nurses by freeing them from other duties and releasing more time to care To reduce even further our current low levels of falls and medication errors. The report details the high scores obtained by the Centre from its patients in the national patient survey. Illustrated with excerpts of the comments made by individual patients. These give any NHS prospective patient consulting this report the confidence to choose our services without worry. All members of staff are engaged in the delivery of quality but those specifically tasked with setting standards measuring and composing this Quality Account for 2009/2010 include: Anne Males - Registered Manager/Corporate Chief of Nursing Services Joyce Bowler -Infection Control & Quality Facilitator Sue Aucutt Matron Adrian Stokes Imaging Manager David O Carroll Surgical Services Manager Ruth Brown IM Manager Sara Clarke IM&T Analyst Clare Pilkington Non Clinical Support Services Manager I confirm that to the best of my knowledge all the information contained in our Quality account is accurate. Fred Little Chief Executive Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 2 of 26

3 Part /10 Summary Strategic Context The Cheshire and Merseyside NHS Treatment Centre is set in the heart of Halton and St Helens. Managed by an Independent Sector provider (InterHealth Canada) it delivers NHS elective orthopaedic surgery to the people and residents of Cheshire and Merseyside. In support of the InterHealth Canada s statement about who we are: We work closely with both private and government organisations and we are committed to deliver high quality patient care that meets international standards and value for money. The Board of Directors has defined five business and clinical objectives 1. To be the provider of elective orthopeadic Surgery services of choice 2. To be the Employer of choice to people wishing to work in an elective orthopaedic arena in the local community 3. To be the most effective service 4. To build on our reputation for quality and efficiency 5. To have excellent clinical outcomes in elective orthopeadic surgery The Cheshire and Merseyside NHS Treatments Centres quality programme is fully aligned with its broader business strategy to ensure that the right issues are prioritised at the right time. Service excellence lies at the heart of our Integrated Business Plan for 2010/11. The Board, in consultation with other parties, has selected a number of key quality priorities for the coming year. Partnership Approach to Quality The Cheshire and Merseyside NHS Treatment Centre works in partnership with eight Primary Care Trusts (PCTs) and has a close working relationship with its sponsor PCT. The commissioner(s) and InterHealth Canada share a complementary approach to improving the quality of orthopaedic surgical services in Cheshire and Merseyside and to ensuring that the people of Cheshire and Merseyside received a First Class Service. The PCT s we work in collaboration with are: Central and Eastern Cheshire Halton and St Helens Knowsley Liverpool Western Cheshire Sefton Warrington Wirral We meet with the sponsor PCT on a quarterly basis, the Joint Service Review, where full and frank discussion relating to the quality and performance of the service takes place. Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 3 of 26

4 Number Number The Cheshire and Merseyside NHS Treatment Centre Activity 2009/10 saw patients admitted to our Treatment centre for varying reasons however the majority was for either hip or knee replacement surgery or as day case. There are small number of other orthopaedic operations that require an overnight stay on the in-patient ward, these are excluded from the figures below: Figure 1 Hip and Knee Replacement Surgery procdeures Number of Hip Replacements per month 2009/ Apr-09 May- 09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar- 10 Hip patients Number of KneeReplacements per month 2009/ Apr-09May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Knee replacements Apr-09 May- 09 Jun-09 Jul-09 Aug- 09 Sep-09 Oct-09 Nov- 09 Dec-09 Jan-10 Feb-10 Mar Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 4 of 26

5 Figure 3 Day Surgery procedures The Cheshire and Merseyside NHS Treatment Centre 400 Number of Day Surgery procedures per month 2009/ Apr-09May-09Jun-09 Jul-09 Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10Feb-10Mar-10 Apr- 09 May- 09 Jun-09 Jul-09 Aug- 09 Sep- 09 Oct-09 Nov- 09 Dec- 09 Jan-10 Feb- 10 Daycase patients Mar- 10 As can been seen from the graphs above we have had periods in the summer where we performed 315 procedures (not including those 1 day admissions to the in-patient ward) and as the year drew to a close we were up to 476 procedures. As we move in 2010/11 we expect that number to remain high and even increase over this year. The figures above are down on the previous 2008/09 year but we have put in a robust marketing campaign and looked at other avenues should as taking outpatient clinics into the community as was seen in Liverpool in order to encourage the use of the Treatment Centre. Infection Prevention and Control InterHealth Canada prides itself on its achievements in Infection Prevention and Control (IP&C). It remains high on the agenda from The Board downwards in recognition of its adverse impacts on both the quality of the service offered by InterHealth Canada and an appreciation of its affect on the national health budget. In order to achieve its low rates of hospital acquired infection rates InterHealth Canada will continue to: ensure uncompromising commitment from managerial and clinical leaders; Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 5 of 26

6 apply rigorously and consistently the measures known to be effective in reducing the risks of healthcare associated infection; The current driving force for IP&C is The Health and Social Care Act This legislative requisite places a number of requirements that must be achieved, InterHealth Canada is not exempt from this. The current body responsible for examining our compliance with The Hygiene Code is the Care Quality Commission. InterHealth Canada is required to be fully compliant against The Hygiene Code by October 1 st 2010 however over it has undertaken the following in preparation for this compliance: Infection Surveillance : this is the ongoing systematic collection and analysis of data and the provision of information which leads to action being taken to prevent and control a disease, usually one of an infectious nature. There are 2 main types of Infection surveillance undertaken at The Cheshire and Merseyside NHS Treatment Centre: Laboratory based surveillance of alert organisms These are useful indicators for the hospital to monitor current trends and audit any targeted practice development that may be required. Organism / Condition Status of Surveillance Clostridium difficile toxin, Mandatory Health Protection Agency (HPA) MRSA bacteraemia, Mandatory Health Protection Agency MRSA screening and colonisation Contract Manager and NHS Northwest Infections (all sites) - Hospital initiative Surgical Site Surveillance: Total Hip Replacement, Mandatory Health Protection Agency Surgical Site Surveillance: Total Knee Replacement, Mandatory Health Protection Agency Surgical site infection within admission Care Quality Commission Ward based surveillance of conditions e.g. vomiting/diarrhoea; chickenpox/ Shingles Surgical wound infection of all surgery Evidence Based initiatives in relation to Hip and Knee Replacements : Advancing Quality NHS NorthWest Norovirus outbreaks voluntary HPA IP&C Audit: InterHealth Canada also monitors its IP&C activities through a programme that incorporates audit of key policies/ practice areas. Once completed an audit report and action plan is prepared by the ICN and distributed to the key people involved. The following are examples of on-going IP&C audit throughout the year: A quarterly audit of the environment using the Infection Control Nurses Association audit tool (2004), in conjunction with the soft and Hard FM provider and the link practitioner for that area every 3 months. A quarterly audit of theatres undertaken by the Infection prevention and Control Link Practitioner for theatre. An annual PEAT assessment involving former patients of the hospital and members of the clinical team including Infection prevention and Control. All results are fed-back to the NPSA Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 6 of 26

7 A monthly hand hygiene audit undertaken by the link practitioner for that clinical area. A weekly audit of the Visual inspection phlebitis (VIP) scores is undertaken for all patients who require overnight stay A monthly audit of High Impact Interventions (HII) of the following: o Peripheral Line o Urinary Catheter o Surgical Site Infection o Clostridium difficile ( where necessary) o Decontamination of equipment MRSA Bacteraemia and Clostridium difficile Infection: There have been no cases of MRSA bacteraemia or Clostridium difficile during InterHealth Canada are proud of their statement that they are MRSA and Clostridium difficile free and they will continue to work hard to maintain this record in the future. Surgical Site infection (SSI): InterHealth Canada is 100% compliant with its national mandatory reporting requirements for SSI. Number inpatient/ readmission Post discharge confirmed Patient reported 2.2% (3 patients) Statement of Assurance SSI Reporting Oct-Dec 2009 Knee Replacement Hip Replacement Cheshire and Merseyside NHS Treatment Centre National Average Cheshire and Merseyside NHS Treatment Centre National Average 0% 0.6% 1% 0.9% (1patient) 0% 0.3% 0% 0.2% No national average 1% ( 1 patient) No national average The Directors and Board members are required to satisfy themselves that the Cheshire and Merseyside NHS Treatment Centre s annual Quality Accounts are fairly stated. In doing so, it has put in place a system of internal control to ensure that proper arrangements are in place. The Cheshire and Merseyside NHS Treatment Centre has appointed a member of the Board (The Chief Executive Officer), the Corporate Chief Nurse and the Infection Control and Quality Facilitator to lead, and advise on all matters relating to the preparation of the annual Quality Accounts. To ensure that the Cheshire and Merseyside NHS Treatment Centre s Quality Accounts present a properly balanced view of performance over the year, we have established a Quality and Audit Committee that is accountable to the Board to provide scrutiny and challenge over our clinical performance. We have quarterly Joint Service Review meetings with our main Commissioner, and has shared the draft Quality Account with the Commissioners and the Health and Scrutiny Committee for comment. During 2009/10 The Cheshire and Merseyside NHS Treatment Centre provided and/ or subcontracted three NHS services. These services incorporated providing elective orthopaedic surgical care for patients over 18 and included, but was not limited to the following surgeries: Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 7 of 26

8 Hip replacement surgery Knee replacement surgery Knee arthroscopy Repair of anterior and posterior cruciate ligaments Complex hand and feet procedures Minor hand and feet procedures Pain relief and steroid injections The services provided are: Out Patient, In-Patient and Day Case services as well as Diagnostics ( namely X-ray; CT scan and MRI scanning). We also sub contracted two NHS services, pharmacy and pathology, from Warrington and Halton Hospitals NHS Foundation Trust. We have reviewed all the data available to us on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 2009/10 represents 100 per cent of the total income generated from the provision of NHS services by the Cheshire and Merseyside NHS Treatment Centre for 2009/10 Innovation Given the unprecedented resource challenge, doing what we have always done in ways that we have always done it is no longer an option. Services and working practices will be reviewed against five key categories: Avoidance of spend: Reducing expenditure by improving procurement and stopping unnecessary interventions/processes/demands Reallocation: Transferring resources from one area to another to produce better care and better value Disinvestment: Ceasing expenditure on areas/services that have little or no impact on improving care Removal of variation: Refining working practices in areas where there are wide variations in activity between similar teams/individuals Investment to save: Investing carefully in infrastructure that saves money over the medium and long term Participation in Clinical Audits During 1st April 2009 to 31st March 2010, four national clinical audits and one national confidential enquiry covered NHS services provided by The Cheshire and Merseyside NHS Treatment Centre During that period we participated in 100% of national clinical audits and 0% of national confidential enquiries of which it was eligible to participate in. These audits/enquiries included: Patient Outcomes in Surgery (POiS) Audit Falls and Bone Health Audit National Comparative Audit of Blood Transfusion National Joint Registry Audit Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 8 of 26

9 Peri Operative Care Study Confidential Enquiry The national clinical audits and national confidential enquiries that The Cheshire and Merseyside NHS Treatment Centre participated in and for which data collection was completed during 1st April 2009 to 31st March 2010 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Patient Outcomes in Surgery (POiS) - Audit 100% Falls and Bone Health Audit 100% National Comparative Audit of Blood Transfusion 100% National Joint Registry Audit 100% Peri Operative Care Study Confidential Enquiry 0% The reports of 4 national clinical audits, one confidential enquiry and 10 local audits were reviewed by the provider during 1st April 2009 to 31st March The Cheshire and Merseyside NHS Treatment Centre intends to take the following actions to improve the quality of healthcare provided. Disseminate audit results to all relevant clinicians Develop and maintain action plans to address shortfall in service provision Carry out re audit in 12 months time to monitor compliance Ensure participation in the national confidential enquiries Participation in Research The Cheshire and Merseyside NHS Treatment Centre in was involved in conducting no clinical research studies. The number of patients receiving NHS services provided or sub-contracted by The Cheshire and Merseyside NHS Treatment Centre in that were recruited during that period to participate in research approved by a research ethics committee was zero. In the last three years, no publications have resulted from our involvement in the National Institute for Healthcare Research (NIHR), helping to improve patient outcomes and experience access the NHS. National Continence Audit 18 cases Goals agreed with Commissioners The Cheshire and Merseyside NHS Treatment Centre income in was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation (CQUIN) payment framework because as an independent contractor it is external to current CQUIN accounts. However, although payment is not dependent on performance, The Cheshire and Merseyside NHS Treatment Centre does undergo scrutiny of performance in relation to a number of key performance indicators via both its sponsor PCT and the Department of Health. A performance indicator or key performance indicator (KPI) is a measure of performance. Such measures are commonly used to help organizations define and evaluate how successful it is, typically in terms of making progress towards its long-term goals. KPIs can be specified by Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 9 of 26

10 answering the question, "What is really important to different stakeholders?" in our case this is patients, carers, relatives, commissioners and the Department of Health. KPIs are frequently used to "value" difficult to measure activities such as the benefits of leadership development, engagement, service, and satisfaction. We have a total of 26 KPI s that we reported on every month throughout 09/10 these are listed below. 1. Inpatient and daycase DNAs (2%) 2. Non-clinical cancellations on or after day of admission (0.5%) 3. Clinical cancellations on or after day of admission (0.65%) 4. Unscheduled returns to theatre (0%) 5. Conversion rate patients listed for surgery after outpatient assessment 6. Rejection of patients 7. Daycase to inpatient conversions (2%) 8. Transfer of inpatients to other provider (1.8%) 9. Emergency re-admissions within 28 days 10. Average length of stay daycases 11. Average length of stay inpatients 12. Average procedure time induction, operating and recovery 13. Additional surgery required within 5 years resulting from original activity 14. Total procedures completed under local, regional and general anaesthetic 15. Clinical outcomes (reported separately) 16. Timeliness, completeness and accuracy of performance data 17. Timeliness, completeness and accuracy of GP letters 18. Patient satisfaction surveys (80% satisfaction) 19. Patient complains 20. Timeliness of complaints handling 21. NPSA reportable incidents 22. Additionality 23. Condition of facility 24. Breach of security services 25. Breach of confidentiality 26. Failure to meet outpatient and inpatient / daycase treat by dates In 2010/11 the KPI s will change with additional performance measures to be included in our monthly reporting that attains to the quality of the service we provide. What Patients, Carers and the Public say The process for hearing people s views There are a number of formal and informal information gathering activities. These include: The national patient survey Complaints, compliments and comments Patients experience survey programme Capture of feedback from patient involvement events Monitoring of the patient opinion website on NHS Choices Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 10 of 26

11 Patient reported outcome measures (PROMS) These activities are managed by a number of staff within The Treatment Centre. The current Cheshire and Merseyside NHS Treatment Centre Patient Experience Survey includes a requirement for Outpatients, In-patients and Day Case Unit to conduct a continuous survey which is reported monthly. The survey initiative requires the Registered Manager to provide a report on the findings each month together with an action plan formulated in response to the specific issues raised within each service. This is presented to the Joint Service Review on a quarterly basis. Messages from the surveys that have been undertaken The main negative themes recurrent in almost all surveys are Requests for clearer directions: This issue frequently arises and we have applied unsuccessfully to increase the number of available signage. We will continue to address this issue with the local borough council Food We have listened to patients comments about the food and have worked closely with our catering providers to revisit and revamp the menu. We recently introduced a concept of Essential Goodness and have aligned the menu with all of the nutritional requirements for a healthy diet. Examples of actions taken in response to feedback on patient experience include: Protective mealtimes for patients so that they are undisturbed by staff or visitors while eating Redesigned visiting times to concur with patients wishes Redesigned the relatives/carers pathway in the day case unit Reviewing the need for an outside seated area for patients for the Spring and Summer We continue to seek and strive for solutions to comments raised about the lack of a manned cafeteria for early morning appointments; the non availability of satellite TV ( we do have a free digital TV service for patients); bottlenecks and extended waiting times within the one-stop-shop system. Despite some concerns being highlighted, most of the feedback received was positive in nature. Everything. I feel all staff was handpicked for their job and all enjoyed it. The cleanliness of the whole area. The dedication of the doctors, nurses and other staff. Very impressed, I would recommend the hospital to anyone Nothing is too much trouble the staff are fantastic Kindness of staff Superb staff in all departments Very helpful, told you what was going on and very clean building Tamas Kustos and nursing staff Professionalism of staff The focus of hygiene Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 11 of 26

12 Top class attention, I would recommend to any friend Scores from the National Patient Survey as shown on NHS Choices The Cheshire and Merseyside NHS Treatment Centre Patient survey score for dignity and respect 9.8 out of 10 Patient survey score for dignity and respect for inpatients treated at this hospital. Patient survey score for involvement in decisions about treatment 9.2 out of 10 Patient survey score for involvement in decisions about treatment for inpatients treated at this hospital. Patient survey score for cleanliness of wards 9.9 out of 10 Patient survey score for cleanliness of wards for inpatients treated at this hospital. Patient survey score for availability of same sex accommodation 9.8 out of 10 Patient survey score for availability of same sex accommodation for inpatients treated at this hospital. Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 12 of 26

13 Excerpts from NHS Choices. J was a patient in May What I liked This hospital should be the NHS Flag Ship it is just outstanding in all respects. I really felt I was attending a BUPA Private hospital it was just that efficient. I just can not praise them enough they have hit the target in patient care as far as I am concerned and I congratulate them on their communication skills. In my humble opinion, this hospital is the best I have ever attended well done all the staff, well done indeed. Thank you all. What could be improved? I just do not believe you can improve on perfection RH was a patient in Feb What I liked I thought the whole process, from the initial telephone conversations and subsequent consultation with the surgeon who carried out the Arthroscopy on my right knee, to the follow up call from the hospital staff to check on my progress, was in a word Exemplary! Everything went like clockwork. The Hospital was very clean and uncluttered and all the staff were extremely attentive, keeping me fully informed and offering reassurance to me and others patients at every stage. Anything else? Thank you very much indeed, for a First Class service. AC was a patient in May What I liked Truly a Flagship for the NHS--- The speed and efficiency of this hospital was quite impressive, from the 'Pre Op' assessment stage through to the hip replacement operation and final discharge.... I would certainly recommend the centre...to anyone considering orthopaedic surgery. My only disappointment was 'an early discharge', a sentiment shared by my two other fellow patients.it may sound crazy but we really did enjoy our stay at 'The Cheshire and Merseyside NHS Treatment Centre'. Choose and Book without reservation! What could be improved? My requests for coffee, cognac and mints after dinner appear to be ignored. Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 13 of 26

14 What others say about The Cheshire and Merseyside NHS Treatment Centre The Cheshire and Merseyside NHS Treatment Centre is required to register with the Care Quality Commission and its current registration status is fully registered and has no conditions set by the Commission and we are registered to carry out the following regulated activities: An acute Independent Hospital to provide services to persons aged 18 years and over. The hospital provides Orthopaedic services to maximum of 44 in-patients with 12 day surgery beds. The Care Quality Commission (CQC) is the organisation that is our regulator. Each year healthcare providers must provide evidence to the CQC that we meet specific standards set by them that assure us, the CQC and the public that we are a capable and safe provider of healthcare services. The inspection can be a self assessment or a site visit by the CQC. This year we had an on-site inspection on the 20 th April. The assessment covered 5 main areas and the outcomes are as follows: 1. Safety do we provide treatment and care safely? The areas assessed were child protection procedures, risk management policy, controlled drugs and infection control. We fully met the required standard for these areas 2. Clinical and cost effectiveness is the best possible treatment provided? Monitoring Quality. We fully met the required standard for this area 3. Governance are we a well run organisation? Human resources policies and procedures. We fully met the required standard for these areas. 4. Patient Focus do we put the patient first? Patient centred care. We fully met the required standard for these areas Information for patients. We nearly met the required standard for this area. It was not fully met because the complaints policy and leaflets contained the wrong address for the CQC Resuscitation equipment. We nearly met the required standard for this area. It was not fully met because the resuscitation trolley in the Out Patient Department was not checked at the weekend. We have subsequently addressed these areas to ensure they now meet the required standard. 5. Environment and amenities is the centre well designed and maintained? Health care premises and health and safety We fully met the required standard for these areas. The Care Quality Commission has not taken enforcement action against The Cheshire and Merseyside NHS Treatment Centre during 2009/10 nor has The Cheshire and Merseyside NHS Treatment Centre had to participate in any special reviews or investigations by the CQC during the same reporting period. As well as the CQC there are a number of other assessments that are undertaken each year. The National Patient Safety Agency undertakes an annual assessment known as the PEAT assessment the scores demonstrate how well individual healthcare providers believe they are performing in key areas including food, cleanliness, infection control and patient environment (including bathroom areas, décor, lighting, floors and patient areas. Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 14 of 26

15 The assessment is undertaken in march each year and we are now able to confirm that the PEAT results 2010 for environment, food and privacy and dignity for each hospital within The Cheshire and Merseyside NHS Treatment Centre has been rated as follows from the NPSA: Privacy & Environment Food Dignity Score Score Site Name Score The Cheshire and Merseyside NHS Treatment Centre Excellent Excellent Excellent Information Governance The Cheshire and Merseyside NHS Treatment Centre submitted records during 2009/2010 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data: which included the patient s valid NHS number was: 100% for admitted patient care; 100% for outpatient care; and which included the patient s valid General Medical Practice Code was: 100% for admitted patient care; 100% for outpatient care; and The Cheshire and Merseyside NHS Treatment Centre score for 2009/2010 for Information Quality and Records Management, assessed using the Information Governance Toolkit was 88%. Clinical Coding: The Cheshire and Merseyside NHS Treatment Centre was not subject to the Payment by Results clinical coding audit during 2009/2010 by the Audit Commission. Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 15 of 26

16 Part /2011 Priorities for Improvement and growth There are a number of key priority areas which we intend to focus on in the coming year. We have aligned these priorities with the 3 domains of Quality ( Patient Experience; Clinical Effectiveness and Patient Safety): Patient Experience Priority 1: Improve Customer Satisfaction nts Process Rationale InterHealth Canada actively seeks feedback about its services and recognises the right of people to comment on or complain about any aspect of the service they receive. InterHealth Canada is committed to trying to resolve things that go wrong as soon as possible and to give patients and carers a satisfactory outcome Aims Current status Therefore, InterHealth Canada acknowledges the importance of an effective and efficient complaints procedure, which enables and encourages complainants to speak openly and freely about their concerns. They should be reassured that whatever they say will be treated with the appropriate confidentiality, sensitivity and care, feeling satisfied with the way their complaint has been handled and confident that InterHealth Canada has learnt from their experience. To increase the level of support for complainants (Listen) To achieve greater customer satisfaction and confidence in the complaints process (Respond) To ensure the experiences of patients, carers and relatives are used to improve the quality of services. (Improve) In 2009/2010, the Cheshire and Merseyside NHS Treatment Centre received 20 formal complaints/concerns: all 20 were complaints resolved through formal investigations 6 complaints were found to be upheld with a further 7 th partially upheld It is hoped that this project will result in an increase in the number of concerns complaints and compliments recorded, as this demonstrates a positive approach to empowering patients and carers to raise concerns and provide feedback and enables us to build on areas of patient preference. Plans The project is also seeking to increase the proportion of service level resolutions, which will demonstrate that staff are better equipped to resolve concerns, accept compliments and to deliver a more customer focused service. To review current customer care initiatives To identify past and current themes/trends regarding complaints, complaints process and satisfaction of outcome of complaint. To apply experience based design to complaints review & evaluation Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 16 of 26

17 Monitoring & reporting Leads Satisfaction survey on complaints handling Reports to Quality and Audit Committee providing aggregated information on themes and trends of concerns and complaints Implementation of actions plans for service improvements identified through concerns and complaints. Customer Care training programme for staff Anne Males (Registered Manager) Joyce Bowler (Infection Control and Quality Facilitator) Priority 2 Experience Based Design Culture Rationale Aims Current status Plans Monitoring & reporting It is recognised that improvements are needed in how the information received from patients, carers and other stakeholders is collated and acted-upon. InterHealth Canada s Quality Strategy outlines a move to using the Experience Based Design (EBD) approach as one key area of improvement. The key principles of this approach are: Understanding what is good design Designing human experiences; as distinct from designing processes or services, or simply seeking opinions or satisfaction Direct user involvement: co-design, participative, interactive Partnership between patients, families, health professionals, managers and designers Understand what people (staff, patients, family) naturally do & feel To involve patients and carers in improving the quality of care and inpatient environment in order to capture, understand, improve and measure the experience patients have. The goals are to: Create specific orthopaedic pathways to follow the natural patterns of those who use the service Create a positive and good experience for patients For patients and staff to see each other in a different way.as people We are in the infancy of patient and public involvement and we currently actively recruiting to a Patients Forum from which to launch user involvement in the services provided at the Cheshire and Merseyside NHS Treatment Centre. Train staff, patients and carers in using experience based design (EBD) Liaise with relevant leads to evaluate effectiveness of EBD Develop of staff guidance documentation (with the involvement of service users and carers) which will be publicised to all services Support those staff undertaking patient experience survey work Introduce survey training for involvement volunteers Develop a more robust system of managing feedback Outcomes will be monitored through the patient experience survey programme and will be reported to the Clinical Quality & Risk Committee Leads Clare Pilkington Non Clinical Support Services manager Anne Males Corporate Chief Nurse Priority 3 Service User Involvement and Engagement Using a recognised tool such as Experience Based Design will enable staff, patients and carers to work in a creative yet systematic manner to focus purely on patient/ need and experience. Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 17 of 26

18 InterHealth Canada Bringing together the two priorities without prescription will enable each clinical area to develop and implement their own individual action plans that will make a difference to patients, carers and staff within their areas. This in turn will produce a First Class Elective Orthopedic Surgery Service that has integrated and aligned itself with the needs and wants of its patients. Clinical Effectiveness Priority 3 Releasing Time to Care R are Rationale Research carried out by the NHS Institute found that nurses in acute settings spend an average of just 40% of their time on direct patient care. This is supported by research carried out by Nursing Times, which shows that nearly three in four ward nurses say that they do not spend enough time on direct patient care, and 90% of those polled say that patient care suffers as a result. Designed by nurses for nurses the Productive Ward and Theatre Programmes offer systematic ways of delivering safe, high quality care to patients. They provide tools and guidance to help ward staff to make changes to their physical environment and working processes that will improve quality of care and heighten safety standards. The approach, which uses improvement techniques from industry, analyses the main tasks taking place on a ward. These tasks are broken into different modules, such as medication rounds and meal rounds, are then redesigned to ensure they are patient-focused and easier for staff. Aim Current status Plans Monitoring & reporting Leads The power of the Productive Series is that change is initiated from frontline staff, patient and carers as they become enthused and empowered by seeing the impact that they can have. The main aim of the Releasing Time to Care programme is to improve and increase the amount of direct time staff has to spend with patients by improving the wards to make them run more efficiently, effective and safer. We currently have the in-patient ward and theatre initiated onto the Programme with the remaining Out Patient department scheduled to start in July 2010 To complete full implementation of clinical areas onto the Productive Programme by the end of 2010 A measures board has been established for each individual clinical area which they display in their local environment for staff, patient and carers to see. The measures table includes a baseline of direct patient care time and one to one therapeutic activity. This is reported to the steering group on a monthly basis. David O'Caroll ( Sterile Services Matron) Adrian Stokes ( Imaging Manager) Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 18 of 26

19 InterHealth Canada Sue Aucutt ( Matron) Priority 4 High Impact Interventions Rationale Aims Current status Plans Monitoring & reporting Leads High Impact Interventions (HII s) relate to those key clinical procedures which can increase the risk of infection if not performed appropriately. They have been developed to provide a simple way of highlighting the critical elements of a particular procedure, the key actions required and a means of demonstrating reliability using compliance measurement. The purpose of the HIIs is to minimise unwarranted variation in practice by providing a way of identifying where compliance needs to be increased and a measure of how often all elements are performed for a given procedure. The tool is also the means by which results can be quickly fed back to staff and actions can be agreed and implemented. The key HII relevant to The Cheshire and Merseyside NHS Treatment centre are: Peripheral Line insertion and ongoing management Urinary catheter insertion and ongoing management Prevention of surgical site infection To have zero variation in the critical elements required to reduce preventable infections We currently have introduced all the above HII s into the clinical areas however they are in the early stages of compliance Ensure all patients receive comprehensive assessment on admission, and regular ongoing review of critical elements throughout an invasive process. Enhance the skills of staff in determining infection prevention risks. Develop new strategies to enable full compliance with HII s HII s are reported on a monthly basis to the Core Risk Committee and assurance of compliance given to the Integrated Governance Committee Joyce Bowler Infection Control and Quality Facilitator David O Carroll ( Surgical Services Manager) Sue Aucutt ( Matron) Patient safety Priority 4 Reducing Medication Errors Rationale Aims There are potential risks to the safety of service users at every stage of the medicines management process- when medicines are procured, prescribed, dispensed, prepared, administered and monitored. Errors may occur despite safeguards and best practice guidelines To review and reduce the current level of medication errors To reduce medication related incidents in all care environments To keep patient safety and effective medicines management as a key priority for InterHealth Canada To prevent medicines related incidents that can cause significant problems Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 19 of 26

20 InterHealth Canada Current status Plans Monitoring & reporting Leads and sometimes unnecessary harm or distress. To maintain compliance with all aspects of Care Quality Commission and other national legislative guidance for medicines management InterHealth Canada has an assurance framework through the Core Risk Committee and Medicines Management Policy that is working towards medication error reduction. An action plan has been implemented and is still ongoing, which demonstrates the recognition of good practice in the safe and secure handling of medicines. This action plan was initiated after two near miss episodes The priority for the first quarter in 2010/2011 is to establish a baseline for medication errors, which will enable progress to be tracked The Cheshire and Merseyside NHS Treatment Centre has undergone an assessment of its risk management standards for medicines management by the NHS litigation Authority To develop a documented process for managing risks associated with medicines in all care environments To implement the recently developed 'nurse competency framework' for handling and administering medicines, particularly for those staff who are new to the organisation, qualifying students, or nurses who have made drug errors. To actively review and revise all documentation, guidelines, protocols, and polices surrounding any aspect of medication The Senior Pharmacist to actively support and be party to the development of any local action plans or lessons learnt from any reported medication incident. For all qualified nursing staff on the inpatient ward to undertake a written assessment of NMC regulations, company policy and drug calculations as part of their medicines management update Monitoring of the risk management processes developed surrounding medicines in all care environments Regular reports on reported medicines incidents to the Core Risk Committee from the risk management systems Mary Byrom Professional development and Education Manager Suzanne Penrose Senior Pharmacist Priority 5 Reducing Falls Rationale Aims Current status Orthopaedic patients admitted to inpatient areas may experience falls for a variety of reasons, for example due to mobility problems, cognitive or sensory impairment and environmental factors. The impact of these falls and possible injury to older adult service users and the effect this may have upon relatives and carers needs to be addressed through effective and skilled multifactorial assessment and intervention. Ill health as a result of falls not only adds risk to the individual and cause distress to relatives and carers, but may also significantly increase the length of in-patient stay To reduce the number of falls occurring to patients within in-patient areas The Cheshire and Merseyside NHS Treatment Centre utilises an integrated Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 20 of 26

21 InterHealth Canada care pathway tool which includes a falls risk assessment, falls management plan and manual handling plan for patients on admission and these are reviewed regularly throughout the inpatient journey. Falls within the inpatient areas are reviewed by the falls team as and when they happen in order to identify appropriate risk reduction measures and interventions. Plans Monitoring & reporting Leads In 2008/2009, nine falls were reported. The figure for 2009/2010 was 11 showing a slight increase on the year before Ensure all older adult in-patients receive comprehensive assessment on admission, and regular review of falls risk throughout their stay. Enhance the skills of staff in determining and managing falls risk. Utilise and manage resources effectively within the in-patient environment in order to reduce risk. Develop new strategies to enable falls risk reduction tailored to identified areas of need. Falls are reported via the Cheshire and Merseyside NHS Treatment centre incident reporting system. Statistics are monitored and reviewed monthly by the Falls Team in order to establish strategies to manage areas of increased or ongoing risk and need. Support is given to areas of good practice where falls risk reduction is occurring. Magaretha Erasmus Lead Nurse In-Patient Ward Toni Kenwright - Physiotherapist Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 21 of 26

22 InterHealth Canada Further Improvement Plans for 2010/2011 Inpatient Services The Cheshire and Merseyside NHS Treatment Centre meets the minimum requirements for the provision of single sex accommodation in both the inpatient ward and the day case unit. However we recognise the need to increase the number of toilet facilities within the day case unit. We plan for this to happen during Service Improvements The key service improvement priorities in 2010/11 which are not included in other service developments are: To increase the number of Clinical Audits currently undertaken to assure ourselves of compliance with key policies and protocols. To review the induction process with particular reference to updating the care staff handbook and learning portfolio Quality Management Systems The Cheshire and Merseyside NHS Treatment Centre develops and embeds quality in the organisation, using a number of quality managements systems which work hand in hand with the three domains of quality outlined above. These include: Leadership Leadership and its development are necessary at all levels of the organisation, and require strengthening. The Cheshire and Merseyside NHS Treatment Centre needs to ensure that its clinicians (of all disciplines) and senior managers are developed to take on a leadership role to drive up quality standards and improve service effectiveness. The challenging financial situation requires clinicians of all disciplines and senior managers to develop effective co-operation between business units, in order to create the conditions for innovation and the development of clinically and cost effective high quality care pathways. Workforce The Workforce Strategy sets out the Cheshire and Merseyside NHS Treatment Centre s strategic intentions to ensure that the workforce delivers best quality customer services. The Cheshire and Merseyside NHS Treatment Centre s vision for the future workforce is to ensure that its workforce will be aligned with the overall goals of the organisation and to utilise professional skills of staff to add value to quality of patient care. Two of the strategic workforce aims are directly related to the delivery of quality service:» Develop a workforce that is highly skilled, motivated and culturally capable» Integrated workforce planning for improved workforce efficiency Information Systems One of the principle objectives of the Cheshire and Merseyside NHS Treatment Centre Information Management & Technology strategy is to provide increasingly sophisticated Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 22 of 26

23 InterHealth Canada information on service delivery that allows intelligent decision making and directly informs action for improvements in the quality of care. For 2010/11 the key priorities are focused on supporting the key business drivers to: Adopt new ways of working and hence improve both efficiency and cost effectiveness Reduce operating risks. Improve business management Meet regulatory, compliance or contractual requirements Links between quality and resources The Cheshire and Merseyside NHS Treatment Centre s Plan for 2010/11 is driven by a continuous need for performance improvement, particularly in relation to quality. Given the public sector spending squeeze, this will require unprecedented levels of efficiency and effectiveness. If the desired productivity improvements are to be achieved, the Cheshire and Merseyside NHS Treatment Centre must combine increased efficiency to avoid unnecessary costs with stronger innovation. We are currently addressing these issues with our work on our Continuous Improvement Programme which incorporates many elements of the Productive Series devised by the NHS Institute for Innovation & Improvement. Recent work by the NHS Institute for Innovation & Improvement suggests that, in addition to the ethical, moral, and professional case for taking action to reduce harm and unwarranted variation in care, there is also a compelling business case for quality. There is growing empirical evidence that a focus on quality would ultimately provide an effective strategy to contain costs; however this is reliant on organisation-wide implementation. The Cheshire and Merseyside NHS Treatment Centre has signed up to the National Patient Safety Agency s Patient Safety First Initiative in an effort to ensure a leadership culture and environment that promote quality and patient safety improvement. This initiative has seen the introduction of Patient Safety Walk-Rounds by members of the Board through 2009, who visit clinical areas to discuss patient safety issues with staff across all disciplines in order to inform organisational decisions. Quality Indicators for Sentinel indicators Post- Operative Mortality Patient Safety Incidents and Serious Untoward Incidents General clinical indicators Returned to Theatre Unexpected Transfers Emergency Readmissions Inpatient Admission of Day Cases Clinical Cancellations Quality Account 2010/11 The Cheshire and Merseyside NHS Treatment Centre Page 23 of 26