Radiology CPG Annual Report for Quality, Safety and Experience Sub-Committee- April 2015

Transcription

1 Radiology CPG Annual Report for Quality, Safety and Experience Sub-Committee- April Purpose of report To provide assurance to the QSE sub-committee of the Radiology CPG s commitment to quality, safety and experience 2. Introduction/Context This paper is a summary review of the QSE activity by the Radiology CPG during 2014/15 3. Main body of the report 3.1 CPG Quality Delivery Plans - position against Quality Delivery Plan The Radiology CPG identified its contribution to the BCU Quality objectives in its submitted QDP. Progress is outlined below Domain 1 safety Reduction of mortality rates for stroke, heart attack and fractured neck of femur. Radiology measure - compliance with CT scan within 24 hours, working towards CT scanning for stroke within 12 hours and scans for thrombolysis within 45minutes. To reduce the time to scan during the out of hours period, non-ct radiographers undertaking night and weekend day shifts are currently being trained to perform CT head scans. To date 33 radiographers have been trained across BCU Involvement in mortality reviews Is as required Reduction in % of patients who have hospital acquired thrombosis up to 90 days post discharge. Radiology support the diagnosis and have a reporting system in place Reduction of pressure ulcers Radiology is currently developing a tool for use for interventional procedures of more than 1 hour. Radiology CPG April 2015 Page 1

2 Safety Checklists Cadiovascular and Interventional Radiological Society of Europe (CIRSE) safety checklist introduced for interventional procedures. Auditing of compliance with using the checklist is just being completed. Checklists are also in place for MRI safety and the safe use of contrast media MRSA and C. Diff rates reduction Radiology not able to measure this target but is actively implementing and monitoring the bare below elbows initiative Hand washing audits are regularly between 95% and 100%. Monthly audit data for bare below elbows across the Divisions report scores between 80% and 100% for 2014/15. Staff are reminded regularly about the requirements for hand washing and Bare below elbows. During 2015/16 it is planned to do random checks using visiting staff to remove any local bias and ensure consistency of application across the divisions Peripheral Vascular Care bundle compliance It has been agreed with the Assistant Director of Nursing for Infection Prevention and Control that the bundle is not suitable for use in Radiology. A Radiology compliance list has been added to the request card that is being introduced June Audits of compliance will then be implemented Antibiotic prescribing A review of antibiotic prescribing within the CPG is currently being carried out by the Clinical Director for Central. There is limited prescribing within radiology and it is usually for prophylaxis during interventional procedures NPSA 16 Failure to act As reported last year this needs to be embedded across referring CPGs with Radiology providing support. It has recently been agreed that the Assistant Director of Therapies will lead a series of task and finish workshops to ensure compliance with this alert Escorts with Patients Some vulnerable and unstable patients are brought to the Radiology departments with inappropriate escort support, from HCA or registered nurses. This has been an issue for the departments for a number of years and numerous meetings have taken place with referring departments and with Directors of Nursing. Escort policies have been developed, but these have not been implemented / resourced. Radiology have taken steps to reduce the risk, for example, establishing a system with the YG ED team to hand over patients in the ED, rather than within the Radiology department so risk can be appropriately assessed within ED prior to transfer. Further work must be done and support from the new Hospital Directors will be needed to address these risks Domain 2 Clinical effectiveness Improve Radiology reporting turn round times to meet national standards The CPG monitors against All Wales standards for report turnaround times (time taken from the scan / x-ray being undertaken to a validated report being issued). The standards are: Referrer A&E and inpatients GP Outpatients working days Radiology CPG April 2015 Page 2

3 Audit and effectiveness Radiology has an active audit calendar with regular meetings held in each division and a series of joint audit sessions across the CPG. There is an identified radiographer and radiologist lead for each division. Number of audits registered 2014/15 = 22 Number of audits completed and action plan submitted = 12 Research Radiology has had 5 papers published in journals both within radiology and other specialties. The continued funding by NISCAR of 1.5WTE research radiographers is allowing the CPG to ensure that IR(ME)R compliance is maintained in relation to research and also initiate primary research. Current projects Image quality & dose implication for trolley imaging Patient anxiety and image quality in MRI scanning Projects looking at the weight bearing MRI scanner Reduction in procedures of limited effectiveness The CPG is working with the GP Engagement Group to reduce lumbar spine plain film examinations performed. A pathway is being developed that includes input from CMATs and the pain control team NICE During 2014 links have been developed to ensure Radiology is linked into the NICE process. NICE guidance involving Radiology is being reviewed and updated. The NICE guidance on HCC has not been implemented and a decision of future provision of service is awaited following a review of the public health research and current guidance by Karen Mottart, Associate Medical Director Cancer mortality support delivery of 31 and 62 day targets The CPG is working with members of the Cancer Performance Board to improve performance Compliance with stroke bundles and SNAP audit See section Domain 3 Patient Experience Radiology CPG April 2015 Page 3

4 Concerns Response times for concerns, has deteriorated over 2014/15 due to staffing issues but these are now in the process of being resolved. The main patterns for concerns during 2014/15 have been time waiting for imaging and reporting discrepancies Review of Datix incident reporting common themes and learning Cancellation of beds for interventional procedures SBAR developed and has been submitted to the East Safer Patient group. Lack of gowns Current supplies of gowns do not meet radiology requirements. The theatre style patient gowns do not afford dignity to patients in radiology and are a source of verbal complaints. Meetings have been held with the laundry and a pilot of a different style of gown is nearing completion. Consideration will need to be given to the cost of new gowns and ensuring supply is restricted to radiology MRI Safety multiple near misses due to referrer s not highlighting patients have pacemakers. CT incidents a series of MDT workshops have been held, taking a whole system view of incidents which has lead to improvements in processes and sharing of good practise across the divisions resulting in a lower number of reportable incidents. As a result of the MRI near misses and the radiation incidents and near misses involving addressograph labels a radiology safety newsletter was created and sent to all CPGs, safer patient groups and put on the radiology webpage Effective Communication A Welsh buddy system is in place. The annual review of compliance against the Radiology standard operating procedure was completed in March 2015 and an action plan has been developed Service user experience For Radiology the term service user includes referrers as well as patients attending for imaging or interventional procedures. The public member and identified staff are currently developing a pilot for snap shot audits that will commence in April In addition the All Wales Imaging Patient experience Survey will be used to measure the experience of 10 patients per month. During 2014/15 the Radiology CPG had engagement sessions with secondary care referrers to feedback on the outcome of the secondary care user survey these served as useful discussion forums. A GP engagement group has held its initial meeting and a work plan agreed. A repeat user survey of GP s is planned for 2015/ Dementia risk assessment The Radiology CPG has identified dementia champions who are working on raising awareness across the CPG. 3.2 Evidence against the robustness of your self assessment scores for Healthcare Standards and outlines planned actions to improve the low scores; The completion of the Health Care standards performance for the Radiology CPG is acknowledged to be low. Standards 14 and 17 are not applicable to Radiology. Standards7, 16, 19 and 21have been completed. Whilst completion of the standards has been poor the CPG can confirm it has robust arrangements in place for governance particularly with respect: Radiology CPG April 2015 Page 4

5 Health & Safety Management HSE inspection July 2014 described the CPG as borderline exemplar Radiation Protection HIW inspection January st time that HIW have lead an inspection where there are no actions for improvement. IPC highest up take of flu vaccine across health board. The Radiology CPG has now commenced its work towards gaining the Imaging Services Accreditation Scheme. An initial workshop has been held and a gap analysis is currently being completed to identify areas for improvement. As part of the process of completing the traffic light ready tool the work will be mapped across to the health care standards. 3.3 An indication of key risks and plans in place to reduce these; Significant identified risks for the CPG Failure to recruit consultant Radiologists mitigation ongoing recruitment, working with WOD on creative strategies for recruitment, increasing radiographer skill mix. There is also a national shortage of radiographers which is being mitigated against by an increase in the number training in North Wales. Failure of the Ysbyty Glan Clwyd CT scanner The current scanner has reached end of life and is due replacement. Failure would lead to loss of service on the YGC site there are limited opportunities to mitigate this risk due to their being little capacity on the radiotherapy planning scanner. A second scanner has been purchased but is not likely to be installed until the latter part of the financial year due to the asbestos strip. Lack of escorts as discussed in above 4. Assessment of risk Please see section 3.3 above. 5. Equality Impact Assessment An equality impact assessment register has been set up for the Radiology CPG 6. Conclusions / Next Steps This section should briefly summarise any conclusions being drawn, together with planned next steps and key dates for delivery. 7. Recommendations Note: To receive the information contained in the report Radiology CPG April 2015 Page 5

6 Radiology CPG Annual Report for Quality, Safety and Experience Sub-Committee- April Purpose of report To provide assurance to the QSE sub-committee of the Radiology CPG s commitment to quality, safety and experience 2. Introduction/Context This paper is a summary review of the QSE activity by the Radiology CPG during 2014/15 3. Main body of the report 3.1 CPG Quality Delivery Plans - position against Quality Delivery Plan The Radiology CPG identified its contribution to the BCU Quality objectives in its submitted QDP. Progress is outlined below Domain 1 safety Reduction of mortality rates for stroke, heart attack and fractured neck of femur. Radiology measure - compliance with CT scan within 24 hours, working towards CT scanning for stroke within 12 hours and scans for thrombolysis within 45minutes. To reduce the time to scan during the out of hours period, non-ct radiographers undertaking night and weekend day shifts are currently being trained to perform CT head scans. To date 33 radiographers have been trained across BCU Involvement in mortality reviews Is as required Reduction in % of patients who have hospital acquired thrombosis up to 90 days post discharge. Radiology support the diagnosis and have a reporting system in place Reduction of pressure ulcers Radiology is currently developing a tool for use for interventional procedures of more than 1 hour. Radiology CPG April 2015 Page 1

7 Safety Checklists Cadiovascular and Interventional Radiological Society of Europe (CIRSE) safety checklist introduced for interventional procedures. Auditing of compliance with using the checklist is just being completed. Checklists are also in place for MRI safety and the safe use of contrast media MRSA and C. Diff rates reduction Radiology not able to measure this target but is actively implementing and monitoring the bare below elbows initiative Hand washing audits are regularly between 95% and 100%. Monthly audit data for bare below elbows across the Divisions report scores between 80% and 100% for 2014/15. Staff are reminded regularly about the requirements for hand washing and Bare below elbows. During 2015/16 it is planned to do random checks using visiting staff to remove any local bias and ensure consistency of application across the divisions Peripheral Vascular Care bundle compliance It has been agreed with the Assistant Director of Nursing for Infection Prevention and Control that the bundle is not suitable for use in Radiology. A Radiology compliance list has been added to the request card that is being introduced June Audits of compliance will then be implemented Antibiotic prescribing A review of antibiotic prescribing within the CPG is currently being carried out by the Clinical Director for Central. There is limited prescribing within radiology and it is usually for prophylaxis during interventional procedures NPSA 16 Failure to act As reported last year this needs to be embedded across referring CPGs with Radiology providing support. It has recently been agreed that the Assistant Director of Therapies will lead a series of task and finish workshops to ensure compliance with this alert Escorts with Patients Some vulnerable and unstable patients are brought to the Radiology departments with inappropriate escort support, from HCA or registered nurses. This has been an issue for the departments for a number of years and numerous meetings have taken place with referring departments and with Directors of Nursing. Escort policies have been developed, but these have not been implemented / resourced. Radiology have taken steps to reduce the risk, for example, establishing a system with the YG ED team to hand over patients in the ED, rather than within the Radiology department so risk can be appropriately assessed within ED prior to transfer. Further work must be done and support from the new Hospital Directors will be needed to address these risks Domain 2 Clinical effectiveness Improve Radiology reporting turn round times to meet national standards The CPG monitors against All Wales standards for report turnaround times (time taken from the scan / x-ray being undertaken to a validated report being issued). The standards are: Referrer A&E and inpatients GP Outpatients working days Radiology CPG April 2015 Page 2

8 Audit and effectiveness Radiology has an active audit calendar with regular meetings held in each division and a series of joint audit sessions across the CPG. There is an identified radiographer and radiologist lead for each division. Number of audits registered 2014/15 = 22 Number of audits completed and action plan submitted = 12 Research Radiology has had 5 papers published in journals both within radiology and other specialties. The continued funding by NISCAR of 1.5WTE research radiographers is allowing the CPG to ensure that IR(ME)R compliance is maintained in relation to research and also initiate primary research. Current projects Image quality & dose implication for trolley imaging Patient anxiety and image quality in MRI scanning Projects looking at the weight bearing MRI scanner Reduction in procedures of limited effectiveness The CPG is working with the GP Engagement Group to reduce lumbar spine plain film examinations performed. A pathway is being developed that includes input from CMATs and the pain control team NICE During 2014 links have been developed to ensure Radiology is linked into the NICE process. NICE guidance involving Radiology is being reviewed and updated. The NICE guidance on HCC has not been implemented and a decision of future provision of service is awaited following a review of the public health research and current guidance by Karen Mottart, Associate Medical Director Cancer mortality support delivery of 31 and 62 day targets The CPG is working with members of the Cancer Performance Board to improve performance Compliance with stroke bundles and SNAP audit See section Domain 3 Patient Experience Radiology CPG April 2015 Page 3

9 Concerns Response times for concerns, has deteriorated over 2014/15 due to staffing issues but these are now in the process of being resolved. The main patterns for concerns during 2014/15 have been time waiting for imaging and reporting discrepancies Review of Datix incident reporting common themes and learning Cancellation of beds for interventional procedures SBAR developed and has been submitted to the East Safer Patient group. Lack of gowns Current supplies of gowns do not meet radiology requirements. The theatre style patient gowns do not afford dignity to patients in radiology and are a source of verbal complaints. Meetings have been held with the laundry and a pilot of a different style of gown is nearing completion. Consideration will need to be given to the cost of new gowns and ensuring supply is restricted to radiology MRI Safety multiple near misses due to referrer s not highlighting patients have pacemakers. CT incidents a series of MDT workshops have been held, taking a whole system view of incidents which has lead to improvements in processes and sharing of good practise across the divisions resulting in a lower number of reportable incidents. As a result of the MRI near misses and the radiation incidents and near misses involving addressograph labels a radiology safety newsletter was created and sent to all CPGs, safer patient groups and put on the radiology webpage Effective Communication A Welsh buddy system is in place. The annual review of compliance against the Radiology standard operating procedure was completed in March 2015 and an action plan has been developed Service user experience For Radiology the term service user includes referrers as well as patients attending for imaging or interventional procedures. The public member and identified staff are currently developing a pilot for snap shot audits that will commence in April In addition the All Wales Imaging Patient experience Survey will be used to measure the experience of 10 patients per month. During 2014/15 the Radiology CPG had engagement sessions with secondary care referrers to feedback on the outcome of the secondary care user survey these served as useful discussion forums. A GP engagement group has held its initial meeting and a work plan agreed. A repeat user survey of GP s is planned for 2015/ Dementia risk assessment The Radiology CPG has identified dementia champions who are working on raising awareness across the CPG. 3.2 Evidence against the robustness of your self assessment scores for Healthcare Standards and outlines planned actions to improve the low scores; The completion of the Health Care standards performance for the Radiology CPG is acknowledged to be low. Standards 14 and 17 are not applicable to Radiology. Standards7, 16, 19 and 21have been completed. Whilst completion of the standards has been poor the CPG can confirm it has robust arrangements in place for governance particularly with respect: Radiology CPG April 2015 Page 4

10 Health & Safety Management HSE inspection July 2014 described the CPG as borderline exemplar Radiation Protection HIW inspection January st time that HIW have lead an inspection where there are no actions for improvement. IPC highest up take of flu vaccine across health board. The Radiology CPG has now commenced its work towards gaining the Imaging Services Accreditation Scheme. An initial workshop has been held and a gap analysis is currently being completed to identify areas for improvement. As part of the process of completing the traffic light ready tool the work will be mapped across to the health care standards. 3.3 An indication of key risks and plans in place to reduce these; Significant identified risks for the CPG Failure to recruit consultant Radiologists mitigation ongoing recruitment, working with WOD on creative strategies for recruitment, increasing radiographer skill mix. There is also a national shortage of radiographers which is being mitigated against by an increase in the number training in North Wales. Failure of the Ysbyty Glan Clwyd CT scanner The current scanner has reached end of life and is due replacement. Failure would lead to loss of service on the YGC site there are limited opportunities to mitigate this risk due to their being little capacity on the radiotherapy planning scanner. A second scanner has been purchased but is not likely to be installed until the latter part of the financial year due to the asbestos strip. Lack of escorts as discussed in above 4. Assessment of risk Please see section 3.3 above. 5. Equality Impact Assessment An equality impact assessment register has been set up for the Radiology CPG 6. Conclusions / Next Steps This section should briefly summarise any conclusions being drawn, together with planned next steps and key dates for delivery. 7. Recommendations Note: To receive the information contained in the report Radiology CPG April 2015 Page 5

11 Radiology CPG Annual Report for Quality, Safety and Experience Sub-Committee- April Purpose of report To provide assurance to the QSE sub-committee of the Radiology CPG s commitment to quality, safety and experience 2. Introduction/Context This paper is a summary review of the QSE activity by the Radiology CPG during 2014/15 3. Main body of the report 3.1 CPG Quality Delivery Plans - position against Quality Delivery Plan The Radiology CPG identified its contribution to the BCU Quality objectives in its submitted QDP. Progress is outlined below Domain 1 safety Reduction of mortality rates for stroke, heart attack and fractured neck of femur. Radiology measure - compliance with CT scan within 24 hours, working towards CT scanning for stroke within 12 hours and scans for thrombolysis within 45minutes. To reduce the time to scan during the out of hours period, non-ct radiographers undertaking night and weekend day shifts are currently being trained to perform CT head scans. To date 33 radiographers have been trained across BCU Involvement in mortality reviews Is as required Reduction in % of patients who have hospital acquired thrombosis up to 90 days post discharge. Radiology support the diagnosis and have a reporting system in place Reduction of pressure ulcers Radiology is currently developing a tool for use for interventional procedures of more than 1 hour. Radiology CPG April 2015 Page 1

12 Safety Checklists Cadiovascular and Interventional Radiological Society of Europe (CIRSE) safety checklist introduced for interventional procedures. Auditing of compliance with using the checklist is just being completed. Checklists are also in place for MRI safety and the safe use of contrast media MRSA and C. Diff rates reduction Radiology not able to measure this target but is actively implementing and monitoring the bare below elbows initiative Hand washing audits are regularly between 95% and 100%. Monthly audit data for bare below elbows across the Divisions report scores between 80% and 100% for 2014/15. Staff are reminded regularly about the requirements for hand washing and Bare below elbows. During 2015/16 it is planned to do random checks using visiting staff to remove any local bias and ensure consistency of application across the divisions Peripheral Vascular Care bundle compliance It has been agreed with the Assistant Director of Nursing for Infection Prevention and Control that the bundle is not suitable for use in Radiology. A Radiology compliance list has been added to the request card that is being introduced June Audits of compliance will then be implemented Antibiotic prescribing A review of antibiotic prescribing within the CPG is currently being carried out by the Clinical Director for Central. There is limited prescribing within radiology and it is usually for prophylaxis during interventional procedures NPSA 16 Failure to act As reported last year this needs to be embedded across referring CPGs with Radiology providing support. It has recently been agreed that the Assistant Director of Therapies will lead a series of task and finish workshops to ensure compliance with this alert Escorts with Patients Some vulnerable and unstable patients are brought to the Radiology departments with inappropriate escort support, from HCA or registered nurses. This has been an issue for the departments for a number of years and numerous meetings have taken place with referring departments and with Directors of Nursing. Escort policies have been developed, but these have not been implemented / resourced. Radiology have taken steps to reduce the risk, for example, establishing a system with the YG ED team to hand over patients in the ED, rather than within the Radiology department so risk can be appropriately assessed within ED prior to transfer. Further work must be done and support from the new Hospital Directors will be needed to address these risks Domain 2 Clinical effectiveness Improve Radiology reporting turn round times to meet national standards The CPG monitors against All Wales standards for report turnaround times (time taken from the scan / x-ray being undertaken to a validated report being issued). The standards are: Referrer A&E and inpatients GP Outpatients working days Radiology CPG April 2015 Page 2

13 Audit and effectiveness Radiology has an active audit calendar with regular meetings held in each division and a series of joint audit sessions across the CPG. There is an identified radiographer and radiologist lead for each division. Number of audits registered 2014/15 = 22 Number of audits completed and action plan submitted = 12 Research Radiology has had 5 papers published in journals both within radiology and other specialties. The continued funding by NISCAR of 1.5WTE research radiographers is allowing the CPG to ensure that IR(ME)R compliance is maintained in relation to research and also initiate primary research. Current projects Image quality & dose implication for trolley imaging Patient anxiety and image quality in MRI scanning Projects looking at the weight bearing MRI scanner Reduction in procedures of limited effectiveness The CPG is working with the GP Engagement Group to reduce lumbar spine plain film examinations performed. A pathway is being developed that includes input from CMATs and the pain control team NICE During 2014 links have been developed to ensure Radiology is linked into the NICE process. NICE guidance involving Radiology is being reviewed and updated. The NICE guidance on HCC has not been implemented and a decision of future provision of service is awaited following a review of the public health research and current guidance by Karen Mottart, Associate Medical Director Cancer mortality support delivery of 31 and 62 day targets The CPG is working with members of the Cancer Performance Board to improve performance Compliance with stroke bundles and SNAP audit See section Domain 3 Patient Experience Radiology CPG April 2015 Page 3

14 Concerns Response times for concerns, has deteriorated over 2014/15 due to staffing issues but these are now in the process of being resolved. The main patterns for concerns during 2014/15 have been time waiting for imaging and reporting discrepancies Review of Datix incident reporting common themes and learning Cancellation of beds for interventional procedures SBAR developed and has been submitted to the East Safer Patient group. Lack of gowns Current supplies of gowns do not meet radiology requirements. The theatre style patient gowns do not afford dignity to patients in radiology and are a source of verbal complaints. Meetings have been held with the laundry and a pilot of a different style of gown is nearing completion. Consideration will need to be given to the cost of new gowns and ensuring supply is restricted to radiology MRI Safety multiple near misses due to referrer s not highlighting patients have pacemakers. CT incidents a series of MDT workshops have been held, taking a whole system view of incidents which has lead to improvements in processes and sharing of good practise across the divisions resulting in a lower number of reportable incidents. As a result of the MRI near misses and the radiation incidents and near misses involving addressograph labels a radiology safety newsletter was created and sent to all CPGs, safer patient groups and put on the radiology webpage Effective Communication A Welsh buddy system is in place. The annual review of compliance against the Radiology standard operating procedure was completed in March 2015 and an action plan has been developed Service user experience For Radiology the term service user includes referrers as well as patients attending for imaging or interventional procedures. The public member and identified staff are currently developing a pilot for snap shot audits that will commence in April In addition the All Wales Imaging Patient experience Survey will be used to measure the experience of 10 patients per month. During 2014/15 the Radiology CPG had engagement sessions with secondary care referrers to feedback on the outcome of the secondary care user survey these served as useful discussion forums. A GP engagement group has held its initial meeting and a work plan agreed. A repeat user survey of GP s is planned for 2015/ Dementia risk assessment The Radiology CPG has identified dementia champions who are working on raising awareness across the CPG. 3.2 Evidence against the robustness of your self assessment scores for Healthcare Standards and outlines planned actions to improve the low scores; The completion of the Health Care standards performance for the Radiology CPG is acknowledged to be low. Standards 14 and 17 are not applicable to Radiology. Standards7, 16, 19 and 21have been completed. Whilst completion of the standards has been poor the CPG can confirm it has robust arrangements in place for governance particularly with respect: Radiology CPG April 2015 Page 4

15 Health & Safety Management HSE inspection July 2014 described the CPG as borderline exemplar Radiation Protection HIW inspection January st time that HIW have lead an inspection where there are no actions for improvement. IPC highest up take of flu vaccine across health board. The Radiology CPG has now commenced its work towards gaining the Imaging Services Accreditation Scheme. An initial workshop has been held and a gap analysis is currently being completed to identify areas for improvement. As part of the process of completing the traffic light ready tool the work will be mapped across to the health care standards. 3.3 An indication of key risks and plans in place to reduce these; Significant identified risks for the CPG Failure to recruit consultant Radiologists mitigation ongoing recruitment, working with WOD on creative strategies for recruitment, increasing radiographer skill mix. There is also a national shortage of radiographers which is being mitigated against by an increase in the number training in North Wales. Failure of the Ysbyty Glan Clwyd CT scanner The current scanner has reached end of life and is due replacement. Failure would lead to loss of service on the YGC site there are limited opportunities to mitigate this risk due to their being little capacity on the radiotherapy planning scanner. A second scanner has been purchased but is not likely to be installed until the latter part of the financial year due to the asbestos strip. Lack of escorts as discussed in above 4. Assessment of risk Please see section 3.3 above. 5. Equality Impact Assessment An equality impact assessment register has been set up for the Radiology CPG 6. Conclusions / Next Steps This section should briefly summarise any conclusions being drawn, together with planned next steps and key dates for delivery. 7. Recommendations Note: To receive the information contained in the report Radiology CPG April 2015 Page 5

16 Radiology CPG Annual Report for Quality, Safety and Experience Sub-Committee- April Purpose of report To provide assurance to the QSE sub-committee of the Radiology CPG s commitment to quality, safety and experience 2. Introduction/Context This paper is a summary review of the QSE activity by the Radiology CPG during 2014/15 3. Main body of the report 3.1 CPG Quality Delivery Plans - position against Quality Delivery Plan The Radiology CPG identified its contribution to the BCU Quality objectives in its submitted QDP. Progress is outlined below Domain 1 safety Reduction of mortality rates for stroke, heart attack and fractured neck of femur. Radiology measure - compliance with CT scan within 24 hours, working towards CT scanning for stroke within 12 hours and scans for thrombolysis within 45minutes. To reduce the time to scan during the out of hours period, non-ct radiographers undertaking night and weekend day shifts are currently being trained to perform CT head scans. To date 33 radiographers have been trained across BCU Involvement in mortality reviews Is as required Reduction in % of patients who have hospital acquired thrombosis up to 90 days post discharge. Radiology support the diagnosis and have a reporting system in place Reduction of pressure ulcers Radiology is currently developing a tool for use for interventional procedures of more than 1 hour. Radiology CPG April 2015 Page 1

17 Safety Checklists Cadiovascular and Interventional Radiological Society of Europe (CIRSE) safety checklist introduced for interventional procedures. Auditing of compliance with using the checklist is just being completed. Checklists are also in place for MRI safety and the safe use of contrast media MRSA and C. Diff rates reduction Radiology not able to measure this target but is actively implementing and monitoring the bare below elbows initiative Hand washing audits are regularly between 95% and 100%. Monthly audit data for bare below elbows across the Divisions report scores between 80% and 100% for 2014/15. Staff are reminded regularly about the requirements for hand washing and Bare below elbows. During 2015/16 it is planned to do random checks using visiting staff to remove any local bias and ensure consistency of application across the divisions Peripheral Vascular Care bundle compliance It has been agreed with the Assistant Director of Nursing for Infection Prevention and Control that the bundle is not suitable for use in Radiology. A Radiology compliance list has been added to the request card that is being introduced June Audits of compliance will then be implemented Antibiotic prescribing A review of antibiotic prescribing within the CPG is currently being carried out by the Clinical Director for Central. There is limited prescribing within radiology and it is usually for prophylaxis during interventional procedures NPSA 16 Failure to act As reported last year this needs to be embedded across referring CPGs with Radiology providing support. It has recently been agreed that the Assistant Director of Therapies will lead a series of task and finish workshops to ensure compliance with this alert Escorts with Patients Some vulnerable and unstable patients are brought to the Radiology departments with inappropriate escort support, from HCA or registered nurses. This has been an issue for the departments for a number of years and numerous meetings have taken place with referring departments and with Directors of Nursing. Escort policies have been developed, but these have not been implemented / resourced. Radiology have taken steps to reduce the risk, for example, establishing a system with the YG ED team to hand over patients in the ED, rather than within the Radiology department so risk can be appropriately assessed within ED prior to transfer. Further work must be done and support from the new Hospital Directors will be needed to address these risks Domain 2 Clinical effectiveness Improve Radiology reporting turn round times to meet national standards The CPG monitors against All Wales standards for report turnaround times (time taken from the scan / x-ray being undertaken to a validated report being issued). The standards are: Referrer A&E and inpatients GP Outpatients working days Radiology CPG April 2015 Page 2

18 Audit and effectiveness Radiology has an active audit calendar with regular meetings held in each division and a series of joint audit sessions across the CPG. There is an identified radiographer and radiologist lead for each division. Number of audits registered 2014/15 = 22 Number of audits completed and action plan submitted = 12 Research Radiology has had 5 papers published in journals both within radiology and other specialties. The continued funding by NISCAR of 1.5WTE research radiographers is allowing the CPG to ensure that IR(ME)R compliance is maintained in relation to research and also initiate primary research. Current projects Image quality & dose implication for trolley imaging Patient anxiety and image quality in MRI scanning Projects looking at the weight bearing MRI scanner Reduction in procedures of limited effectiveness The CPG is working with the GP Engagement Group to reduce lumbar spine plain film examinations performed. A pathway is being developed that includes input from CMATs and the pain control team NICE During 2014 links have been developed to ensure Radiology is linked into the NICE process. NICE guidance involving Radiology is being reviewed and updated. The NICE guidance on HCC has not been implemented and a decision of future provision of service is awaited following a review of the public health research and current guidance by Karen Mottart, Associate Medical Director Cancer mortality support delivery of 31 and 62 day targets The CPG is working with members of the Cancer Performance Board to improve performance Compliance with stroke bundles and SNAP audit See section Domain 3 Patient Experience Radiology CPG April 2015 Page 3

19 Concerns Response times for concerns, has deteriorated over 2014/15 due to staffing issues but these are now in the process of being resolved. The main patterns for concerns during 2014/15 have been time waiting for imaging and reporting discrepancies Review of Datix incident reporting common themes and learning Cancellation of beds for interventional procedures SBAR developed and has been submitted to the East Safer Patient group. Lack of gowns Current supplies of gowns do not meet radiology requirements. The theatre style patient gowns do not afford dignity to patients in radiology and are a source of verbal complaints. Meetings have been held with the laundry and a pilot of a different style of gown is nearing completion. Consideration will need to be given to the cost of new gowns and ensuring supply is restricted to radiology MRI Safety multiple near misses due to referrer s not highlighting patients have pacemakers. CT incidents a series of MDT workshops have been held, taking a whole system view of incidents which has lead to improvements in processes and sharing of good practise across the divisions resulting in a lower number of reportable incidents. As a result of the MRI near misses and the radiation incidents and near misses involving addressograph labels a radiology safety newsletter was created and sent to all CPGs, safer patient groups and put on the radiology webpage Effective Communication A Welsh buddy system is in place. The annual review of compliance against the Radiology standard operating procedure was completed in March 2015 and an action plan has been developed Service user experience For Radiology the term service user includes referrers as well as patients attending for imaging or interventional procedures. The public member and identified staff are currently developing a pilot for snap shot audits that will commence in April In addition the All Wales Imaging Patient experience Survey will be used to measure the experience of 10 patients per month. During 2014/15 the Radiology CPG had engagement sessions with secondary care referrers to feedback on the outcome of the secondary care user survey these served as useful discussion forums. A GP engagement group has held its initial meeting and a work plan agreed. A repeat user survey of GP s is planned for 2015/ Dementia risk assessment The Radiology CPG has identified dementia champions who are working on raising awareness across the CPG. 3.2 Evidence against the robustness of your self assessment scores for Healthcare Standards and outlines planned actions to improve the low scores; The completion of the Health Care standards performance for the Radiology CPG is acknowledged to be low. Standards 14 and 17 are not applicable to Radiology. Standards7, 16, 19 and 21have been completed. Whilst completion of the standards has been poor the CPG can confirm it has robust arrangements in place for governance particularly with respect: Radiology CPG April 2015 Page 4

20 Health & Safety Management HSE inspection July 2014 described the CPG as borderline exemplar Radiation Protection HIW inspection January st time that HIW have lead an inspection where there are no actions for improvement. IPC highest up take of flu vaccine across health board. The Radiology CPG has now commenced its work towards gaining the Imaging Services Accreditation Scheme. An initial workshop has been held and a gap analysis is currently being completed to identify areas for improvement. As part of the process of completing the traffic light ready tool the work will be mapped across to the health care standards. 3.3 An indication of key risks and plans in place to reduce these; Significant identified risks for the CPG Failure to recruit consultant Radiologists mitigation ongoing recruitment, working with WOD on creative strategies for recruitment, increasing radiographer skill mix. There is also a national shortage of radiographers which is being mitigated against by an increase in the number training in North Wales. Failure of the Ysbyty Glan Clwyd CT scanner The current scanner has reached end of life and is due replacement. Failure would lead to loss of service on the YGC site there are limited opportunities to mitigate this risk due to their being little capacity on the radiotherapy planning scanner. A second scanner has been purchased but is not likely to be installed until the latter part of the financial year due to the asbestos strip. Lack of escorts as discussed in above 4. Assessment of risk Please see section 3.3 above. 5. Equality Impact Assessment An equality impact assessment register has been set up for the Radiology CPG 6. Conclusions / Next Steps This section should briefly summarise any conclusions being drawn, together with planned next steps and key dates for delivery. 7. Recommendations Note: To receive the information contained in the report Radiology CPG April 2015 Page 5

21 Radiology CPG Annual Report for Quality, Safety and Experience Sub-Committee- April Purpose of report To provide assurance to the QSE sub-committee of the Radiology CPG s commitment to quality, safety and experience 2. Introduction/Context This paper is a summary review of the QSE activity by the Radiology CPG during 2014/15 3. Main body of the report 3.1 CPG Quality Delivery Plans - position against Quality Delivery Plan The Radiology CPG identified its contribution to the BCU Quality objectives in its submitted QDP. Progress is outlined below Domain 1 safety Reduction of mortality rates for stroke, heart attack and fractured neck of femur. Radiology measure - compliance with CT scan within 24 hours, working towards CT scanning for stroke within 12 hours and scans for thrombolysis within 45minutes. To reduce the time to scan during the out of hours period, non-ct radiographers undertaking night and weekend day shifts are currently being trained to perform CT head scans. To date 33 radiographers have been trained across BCU Involvement in mortality reviews Is as required Reduction in % of patients who have hospital acquired thrombosis up to 90 days post discharge. Radiology support the diagnosis and have a reporting system in place Reduction of pressure ulcers Radiology is currently developing a tool for use for interventional procedures of more than 1 hour. Radiology CPG April 2015 Page 1

22 Safety Checklists Cadiovascular and Interventional Radiological Society of Europe (CIRSE) safety checklist introduced for interventional procedures. Auditing of compliance with using the checklist is just being completed. Checklists are also in place for MRI safety and the safe use of contrast media MRSA and C. Diff rates reduction Radiology not able to measure this target but is actively implementing and monitoring the bare below elbows initiative Hand washing audits are regularly between 95% and 100%. Monthly audit data for bare below elbows across the Divisions report scores between 80% and 100% for 2014/15. Staff are reminded regularly about the requirements for hand washing and Bare below elbows. During 2015/16 it is planned to do random checks using visiting staff to remove any local bias and ensure consistency of application across the divisions Peripheral Vascular Care bundle compliance It has been agreed with the Assistant Director of Nursing for Infection Prevention and Control that the bundle is not suitable for use in Radiology. A Radiology compliance list has been added to the request card that is being introduced June Audits of compliance will then be implemented Antibiotic prescribing A review of antibiotic prescribing within the CPG is currently being carried out by the Clinical Director for Central. There is limited prescribing within radiology and it is usually for prophylaxis during interventional procedures NPSA 16 Failure to act As reported last year this needs to be embedded across referring CPGs with Radiology providing support. It has recently been agreed that the Assistant Director of Therapies will lead a series of task and finish workshops to ensure compliance with this alert Escorts with Patients Some vulnerable and unstable patients are brought to the Radiology departments with inappropriate escort support, from HCA or registered nurses. This has been an issue for the departments for a number of years and numerous meetings have taken place with referring departments and with Directors of Nursing. Escort policies have been developed, but these have not been implemented / resourced. Radiology have taken steps to reduce the risk, for example, establishing a system with the YG ED team to hand over patients in the ED, rather than within the Radiology department so risk can be appropriately assessed within ED prior to transfer. Further work must be done and support from the new Hospital Directors will be needed to address these risks Domain 2 Clinical effectiveness Improve Radiology reporting turn round times to meet national standards The CPG monitors against All Wales standards for report turnaround times (time taken from the scan / x-ray being undertaken to a validated report being issued). The standards are: Referrer A&E and inpatients GP Outpatients working days Radiology CPG April 2015 Page 2

23 Audit and effectiveness Radiology has an active audit calendar with regular meetings held in each division and a series of joint audit sessions across the CPG. There is an identified radiographer and radiologist lead for each division. Number of audits registered 2014/15 = 22 Number of audits completed and action plan submitted = 12 Research Radiology has had 5 papers published in journals both within radiology and other specialties. The continued funding by NISCAR of 1.5WTE research radiographers is allowing the CPG to ensure that IR(ME)R compliance is maintained in relation to research and also initiate primary research. Current projects Image quality & dose implication for trolley imaging Patient anxiety and image quality in MRI scanning Projects looking at the weight bearing MRI scanner Reduction in procedures of limited effectiveness The CPG is working with the GP Engagement Group to reduce lumbar spine plain film examinations performed. A pathway is being developed that includes input from CMATs and the pain control team NICE During 2014 links have been developed to ensure Radiology is linked into the NICE process. NICE guidance involving Radiology is being reviewed and updated. The NICE guidance on HCC has not been implemented and a decision of future provision of service is awaited following a review of the public health research and current guidance by Karen Mottart, Associate Medical Director Cancer mortality support delivery of 31 and 62 day targets The CPG is working with members of the Cancer Performance Board to improve performance Compliance with stroke bundles and SNAP audit See section Domain 3 Patient Experience Radiology CPG April 2015 Page 3