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1 Clinical Governance report prepared for NHS Lanarkshire Board Report title Clinical Governance Corporate Report - November 2014 Clinical Quality Service Page 1 of 26 Print Date:18/11/2014

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13 Clinical Governance report prepared for NHS Lanarkshire Board Report title Clinical Governance Corporate Report - November 2014 Safe: Cardiac Arrest Rate - NHSL Cardiac Arrest Rate (True cardiac +/- respiratory arrests) per 1000 Title: total deaths and live discharges (NHSL) Numerator: Denominator: Narrative: Total number of true cardiac +/- respiratory arrests Total number of deaths & live discharges for the same period This chart shows a point which is out with control limits in Feb 2013; this is as a result of a high number of arrests and a lower number of discharges that month - on its own the number of arrests is not stand out, but combined with a lower denominator by approximately on comparison to an average month this results in a breach of control limits. There is no statistically significant improvement evident. Clinical Quality Service Page 13 of 26 Print Date:18/11/2014

14 Clinical Governance report prepared for NHS Lanarkshire Board Report title Clinical Governance Corporate Report - November 2014 Safe: Cardiac Arrest Rate - Hairmyres Cardiac Arrest Rate (True cardiac +/- respiratory arrests) per 1000 Title: total deaths and live discharges (Hairmyres) Numerator: Denominator: Narrative: Total number of true cardiac +/- respiratory arrests Total number of deaths & live discharges for the same period No statistically significant improvement noted or reduction in Cardiac Arrests. A recent case note review of 50 Cardiac arrests was undertaken and the key findings and emerging themes was presented to the patient safety strategic group at its November meeting. Further work is underway to improve processes for data collection and reporting to ensure the micro system process measures and outcomes are measured and reported as part of the reducing harm collaborative. Aligning the work of DNACPR and associated measures has been identified as an additional area of benefit in progressing this agenda. Clinical Quality Service Page 14 of 26 Print Date:18/11/2014

15 Clinical Governance report prepared for NHS Lanarkshire Board Report title Clinical Governance Corporate Report - November 2014 Safe: Cardiac Arrest Rate - Monklands Cardiac Arrest Rate (True cardiac +/- respiratory arrests) per 1000 Title: total deaths and live discharges (Monklands) Numerator: Denominator: Narrative: Total number of true cardiac +/- respiratory arrests Total number of deaths & live discharges for the same period No statistically significant improvement noted or reduction in Cardiac Arrests. A recent case note review of 50 Cardiac arrests was undertaken and the key findings and emerging themes was presented to the patient safety strategic group at its November meeting. Further work is underway to improve processes for data collection and reporting to ensure the micro system process measures and outcomes are measured and reported as part of the reducing harm collaborative. Aligning the work of DNACPR and associated measures has been identified as an additional area of benefit in progressing this agenda. Clinical Quality Service Page 15 of 26 Print Date:18/11/2014

16 Clinical Governance report prepared for NHS Lanarkshire Board Report title Clinical Governance Corporate Report - November 2014 Safe: Cardiac Arrest Rate - Wishaw Cardiac Arrest Rate (True cardiac +/- respiratory arrests) per 1000 Title: total deaths and live discharges (Wishaw) Numerator: Denominator: Narrative: Total number of true cardiac +/- respiratory arrests Total number of deaths & live discharges for the same period No statistically significant improvement noted or reduction in Cardiac Arrests. A recent case note review of 50 Cardiac arrests was undertaken and the key findings and emerging themes was presented to the patient safety strategic group at its November meeting. Further work is underway to improve processes for data collection and reporting to ensure the micro system process measures and outcomes are measured and reported as part of the reducing harm collaborative. Aligning the work of DNACPR and associated measures has been identified as an additional area of benefit in progressing this agenda. Clinical Quality Service Page 16 of 26 Print Date:18/11/2014

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18 Clinical Governance report prepared for NHS Lanarkshire Board Report title Clinical Governance Corporate Report - November 2014 Safe: Percent of Low, Medium, High & Very High incidents recorded, verified, investigated and closed in Datix within 10 (low), 20 (med) & 45 (High+Very High) working days of the incident occurring as a percentage of total low rated incidents Title: Numerator: Denominator: Narrative: Percent of Low, Medium, High & very High rated incidents recorded, verified, investigated and closed in Datix within 10 (low), 20 (med) & 45 (high+very High) working days of the incident occurring as a percentage of total low rated incidents Total No. incidents recorded, verified, graded as low & closed in 10 days, Medium closed in 20 days, High & Very High closed in 45 days. Total number incidents recorded, verified & closed in DATIX graded as low, medium & high. See below: Clinical Quality Service Process Measure RSKH_NHSL Datix Incidents - NHSL Effective from 1st July 2014, and in line with the National Framework for the Management of Adverse Events, NHSL implemented the new Incident Policy and Procedures, impacting on the KPI dashboard reporting for closure of incidents. As a result of these changes and the further modifications required to be made to the reporting function within the Datix system, the KPI reporting is being reviewed and full reporting will resume in January Description: The risk management steering group set performance indicators (KPIs) The KPIs inform the board on the effectiveness of incident management. The board should look for performance to be improving. Data reliability = Intermediate (see appendix c) Page 18 of 26 Print Date:18/11/2014

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24 Clinical Governance report prepared for NHS Lanarkshire Board Report title Clinical Governance Corporate Report - November 2014 Clinical Quality Service Appendix B - Notes on the data Average Hospital Length of Stay. The data reported only shows Inpatient Hospital Discharges. Total Hospital Length of Stay (HLOS) is linked to the discharge specialty and discharge date even if part of the hospital stay took place under different specialties and/or across different specified dates. This ultimately means some outlier long stays could have a big impact on Average HLOS for a specific specialty. The data reported only shows admissions where hospital Spell start date = admission date, therefore some hospital transfers will be excluded. Measures have not been standardised by age, sex and deprivation Average HLOS has not been adjusted for case mix so may reflect variations in complexity of patients treated Denominators are based on discharge dates to allow shorter reporting lag times. This means that the data on the local report will not be directly comparable with the national Early Warning Scorecard which uses admission dates for reporting. Data are subject to change following SMR validation processes. Readmissions data Measures have not been standardised by age, sex and deprivation Rates are only calculated using linked data held in the Lanarkshire TrakCare PMS and therefore does not include readmissions to other Health Boards Denominators are based on discharge dates to allow shorter reporting lag times. This means that the data on the local report will not be directly comparable with the national Early Warning Scorecard which uses admission dates for reporting. Data are subject to change following SMR validation processes. Deaths and Live Discharges The denominator for Unadjusted Patient Mortality includes Deaths and Live Discharges in all areas except for Obstetrics. Both the numerator and the denominator for Cardiac Arrest Rate exclude Cardiac Arrests and Deaths and Live Discharges in these areas respectively: - -Hairmyres CCU -Hairmyres Day Surgery Unit -Hairmyres Dental Day Unit -Hairmyres ITU -Hairmyres Maternity Day Assessment -Monklands Endoscopy Unit -Monklands Hospital Day Surgery Unit -Monklands Ward 16 Haematology Day Unit -Monklands Ward 26 ITU -Wishaw General CCU -Wishaw General ICU -Wishaw General Medical Day Unit -Wishaw General Neonatal ICU -Wishaw General Surgical Day Unit -Wishaw General Ward 19 -Wishaw General Ward 20 -Wishaw General Ward 21 -Wishaw General Ward 22 -Wishaw General Ward 23 -Wishaw General Ward 24 Page 24 of 26 Print Date:18/11/2014

25 Clinical Governance report prepared for NHS Lanarkshire Board Report title Clinical Governance Corporate Report - November 2014 Clinical Quality Service Appendix B - Notes on the data (continued) Interpreting run charts using run chart rules RULE 1: A SHIFT 6 or more consecutive points either all above or all below the median line RULE 2: A TREND 5 or more consecutive points all going in the one direction (up or down) RULE 3: TOO MANY OR TOO FEW RUNS A non random pattern would be indicated by the data crossing the median too many or too few times (Reference table for this one) RULE 4: AN ASTRONOMICALVALUE A value that is obviously, blatantly different and really stands out as being highly unusual Data Reliability Each metric has been graded for data reliability against the Clinical Quality Data Reliability Matrix (see Appendix C). The Data Reliability score is calculated based on the data source and sample size vs. the highest level of validation the data has been subject to. Notes: Whilst there is a drive to provide Clinical Quality data that is as complete, accurate and valid as possible, it is also important that data for local improvement is available as real time as possible and full validation is therefore not always possible or necessary. Clinical Quality data is reported from a variety of sources. The method of data collection and source of data will have an impact on the level of data validation, and subsequently the reliability of data reported: For example, data collected via direct observations of clinical practice (e.g. patient safety process measures) are based on an individual s judgement that something has happened at a particular point in time. This data can never be checked against source data (e.g. clinical records) and there is a reliance on the individual to provide an accurate account of events. Observational data would therefore be considered of low reliability in terms of accuracy. However, since observational measurement is in the main data for improvement, this level of reliability would be acceptable. Conversely, data extracted from clinical systems (e.g. laboratory results) should be of high reliability in terms of accuracy, as this is clinical data used for managing patient care. For reporting purposes however, this type of data would still need to be checked for format, completeness, duplicates and outliers and the level of reliability would increase depending on the level of validation applied. Page 25 of 26 Print Date:18/11/2014

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