Birmingham Children s Hospital NHS Foundation Trust. Quality Account

Transcription

1 Birmingham Children s Hospital NHS Foundation Trust Quality Account

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3 Chief Executive s Statement on Quality Our organisation is committed to putting the quality of care we provide at the centre of everything that we do. We have ensured that this remains at the forefront of our agenda by embedding it as the first of our six strategic objectives. This commitment is not just about maintaining the status quo but about continual learning and improvement. There is no health care organisation worldwide that can t in some way improve the services it provides for its patients and our hospital is no exception. During the year our Quality Committee has become central to this agenda, ensuring that there is a continual oversight and challenge as to how we can further improve what we do. This is enhanced through the work programme of the Board of Directors - its agenda is structured to focus on service quality and safety first and foremost. This is achieved through a range of methods, for example a detailed quality report is scrutinised, discussed and debated on a monthly basis. We also use patient stories and quality walkabouts to ensure that we look beyond the figures within the report. We are proud of some of the initiatives and innovations that have been developed over the past year to improve quality. We recognise that feedback from our staff about the services that we provide and their own experience of working at the Trust is invaluable in the quality agenda. For example, we have developed tools to support junior doctors (Training Advice & Liaison Service) and to capture their experience of training at the hospital. Recognising the hard work and commitment of staff as our most valuable asset is important to the Trust. We launched a monthly Star of the Month award during the last year and some of the stories of staff working in a diverse range of roles are truly inspirational. Each year we celebrate the work of our staff with an annual awards event saying thank you for their contribution over the past twelve months. We have also used technology to improve the quality of the patient experience. Our App for Smart Phones allows us to capture the experience of our patients and their families in real time and quickly address any issues. All these responses are captured live on our public website increasing transparency of the whole process. We are rightly upheld at a local, regional and national level for the work that we do on patient experience. We are proud of the various ways in which we engage with children and young people to address how we can improve our services. Our Young Persons Advisory Group (YPAG) has been visited most recently by Dr Hilary Cass, president of the Royal College of Paediatrics and Child Health, and had input into a range of service areas and initiatives. For example, the group helped design a new Dignity Giving Suit to replace the traditional backless robes used in hospitals. To the best of my knowledge the information contained in this Quality Account is accurate. David Melbourne, Interim Chief Executive 3

4 Priorities for Improvement At Birmingham Children s Hospital, ensuring that we provide a high quality service is central to everything we do and this is embedded within our strategy. We are always looking for ways that we can improve the quality of our services. This can include making the experience better for the patients and families that use our services; changing the way we work so we can treat every patient that needs or chooses to come to BCH without any delays; making things safer than ever before and improving health outcomes for the diverse range of children and young people that we see every day. It is important that we focus our resources on making improvements where they are needed most, so we continually monitor and analyse a wide range of information that tells us where we could do better. This includes: Listening to the children, young people and families that use our services There are lots of ways they can tell us what they think, and we take account of it all to work out what s most important to them: Complaints, comments and concerns Surveys Feedback App Consultations Feedback cards Patient stories Websites like NHS Choices and Patient Opinion Mystery Shoppers Listening to our staff The views of the staff who work in our hospital every day are vital and we encourage them to tell us what they think through surveys, consultations and feedback events. It s also really important that we keep an eye on their happiness and make sure they re fully supported so that they are able to deliver the best services they can. Listening to others The views of BCH groups like the Young Person Advisory Group help us focus on how to make the improvements that are needed. Analysing information about the quality of services, such as patient safety incidents and clinical audits. Using best practice examples, national targets and learning from and benchmarking with other organisations. Using this information has helped us to identify Quality Priorities, which are the main areas we want to focus on to improve quality. Each priority has a goal and a way of measuring our progress in reaching it. These relate to the three elements of quality: Patient Experience, Clinical Effectiveness, and Safety. The priorities we are reporting on this year are: Patient Experience Clinical Effectiveness Safety Emergency Department Transfers Nursing Care Quality Indicators Pressure Ulcers Staff Survey CAMH Service User Satisfaction Preventing MRSA Food and Nutrition Asthma Care Reducing Acute Life Threatening Events, and Cardiac and Respiratory Arrests Tertiary Inpatient Referrals Health Promotion Reducing Healthcare Acquired Infections in PICU Play and Activities Cancelled Operations Reducing MSSA Zero Avoidable Deaths Reducing rates of Clostridium Difficile Reducing Medication Incidents Resulting in Harm WHO Safe Surgery Checklist Completion 4

5 In 2013/14 we will also report on some additional priorities that we have been developing during 2012/13: Safety: Extravasation Injuries Patient Experience: Friends and Family test (for children and young people) Clinical Effectiveness: Implementing the Sepsis Care Bundle These priorities and what we ve achieved in 2012/13 are set out over the next few pages of this Quality Account. 5

6 Listening to Patients and Families: Food & Nutrition A healthy diet can help patients get better quicker and go home earlier. Having tasty food, with plenty of choice, which meets everyone s needs, is vital to the wellbeing of our children and young people, and ensures they have a good experience while they are in hospital. Figure 1 Percentage of patients weighed and measured per Quarter 2011/ /13 How have we done? We have continued to perform really well with this measure. We will continue to monitor this but as we have demonstrated sustained high performance we will not report it separately from the other Nursing Care Quality Indicators (NCQIs) next year. In 2013/14 we will be focusing on offering appropriate healthy eating advice where it is needed. We will also be using a new electronic process to collect the NCQI data which will allow us to monitor this every month rather than quarterly, which will help us address issues more quickly. Everything is good except for the food. Food needs to be improved. I like the way my food order follows me round the hospital on MAPLE so when I move wards I still get the meals I've ordered. Figure 2: Percentage of patients who choose what they want and are happy with their choice 2009/2012/13 The food is alright better than I expected. Generally the food tastes nice. 6

7 How have we done? Until 2012 these questions were answered through a Food Survey but in 2012 we started asking the questions during our regular Catering Quality Walkabouts when we carry our checks on food service on wards and address any immediate issues. This way we can only ask a few children and young people at a time, so next year we want to develop new ways of getting views from as many people as possible. What are we doing to improve? In 2012/13 we introduced a new electronic food ordering system called MAPLE which was developed with local software developer Ambinet and our caterer Sodexo. MAPLE is an interactive, fun way for our patients to order their meals and is programmed to meet individual dietary requirements. MAPLE has been really successful our patients and families say it is practical and easy to use and it has received five awards. The MAPLE food ordering system means that children and young people will now always be able to order what they want from the menu. We will consult with our Young Person Advisory Group (YPAG) about new questions we should ask children and young people to ensure we get the information we need to help us improve. Food will also be a theme of YPAG walkabouts in 2013/14. 7

8 Listening to Patients and Families: Play & Activities Play and activities are important for the wellbeing of all children and young people who spend time in hospital. They can also provide an essential distraction from distressing aspects of care. It s important that activities, toys and equipment are of good quality, are age appropriate, and easily accessible. We categorise feedback about play and activities as either positive or need to improve. Although my child enjoyed playing in the playroom it was quite small and not easily accessible if the patient is on IVs etc, and have a drip-stand attached to them. I liked that the nurses gave me colouring books and pens when I was bored. There was no adolescent room like there is on other wards. Figure 3: Percentage of positive and need to improve comments received 2011/12 & 2012/13 How have we done? The picture is very similar to last year. Having the right toys, equipment and activities continues to be really important to people who visit and stay at our hospital. Need to Improve comments can include things we need to change or do better, like provide more things to do for older children and young people. These comments also include lots of suggestions about different toys, games and activities that children and young people would really like to be available. It s important that we continue to monitor everything that people are saying so we know where we need to do better and understand what it is that children and young people want and need. What are we doing to improve? We will be investing all our 2013/14 allocation for improving patient experience to upgrading the ward play areas. We have a new weekly Stay and Play group to provide patients and siblings the opportunity to play in a supportive environment. Feedback from initial sessions is really positive. We will run a 'promoting happy parenting' course to help parents with the challenges they face when their children are in hospital. We will improve information about play and activities so that children, young people and families know what is available at the hospital. We will share our play and activity resources better between wards to ensure that more children and young people in the hospital have opportunities use everything that is available. We will ask our volunteers to support improvements in play and activities. We are developing an activity book for children and young people who come to the Emergency Department to entertain and educate them about what they might see and what might happen to them while they are there. This is linked to activities in schools to educate young people about accessing health care. We are creating a Play Charter which will allow us to set some specific, measurable objectives to support improvements in play. 8

9 Listening to Patients and Families: Emergency Department Transfers Until 2010/11 patients who came to our Emergency Department were regularly transferred to other hospitals after treatment because there were no inpatient beds available. This was a really bad experience for patients and their families so we adapted our processes and procedures to ensure this would change. Figure 4: Patients transferred out of ED per month 2010/ /13 How have we done? We have continued to follow the processes we set in 2010/11 and maintained our objective for most of the year. In July 2012 one patient was transferred out. This has been reviewed, and while the decision to transfer was clinically right, there were processes that could have been followed that would have avoided the need for this transfer. We will continue to monitor this indicator but we will not report this as a quality priority in our next Quality Account if we continue to perform well. 9

10 Listening to Patients and Families: Tertiary Inpatient Referrals When a child or young person needs to come to BCH for urgent inpatient care from home or from another hospital, it s important that their admission is not delayed as this could have a negative impact on their care. In 2010/11 we decided to make sure delays did not happen and put processes in place to meet our goal. Figure 5 number of patients not offered a BCH bed within 24 hours 2010/ /13 How have we done? With more people than ever before wanting to access our services, 2012/13 was a really challenging year and our staff had to work very hard to meet our goal. What are we doing to improve? Meeting our goal while demand for our services increases means we need to increase the capacity in our hospital. This does not necessarily mean creating physical space for more beds. It s also important that we find ways of reducing the time that people need to spend in hospital, and the number of times they need to be admitted, so that more beds are available. Some examples of what we are doing to achieve this are: Developing services like so some children can be discharged earlier; Improving discharge processes so that once a child is ready to be discharged this happens much quicker; Developing our outpatient services so that children with long-term conditions like Diabetes and Asthma are less likely to deteriorate and need admission to hospital; Improving flow through the hospital so that people can get into wards quicker and can be discharged earlier; Establishing new services like our PACE team (see page 11) which supports high dependency patients on wards and allows earlier access to PICU for children and young people who need it. Other examples can be found on page 11 in the section about cancelled operations. 10

11 Listening to Patients and Families: Cancelled Operations Patients, families and staff have told us that when an operation has to be cancelled by the hospital this can have a huge impact. It might mean travel arrangements and time off school and work have to be rearranged and could also mean that tests and assessments have to be done again. We know this can be very stressful and inconvenient. There are times when we can t avoid cancelling operations because of emergencies like transplants which can t wait, or when another operation is more complex than expected, so it takes longer than planned. Sometimes an operation can t go ahead because there aren t enough beds that day on PICU to care for the patient after the operation. Over the last few years we have been working hard to try to reduce the number of operations that we cancel, especially those that we cancel on the actual day. At the same time we have been finding ways to make the experience better for patients and families when we can t avoid cancelling their operation. Figure 6 Monthly cancelled operations 2010/ /13 When you ve been told how important it is to get the operation done you start to get really worried that it s not happening and you get more and more worried that she will be getting worse. Whoever told us was very nice, supportive, and apologetic. You learn to understand that emergencies come first. You put everything back into perspective a little while afterwards but at the time we were really upset. How have we done? We have not met our target, with 1.68% of operations cancelled on the day. We have been experiencing our highest ever activity levels, which has put pressure on our theatres, PICU and wards, and we were therefore unable to meet our goal in 2012/13. Opening our new PICU extension in November 2012 helped us improve, and in January 2013 we launched our new Paediatric Assessment Clinical Intervention and Education (PACE) team which frees up more beds for our sickest children when they have had an operation. What else are we doing to improve? Improving the experience for children, young people and families Because we know that we will always have to cancel some less urgent operations we have been talking to patients and families to understand how we can make the experience better when this happens. We know that communication is really important, so they know what s going on as early as possible. We also know we need to make sure our staff are trained in the best ways to talk to families when their operation is cancelled, so that they give them all the information they need and are able to support them when they re upset or angry. Identifying all the reasons for cancellations and taking action We have set up a Task and Finish Group which is examining the reasons for all cancelled operations very closely to identify ways we can improve. They are already making progress, for example 11

12 patients are now contacted three days before their operation to make sure they have all the information they need. Improving processes like discharge, so beds are available more quickly We have changed the model of care on the Medical Day Care Unit so that it is now nurse-led. This means that each child and young person is admitted, treated and discharged by a named nurse. This has reduced delays for these patients along every step of their pathway, ensuring not only a speedy stay with us, but a fantastic patient journey. Reviewing patient pathways, to improve flow through wards The Surgical Day Care Unit cares for children requiring short stay surgery. We have changed the way we work on this Unit to a 23-hour model which means that some children can have procedures later in the day, and be discharged up to 11pm, and other children who require an overnight stay can be discharged at 7am. Patients, parents and carers have given very positive feedback about these changes as they appreciate being able to return to their home environment as soon as possible. By switching to this new way of working, we have maximised capacity, ensuring cancellations due to lack of beds has been significantly reduced. In 2013/14 we will also be: Opening more beds to increase capacity Another five beds are planned in PICU for We are opening more day beds/treatment chairs in the Medical Day Unit, which will allow us to treat more patients in the Unit, freeing up beds on the inpatient wards. Developing new areas to improve the experience and increase capacity Some of our parents and children have said that they do not like being in a bed before an operation as this can make them more anxious. To make this better we are creating a new lounge area in the Surgical Day Care Unit where children can stay and play until they are ready to walk to theatre for their operation. Only once they have had their operation will they need to be in a bed to recover. This new way of working will help us free up more beds, allowing us to do more operations every day. Expanding our Pre-Admission Service to prevent avoidable delays We are developing this service to ensure that all children and young people will have access to it, which will help prevent cancellations caused by things like: Families changing their minds about having an operation; Incorrect listing of an operation; Children having eaten too close to the planned operation. Developing plans to increase physical capacity We know we need more physical operating capacity due to increasing demand so we are working on plans to open more theatres. Working with other children s hospitals to see what we can learn from the way that they work Every children s hospital is unique, with different services meeting a range of different needs, but we can all learn from each other to make sure all children have a fantastic experience. We have set up a group with other children s hospitals around the country to see if we can learn from each other about ways of reaching our goals. 12

13 Listening to our Staff: Staff Survey Staff are our most important resource. Understanding their views about the quality of our services is crucial to ensuring that we can make improvements where they are needed. Figure 7: Key Staff Survey Results Figure 8: Staff Satisfaction Score 2011/12 How have we done? There has been very little change in the results but we are disappointed not to have done better. 2012/13 was a challenging year for our staff due to higher levels of activity and more patients with complex needs, and we know they have been working really hard to make sure children, young people and their families have safe, high quality care and a fantastic patient experience. What are we doing to improve? We are developing new ways to monitor how our staff are feeling - such as sickness absence and staff turnover - and we integrate this with information about the safety and quality of services. This helps us predict which areas might be coming under pressure. We are also doing lots more to gather the views of our staff throughout the year, keep them informed and support them to continue to provide the best services possible. Other methods we are adopting to improve staff experience include: Star of the Month nominated by staff, patients and families; Regular polls to help us understand staff mood; Launch of a new Health and Wellbeing Strategy with lots of opportunities for staff to improve their health and get support when they need it; Helping our leaders to support their staff when they feel stressed; Annual Night of Stars and Long Service Awards to reward outstanding contributions. Engaging with staff to obtain their views on themes arising out of the Francis report (see page 106) 13

14 Providing Even Better Nursing Care: Nursing Care Quality Indicators (NCQIs) Excellent nursing care is vital to ensuring our patients are safe, have a good experience and have good clinical outcomes. In 2010/11 we developed quality indicators in the most important areas. A new indicator was added for cannula care in 2012/13. Figure 9: NCQI Performance 2010/ /13 What are we doing to improve? How have we done? We have continued to do really well, with improvements in every indicator in 2012/13, especially in pain management. We are also really pleased with such high performance in our first year in monitoring cannula care. We are creating an electronic method to collect performance data which will allow us to monitor this every month rather than just quarterly. This will enable us to identify and address any issues much earlier. 14

15 Providing Even Better Nursing Care: Asthma Care When children and young people with asthma use an inhaler, it s essential that they use it properly to get the full benefits. It s also important that we ensure that they are involved in decisions about their care and we do this by agreeing their care plan with them and giving them a copy. How have we done? We continue to perform above the national average (which has improved), but our performance has dipped compared to the last two years. This is really disappointing as we know from previous years that we are able to do this well. Figure 10: BTS National Audit Performance What are we doing to improve? During 2013/14 we will be looking into ways of ensuring that adherence to the asthma care pathway is embedded in normal clinical practice. We will also amend the asthma care pathway to reflect the new NICE Asthma Quality Standards. We will report on our progress in our next Quality Account. 15

16 Providing Even Better Nursing Care: Pressure Ulcers Some of our patients - in particular the sickest patients on PICU - are at risk of developing pressure ulcers which, if left untreated, can become very serious. We are working toward the complete eradication of pressure ulcers, in line with the ambition of the whole NHS. Figure 11: Pressure Ulcer rates 2012/13 How have we done? We have done really well in 2012/13. Whenever a pressure ulcer is identified the patient s care is reviewed by a clinical expert. So far in 2012/13, the care provided in all cases has been appropriate. There have been no grade 3 or 4 pressure ulcers. Zero Grade 2 pressure ulcers have been categorised as avoidable. The number of Grade 2 pressure ulcers has decreased over the year. What are we doing to improve further? We have been asked to contribute to the development of NICE guidance on paediatric pressure ulcers so that the improvements that we have achieved will benefit children and young people in hospitals across the NHS. 16

17 Improving Health Outcomes: Health Promotion We have an important role to play in improving general health outcomes and reducing health inequalities for children and young people. Good general health for the whole family is even more important when a child becomes ill or has a long-term condition. How have we done? We have met all of our goals. Referrals to Stop Smoking services have significantly increased. We have achieved status as a World Health Organisation (WHO) Health Promoting Hospital so we now part of an international network of hospitals that aim to improve health by developing structures, cultures, decisions and processes. What are we doing to improve? We are providing training and awareness sessions for staff. We have established a smoking referral pathway. We have new data recording systems so that we can monitor the impact of our work. We are displaying information about alcohol on screens in the main Outpatients department. 17

18 Improving Health Outcomes: CAMH Service User Satisfaction Measuring the difference our services make to the people who use them helps us to understand what we are doing well and where we might need to make improvements. Figure 12: CAMHS Questionnaire Scores 2011/ /13 How have we done? We have met the national target for all questions except the percentage of service users who feel the service has helped to make their problems better. What are we doing to improve? We are improving the way that we engage with young people to better understand their views on CAMHS. We have set up focus groups to ensure that we ask young people about the specific care pathways they are on to support redesign and development. We are also improving our website with the help of our young people and their families and providing further opportunities for them to give us their views through the Trust feedback app. 18

19 Reducing Infection: Reducing Healthcare Acquired Infections in PICU Our sickest patients on our Paediatric Intensive Care Unit (PICU) are most at risk of healthcare associated infections (HCAIs). This can be very serious and means they have to spend more time in hospital. Reducing the risk of infections for these patients can help them get well quicker and be discharged earlier. Figure 13: HCAIs in PICU 2011/ /13 How have we done? We have achieved our goal and improved on last year s performance in relation to Ventilator Associated Pneumonia (VAP). We have shared the VAP results with the International Forum on Quality and Safety in Healthcare. We have seen a small increase in our Central Venous Catheter (CVC) infection rate in 2012/13. Although this is still below our target rate of 1.4, we are investigating the reasons for this to determine what we can do to reduce this rate even further. What are we doing to improve? We are now monitoring rates of infections in other areas of the hospital too, with most wards doing well. We will continue to develop the practices we have put in place and to learn from every infection that does occur to reduce the rate of infections in PICU and across the hospital to a minimum level. 19

20 Reducing Infection: Reducing Rates of Clostridium Difficile Clostridium difficile are bacteria present naturally in the gut of around twothirds of children and 3% of adults. C.difficile does not cause any problems in healthy people. However, some antibiotics used to treat other health conditions can interfere with the balance of 'good' bacteria in the gut. When this happens, the bacteria can multiply and produce toxins, which cause illness such as diarrhoea and fever. As C.difficile infections are usually caused by antibiotics, most cases happen in a healthcare environment. Reducing rates of C.difficile in hospitals is a national priority. Figure 14: C.Difficile infections 2010/ /13 How have we done? We had one case of C.difficile in 2012/13 and made sure that the ward where this occurred had extra cleaning until there was no trace of C.difficile in the environment. We also carried out tests in other high risk wards and found no C.difficile at all. What are we doing to improve? We have tried out a new sampling technique and now carry out extra testing to identify patients who do not have true C.difficile infection but might be carrying the bacteria which could put other patients at risk. Early identification and protection measures reduce this risk. 20

21 Reducing Infection: Preventing MRSA Blood stream infections with MRSA can be very serious for people who are unwell and can result in additional treatment and an increased length of stay. Figure 15: MRSA infections 2007/ /13 How have we done? For the second year in a row we have had no MRSA infections at all. How will we maintain this? Achieving this goal has been a challenge in 2012/13, particularly with some patients who are at very high risk of MRSA bacteraemia. We will continue to practice everything we have learned that has ensured that we have had no MRSA infections since 2010, and we will continue to apply new best practice and learning from other organisations. 21

22 Reducing Infection: Reducing MSSA MSSA is a common bacteria carried on the skin of 30% of the population. MSSA bloodstream infection is a risk for some of our patients, especially those who have a central venous catheter (CVC). Figure 16: MSSA post 48 hours rates 2011/ /13 How have we done? In 2011/12, our first year of monitoring, we achieved substantial reductions, exceeding our target. In 2012/13 it has been challenging to reduce this any further, with a similar number of infections during both years. We did not therefore meet our target. We have analysed every MSSA infection to identify the cause and any opportunity to prevent them. Dr Jim Gray, Head of Microbiology and his team were recognised at the national NHS Innovation Challenge Prizes, where they were highly commended for their work in reducing MSSA bloodstream infections in children who receive their parenteral nutrition at home. The hard work of the team reduced the numbers of infections by a third and it is hoped that this example of good practice will be rolled out across the hospital. What are we doing to improve? We believe we can improve even further and will focus in particular in 2013/14 on reducing MSSA as contaminants in blood cultures. 22

23 Providing the Safest Possible Care: Medication Incidents We encourage staff to report every incident, from the most serious to near-misses. At BCH we use a lot of medicines so there are many opportunities for errors to occur, and medication incidents are the most frequently reported incident type. We want to see a high number of reported medication incidents at a low level of harm, as this shows a good safety culture. Figure 17: Medication Incidents (Harm Category) 2012/13 How have we done? We have met both goals: 0.94% of all medication incidents caused harm. Zero medication incidents caused serious harm. We take every incident seriously and next year we want to see a further reduction in the percentage of incidents that cause any harm at all. What are we doing to improve? We have created detailed easy to read staff guidance on all high risk injectable drugs. We have developed standardised labels for marking high risk drug infusions. We have reviewed the ward stock arrangements so that most high risk drugs need to be specifically ordered from our pharmacy department. This means that the pharmacy staff can highlight any guidance when issuing the drug. We will deliver additional training on preparing liquid medication. We will develop standardised guidelines for each drug which will be reviewed at regular intervals. We have introduced the role of Medicines Safety Nurses to act as local educators and champions of best practice. We have included additional guidance on good prescribing practice on the junior doctors induction. We have produced dose calculators for a number of intravenous medications to minimise the chance of making a calculation error. 23

24 Providing the Safest Possible Care: Acute Life-Threatening Events (ALTEs), Cardiac Arrests and Respiratory Arrests Good monitoring on wards means that we will pick up deteriorating patients more quickly and avoid preventable emergency and lifethreatening events. How have we done? During 2012/13 there have been no preventable acute life-threatening events (ALTEs), cardiac arrests or respiratory arrests. We have therefore reached our goal this year. Figure 18: Emergency Events 2012/13 What are we doing to improve? We will continue to review each event to identify any learning that could prevent or help predict events in the future. We are developing a pre-transfer checklist for Extracorporeal Life Support (ECLS) to ensure all monitoring functioning is checked. 24

25 Providing the Safest Possible Care: Mortality Thankfully, the number of deaths at BCH is very low relative to the number of patients we treat and the seriousness and complexity of their illnesses. We review every individual death to see if there is anything we can learn, and to ensure that no death is avoidable. Figure 19: Deaths and deaths per 1,000 admissions 2011/ /13 How have we done? There were more deaths in 2012/13 than in the previous year but the number of deaths per 1,000 admissions has remained at a very similar level, which suggests this reflects the increased number of patients that we treated. We also, however, look at a wide range of other information, including details of every individual death to identify any care failings that may have contributed to the death. Our reviews have found that no deaths during 2012/13 were avoidable. What are we doing to improve? We will continue to monitor mortality rates in a number of different ways to ensure that any concerns are identified and that we learn from every death in case there was anything we could have done differently. In 2013/14 we will also commission independent reviews of our mortality review processes to ensure they are of the highest quality and to identify any ways that they can be improved. More information about the way we review mortality can be found at page

26 Providing the Safest Possible Care: WHO Safe Surgery Checklists Research by the World Health Organisation (WHO) has confirmed that the use of the WHO Safe Surgery Checklist significantly reduces surgical morbidity and mortality. The checklist should be completed at three stages of surgery. Figure 20: Overall WHO Checklist Compliance: March 2011-January 2013 How have we done? In September 2012 our theatres department implemented an e-checklist to improve compliance and safety by making completion of all fields a mandatory requirement of the system. Since then overall compliance has been consistently high. We will continue to monitor completion of the checklist but if compliance continues to be high, we will not report on this in our next Quality Account. 26

27 New Priorities for 2013/14: Extravasation Why is this a priority? When medicine is given into a vein, it can leak into and damage the surrounding tissue and cause a potentially serious injury. This can be a particular problem for children. What have we been doing? We have developed a Nursing Care Quality Indicator (NCQI) for cannula care which focuses on accurate observations, dressing changes and observations of early signs of an injury. We are also reviewing medication involved in extravasation incidents, to identify whether there are specific associations between the medication used and the likelihood of injury. Goal Reduce the episodes of harm from extravasation injuries by 25% year on year. Measure We will use a new process: SCAN (Safe Children Audit No harm) to monitor the number of extravasation injuries per month. New Priorities for 2013/14: Sepsis Care Why is this a priority? The rate of mortality from Septic Shock in children is approximately 10%. Survival is significantly increased if antibiotics are given within an hour of diagnosis (as well as other treatment such as intra-venous fluids). At BCH we treat many patients who are at high risk of sepsis, such as oncology patients or those who are immuno-compromised. Our complex patients sometimes need unusual antibiotics. Sepsis can be difficult to detect so it s essential we act quickly as soon as it is detected. What have we been doing? We have developed a Sepsis Care Pathway bundle which describes what must be done when a patient has sepsis. This has been piloted in the Emergency Department and is being implemented on PICU before complete roll-out to other areas in 2013/14. Goal All patients needing antibiotics as defined by the care pathway should receive them within 1 hour of prescription. Measure 100% compliance with Sepsis Care Pathway monitored by way of audit. New Priorities for 2013/14: Friends & Family Test Why is this a priority? A helpful way for any organisation to measure what the users of their services think of them is to ask them whether they would promote them to their friends or family. What have we been doing? Last year our commissioners asked us to ask this question of all adults within hours of discharge. As all of our patients are under 18, it was important to us to make sure that their views are recorded too. So with the help of a group of young people we developed a similar more meaningful question for young people and put this to children and young people from the age of 10. We have also developed a smart phone app, which people can use to give us their feedback. Goal Improvement on the first quartile score. Measure Number of promoters minus the number of detractors. 27

28 STATEMENTS OF ASSURANCE ON THE QUALITY OF OUR SERVICES Review of Services During 2012/13 Birmingham Children s Hospital NHS Foundation Trust provided and/or subcontracted 37 NHS services. Birmingham Children s Hospital NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 2012/13 represents 100 per cent of the total income generated from the provision of NHS services by Birmingham Children s Hospital NHS Foundation Trust for 2012/13. On a regular basis, the Board reviews the following data which enables a comprehensive understanding of the three dimensions of quality patient safety, clinical effectiveness and patient experience across every service provided by the Trust: Quality Report this report includes details of the following: Major clinical risks Incident analysis Mortality Serious Incidents Emergency clinical events Never Events Performance against Safety Strategy objectives Patient Feedback Quality walkabouts Formal complaints PALS concerns Surveys Resources Report in addition to financial performance this report includes the following: Activity Performance against our objectives relating to access to our services Workforce indicators including: o Rates of appraisals o Mandatory training attendance o Sickness rates and analysis o Turnover o Use of temporary staff Consideration of these reports together provides an overview of areas in the Trust where there might be concerns about the quality of care. Members of the Board, senior hospital staff, Governors and members of the Young People s Advisory Group undertake regular Quality Walkabouts to the wards, where the focus is on either safety or patient experience. The walkabout involves ward observations and discussions with members of the ward multi-disciplinary teams, patients and families to identify any safety or patient 28

29 experience issues or concerns. The outcome of the walkabout is fed back to the ward staff with a requirement to take action where improvements are necessary. The Clinical Risk and Quality Assurance Committee has delegated responsibility from the Board for reviewing risks to safety and quality and identifying and monitoring actions to address these risks and improve quality. This Committee reports to the Quality Committee which is responsible for driving the Trust s quality strategy, bringing the three elements of quality together, allowing integrated reporting to the Board of Directors. In 2010/11 we developed a Safety Dashboard, which acts as an early warning system. It allows an aggregated comparison of safety metrics against each ward and department and incorporates a series of defined triggers which, in combination, may indicate problems with safety or quality in a specific area. The dashboard approach allows us to really focus on the areas where potential for harm is the highest. Whenever the dashboard identifies a potential concern a more detailed analysis is provided for the area in question and this is considered in depth at the Clinical Risk and Quality Assurance Committee. Participation in Clinical Audit and National Confidential Enquiries During 2012/13, 15 national clinical audits and one national confidential enquiry covered NHS services that Birmingham Children s Hospital NHS Foundation Trust provides. During 2012/13 Birmingham Children s Hospital NHS Foundation Trust participated in 100% of national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries that it was eligible to participate in. The national clinical audits and national confidential enquiries that the Trust was eligible to participate in during 2012/13 are as follows: (see table below). The national clinical audits and national confidential enquiries that Birmingham Children s Hospital NHS Foundation Trust participated in, and for which data collection was completed during 2012/13, 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. Table 1: National Clinical Audits and National Confidential Enquiries 2012/13 eligibility, relevance, participation and percentage cases submitted NATIONAL CLINICAL AUDITS AND NATIONAL CONFIDENTIAL ENQUIRIES IN WHICH THE TRUST WAS ELIGIBLE TO PARTICIPATE IN 2012/13 Audit Relevant Participation % Cases submitted Paediatric asthma (British Thoracic Society) Yes Yes 95% Childhood epilepsy (RCPH National Childhood Epilepsy Audit) Yes Yes 100% Fever in children (CEM) Yes Yes 100% Paediatric intensive care (PICANet) Yes Yes Ongoing Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit) Yes Yes 100% Diabetes (RCPH National Paediatric Diabetes Audit) Yes Yes 100% Potential donor audit (NHS Blood & Transplant) Yes Yes 100% Ulcerative colitis & Crohn s disease (UK IBD Audit) Yes Yes 100% Cardiac arrhythmia (Cardiac Rhythm Management Audit) Yes Yes 100% 29

30 Renal replacement therapy (Renal Registry) Yes Yes 100% Renal transplantation (NHSBT UK Transplant Registry) Yes Yes 100% Severe trauma (Trauma Audit & Research Network) Yes Yes 100% Bedside transfusion (National Comparative Audit of Blood Transfusion) Yes Yes 100% National review of Asthma Deaths (NRAD) Yes Yes 100% Maternal, infant and newborn programme (MBRRACE-UK)* Yes Yes 100% Mental Health programme: National Confidential Inquiry into Suicide and Homicide for people with Mental Illness (NCISH) Yes Yes 100% The reports of 25 national clinical audits were reviewed by the Trust in 2012/13 and the Trust intends to take the following actions to improve the quality of healthcare provided: BTS Paediatric Asthma Audit (2012) The use of the Asthma/Wheeze care pathway will be audited. Patients admitted with severe/life threatening exacerbation of asthma will now have a follow up appointment booked following discharge. Feedback will be given to the BTS regarding the use of peak flow and length of stay and its use in the national audit. Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit) (2012) Continue to liaise with Heart Suite suppliers to rectify the misplacement of co-morbid data and the placing of more than one code in a diagnostic or procedure field. Regularly export the BCH data from the Congenital Database to review the procedures analysis against the algorithm and locally held data (reverse validation). All therapeutic implantable devices and electrophysiological procedures in patients with congenital heart disease will now be submitted to congenital CCAD. Severe trauma (Trauma Audit & Research Network) (2012) A Working Group is reviewing rehabilitation services including patient journeys. Collate data for the region, comparing key metrics between each Major Trauma Centre and Trauma Unit to inform the ongoing development of trauma networks. Diabetes(2012) The diabetes PREM questionnaire has been distributed in the diabetes clinics. Pain Management (College of Emergency Medicine 2012) Pain set as a priority for the Emergency Department. Re-evaluation of scores has improved since the implementation of a reminder stamp at triage. The reports of 25 local clinical audits were reviewed by the Trust in 2012/13 and the Trust intends to take the following actions to improve the quality of healthcare provided: Tissue Viability - Annual Audit of Pressure Ulcers The tissue viability assessment tool and wound assessment paperwork will be united into a skin care bundle. 30

31 Burns Ward - Assessment and Referral of Burns in ED More education is planned for staff regarding referral guidelines and the level of detail required during assessment. Emergency Department - Left before treatment / Triage Regular triage training for staff to be arranged. Clarification of police role to be highlighted to all staff. New doctors to be made aware of the Left Before Triage guideline as part of their induction training. Palliative Care - Clinical audit on advanced care plan for management of cardio-respiratory arrest in children and young person with advanced malignancy Ensure all staff are aware of the importance of early palliative discussions and are aware of and are using the Palliative Care Toolkits. Ophthalmology - An innovative approach to paediatric fundus photography Continue to use this method as it has been proven successful. Audit results to be published in Ophthalmology Journal Audiology - Bone anchored hearing aids (BAHA) in very young children The decision to implant a BAHA in children between the ages of three and five years will continue to be made on a case by case basis with the inclusion of the family and multidisciplinary team. Neurology - Guillain Barre syndrome (GBS) Ensure the departmental guidelines are up to date and accessible. MRI scan to be added to the list of investigations required for patients with GBS. Participation in Clinical Research The number of patients receiving NHS services provided by Birmingham Children s Hospital NHS Foundation Trust that were recruited during that period to participate in research by a research ethics committee was 2,863. This demonstrates our continued improvement in this area over the last four years as we work towards our aim that every child and young person treated at the hospital is either offered participation in a research project or is aware that research is a major driver to our desire to deliver the best and safest clinical care in the country. Figure 21: Numbers of patients recruited to participate in research 2009/ /13 31

32 One of our strategic objectives is to strengthen Birmingham Children s Hospital s position as a provider of specialised and highly specialised services, so that we become the leading provider of Children s Healthcare in the UK. To help us achieve this, we are implementing a Research & Development Strategy towards becoming a leader in paediatric clinical research. Clinical research is important as it helps us to understand conditions and improve and discover new treatments, resulting in improved quality of care for patients. A good way of finding out how well we are doing on clinical research is to monitor the number of peer reviewed research publications - excluding abstracts and letters - that we deliver each year. When a research publication is reviewed by other professionals, or peers, this ensures that it is of a high enough standard to be used to help develop treatments for patients. Another important indicator of research quality is the impact factor of the journals in which the research is published, which reflects the number of times the journal is cited by other researchers and the number of citations of particular publications over a period of time. Figure 22: Peer Reviewed Publications per year 2008/ /13 Use of the CQUIN Framework A proportion of Birmingham Children s Hospital NHS Foundation Trust s income in 2012/13 was conditional upon achieving quality improvement and innovation goals agreed between Birmingham Children s Hospital NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation (CQUIN) payment framework. The exception to this is the Quality Improvement Development Innovation Scheme (QIDIS) used by the National Specialised Commissioning Team to support Trusts to improve the quality of care and clinical outcomes for nationally designated services, replacing CQUIN arrangements for those services. Further details of the agreed goals for 2012/13 and for the following 12 month period are available online at: 32

33 Table 2: Schemes agreed for Quality Improvement and Innovation 2012/13 CQUIN Goal Name WM PCT Cluster WMSCT Total Goal Weight Value Goal Weight Value Value End of year performance Safety Thermometer - National 1 10% 179, % 92, ,979 Targets met Safety Thermometer - Paediatric Specific 2 10% 179, % 92, ,979 Targets met Friends & Family Test - Regional 3A 4% 71,863 8a 1% 23,080 94,944 Targets met Friends & Family Test Board Minutes Friends & Family Test - Weekly Reporting Friends & Family Test - Performance Improvement 3B 4% 71,863 8b 1% 23,080 94,944 Targets met 3C 4% 71,863 8c 1% 23,080 94,944 Targets met 3D 4% 71,863 8d 1% 23,080 94,944 Targets met Net Promoter - Paediatric Specific 4 16% 287, % 92, ,774 Targets met Healthy Lifestyles - Smoking 5A 8% 143, ,727 Targets met Healthy Lifestyles - Alcohol 5B 6% 114, ,981 Targets met Healthy Lifestyles - Making Every Contact Count 5C 2% 28,745 28,745 Targets met CAMHS QNCC 6 16% 287, ,454 Targets met Antimicrobial Stewardship 7 16% 287, ,454 Targets met Implementation of clinical dashboards for specialised services (PIC) To minimise the number of patients undergoing unplanned extubation. CAMHS Tier 4: Education, training and meaningful activity CAMHS Tier4: Patient Involvement in Recruitment CAMHS Tier4: Feasibility study for conversion to single room accommodation 2 10% 184, ,641 Targets met 3 10% 184, ,641 Targets met 4 5% 92,320 92,320 Targets met 5 5% 92,320 92,320 Targets met 6 5% 92,320 92,320 Targets met Local CQUIN: Enhancing HDU 10 25% 461, ,602 Targets met Local CQUIN: CNS Pathway 11 20% 369, ,282 Targets met Planned CQUIN income 100% 1,796, % 1,846,409 3,642,994 Other Commissioners 276,508 Total Planned CQUIN income 3,919,502 33

34 The monetary total for the amount of income conditional upon achieving CQUIN goals in 2012/13 and the monetary total for the associated payment in 2011/12 is detailed below: Table 3: CQUIN income data 2011/12 and 2012/13 Percentage of income conditional upon achieving goals (total value 3.92m) 2011/ /13 1.5% 2.5% Income not achieved 0 0 Table 4: Schemes agreed for Quality Improvement Development Innovation Scheme (QIDIS) 2012/13 Service Nature of Scheme Contract Value QIDIS Value QIDIS % (of 2.5%) Alstrom Syndrome Bardet Biedl Syndrome (Children) Complex Childhood Osteogenesis Imperfecta Craniofacial Surgery For Congenital Conditions Epidermolysis Bullosa ECMO For Reversible Respiratory Failure (Children) Liver Transplantation (Children) Lysosomal Storage Disorders (Children) Retinoblastoma Small Bowel Transplantation (Children) Specialist Paediatric Liver Disease Wolfram Syndrome Dashboard Scheme 10% / PPE Scheme 20% / No Strategic Schemes Dashboard Scheme 10% / PPE Scheme 20% / Strategic Schemes 70% Dashboard Scheme 10% / PPE Scheme 20% / Strategic Schemes 70% Dashboard Scheme 10% / PPE Scheme 20% / Strategic Schemes 70% Dashboard Scheme 10% / PPE Scheme 20% / Strategic Schemes 70% No schemes as cost per case and not eligible for QIDIS payments Dashboard Scheme 10% / PPE Scheme 20% / Strategic Schemes 70% Dashboard Scheme 10% / PPE Scheme 20% / Strategic Schemes 70% Dashboard Scheme 10% / no PPE Scheme / Strategic Schemes 35% Dashboard Scheme 10% / no PPE Scheme / no Strategic Scheme Dashboard Scheme 10% / PPE Scheme 20% / Strategic Schemes 70% Dashboard Scheme 10% / PPE Scheme 20% / no Strategic Scheme 109, % 193,017 4, % 712,399 17, % 2,030,299 50, % 559,367 13, % 273,845-0% 3,740,250 93, % 428,579 10, % 1,207,673 13,586 45% 1,215,533 3,039 10% 2,845,056 71, % 160,048 1,200 30% Total 13,475, ,372 84% Liver Transplantation (Children) Income deferred to 2013/14 to cover costs not yet incurred -54,000 Net Total 227,372 Care Quality Commission Birmingham Children s Hospital NHS Foundation Trust is required to register with the Care Quality Commission (CQC) and its current registration status is: Registered to carry out the following legally regulated services: 34

35 Transport services, triage and medical advice provided remotely Treatment of disease, disorder or injury Assessment or medical treatment for persons detained under the Mental Health Act 1983 Surgical procedures Diagnostic and screening procedures Management of supply of blood and blood derived products The Care Quality Commission has not taken enforcement action against Birmingham Children s Hospital NHS Foundation Trust during 2012/13. Birmingham Children s Hospital NHS Foundation Trust has not participated in special reviews or investigations by the Care Quality Commission during 2012/13: On 6 November 2012 the CQC undertook a routine, unannounced inspection of CAMHS at our Parkview Clinic, to assess compliance with the following standards: 04: Care and welfare of people who use services 06: Cooperating with other providers 07: Safeguarding people who use services from abuse 13: Staffing The CQC found that the services at Parkview met all these standards. On 21 November 2012 the CQC undertook a routine, unannounced inspection of the Trust s services at our main site at Steelhouse Lane, to assess compliance with the following standards: 04: Care and welfare of people who use services 09: Management of medicines 11: Safety, availability and suitability of equipment 14: Supporting workers The CQC found that the services at Steelhouse Lane were compliant with the first three of these standards, but found that action was needed to ensure compliance with standard 14: Supporting workers. The evidence CQC collected in theatres identified some minor concerns about the risks relating to how staff were supported in this area. CQC issued a compliance action to ensure that improvements to support staff are made. We have taken the following actions to ensure we are now compliant with this standard: Recruited to vacant posts in theatres; Changed and improved the way we were implementing our Integrated Theatre Recovery Team Project; Strengthened, developed, and added to arrangements for supporting and engaging with staff in theatres. Data Quality Birmingham Children s Hospital NHS Foundation Trust submitted records during 2012/13 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: 35

36 98.6% for admitted patient care; 99.5% for outpatient care; and 98.3% for accident and emergency care The percentage of records in the published data which included the patient's valid General Practitioner Registration Code was: 100% for admitted patient care; 100% for outpatient care; and 100% for accident and emergency care Birmingham Children s Hospital NHS Foundation Trust s Information Governance Assessment Report overall score for 2012/13 was 82% and was graded green (satisfactory). Birmingham Children s Hospital NHS Foundation Trust will be taking the following actions to improve data quality: Having made significant improvements against the data quality items published centrally we are now progressing to developing further local data quality indicators. These will include looking at timeliness of data capture; We have expanded our Data Quality Group and will use this forum to push forward the data quality agenda. Birmingham Children s Hospital NHS Foundation Trust was subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission and the error rates reported in the latest published audit for that period for diagnoses, treatment and investigation coding (clinical coding) were: Diagnosis: N/A (not part of the 2012/13 audit) Treatment (procedure): 10.3% Investigations: 10.4% 150 cases were reviewed within the sample. Note: the results should not be extrapolated further than the actual sample audited. Core National Indicators Due to the time it takes central bodies to collate and publish some of the data, sometimes comparative figures are not available at all (N/A). It should also be appreciated that some of the Highest and Lowest performing Trusts on some of the data may not be directly comparable to Birmingham Children s Hospital. There are several core national indicators that are not applicable to Birmingham Children s Hospital, because they relate to adult patients/services only, or due to the specialist nature of many of our services. These indicators include: Summary Hospital-level Mortality Indicator (SHMI) though we do provide details of a different mortality indicator at page 113 which compares our mortality rates with those of a range of other children s services; 36

37 The percentage of patient deaths with palliative care; The percentage of patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric in-patient care; The percentage of admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper during the reporting period; Patient reported outcome measures scores; The Trust s responsiveness to the personal needs of its patients; Patient experience of community mental health services; The percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism. Hospital Readmissions: The percentage of patients readmitted to Birmingham Children s Hospital within 28 days of being discharged in 2012/13 AGE 2011/ /13 National Average Highest Trust Lowest Trust 0 to or over AGE 2010/ / /13 N/A National Average 2010/ % 10.0% 9.97% 10.15% 16 or over 9.9% 11.0% 7.7% 11.42% Highest Trust N/A Lowest Trust Birmingham Children s Hospital NHS Foundation Trust considers that these percentages are as described for the following reasons: Between 2010/11 and 2012/13 we undertook a monthly audit including a detailed review of every emergency readmission and reported this to our commissioners. There have been no concerns with the discharge decision in any of the cases. Birmingham Children s Hospital NHS Foundation Trust intends to take the following actions to improve these percentages, and so the quality of its services, by: We will continue to regularly monitor emergency readmissions to identify any concerns. Staff Survey: Percentage of staff who would recommend the Trust to family or friends Average Acute Trust 85% 83% 87% Birmingham Children s Hospital NHS Foundation Trust considers that this percentage is as described for the following reasons: We acknowledge that the result is slightly below the national average and that this has remained consistent over the last few years. Birmingham Children s Hospital NHS Foundation Trust intends to take the following actions to improve this percentage, and so the quality of its services, by: We are taking steps to improve the way we support and engage with staff and act on their views and concerns. Central to these plans in 2013/14 is our approach to responding to the Francis report. From March 2013 we have been holding listening events with staff, which over 250 staff members have attended so far. Staff at these events are encouraged to be completely open, demonstrating 37

38 their commitment to our values courage, trust, respect, commitment and compassion. The listening events will culminate in a week of events in September when we will focus on actions to address the issues that have been raised. Our Quality Walkabouts now also include a focus on staff health and wellbeing. We have put in place a process by which anonymous contact can be made direct to the Chief Executive Officer to raise any concerns or to provide views. We have also put in place processes to ensure we listen to and act upon the concerns of specific staff groups, for example, our Trainee Advice & Liaison Service (TALS) and Safety Hotline for junior doctors. During 2013/14 we will be regularly undertaking a staff poll, asking them whether they would recommend the Trust as a place to be treated to friends and family, so that we can monitor this more regularly during the year and act on any poor results more quickly. The percentage of positive responses to this question has risen during the early part of the year to 98%. C.difficile: rate per 100,000 bed days of cases of C.difficile infection reported within the Trust amongst patients aged 2 or over 2011/ /12 National Average 2011/12 highest Trust 2011/12 Lowest Trust Birmingham Children s Hospital NHS Foundation Trust considers that this rate is as described for the following reasons: There was one case of C.Difficile at the Trust in 2011/12. Birmingham Children s Hospital NHS Foundation Trust intends to take/has taken the following actions to improve this rate, and so the quality of its services, by: Actions we are taking to minimise the risk of C.Difficile are described at page 89. Patient Safety Incidents: the number and rate of patient safety incidents reported, and the number and percentage of such patient safety incidents that resulted in severe harm or death This year is the first time that this indicator has been required to be included within the Quality Report alongside comparative data provided, where possible, from the Health and Social Care Information Centre. The National Reporting and Learning Service (NRLS) was established in The system enables patient safety incident reports to be submitted to a national database on a voluntary basis designed to promote learning. It is mandatory for NHS trusts in England to report all serious patient safety incidents to the Care Quality Commission as part of the Care Quality Commission registration process. To avoid duplication of reporting, all incidents resulting in death or severe harm should be reported to the NRLS who then report them to the Care Quality Commission. Although it is not mandatory, it is common practice for NHS Trusts to reports patient safety incidents under the NRLS s voluntary arrangements. As there is not a nationally established and regulated approach to reporting and categorising patient safety incidents, different trusts may choose to apply different approaches and guidance to reporting, categorisation and validation of patient safety incidents. The approach taken to determine the classification of each incident, such as those resulting in severe harm or death, will 38

39 often rely on clinical judgement. This judgement may, acceptably, differ between professionals. In addition, the classification of the impact of an incident may be subject to a potentially lengthy investigation which may result in the classification being changed. This change may not be reported externally and the data held by a trust may not be the same as that held by the NRLS. Therefore, it may be difficult to explain the differences between the data reported by the Trusts as this may not be comparable. Number of patient safety incidents (acute specialist) Rate of patient safety incidents per 100 patient admissions (acute specialist) Percentage of such patient safety incidents that resulted in severe harm or death (small acute) Oct 2011-March 2012 BCH Oct 2011-March 2012 Highest Trust Oct 2011-March 2012 Lowest trust 1,370 1, % 2.36% 0.00% Birmingham Children s Hospital NHS Foundation Trust considers that this number and/or rate is as described for the following reasons: We are pleased to note the high number of reported incidents and the low percentage of these that resulted in severe harm or death compared with the national average, as this indicates an open safety culture. Birmingham Children s Hospital NHS Foundation Trust intends to take/has taken the following actions to improve this number and/or rate, and so the quality of its services, by: Actions we are taking to monitor and improve our safety culture are described on page 111; We investigate and learn from every incident; We take actions to address safety issues identified through safety monitoring and analysis; Safety themes identified through incident analysis are addressed through safety targets as part of our Safety Strategy for example, extravasation injuries and medication incidents. 39

40 Safety Patient Experience Effectiveness Other information Linking our Priorities to the Priorities of the NHS QUALITY STRAND QUALITY DOMAIN (NHS OUTCOMES FRAMEWORK) Preventing people from dying prematurely BCH QUALITY INDICATOR Nursing Care Quality Indicators Asthma Care Health Promotion Implementing the Sepsis Care Bundle Enhancing quality of life for people with long-term conditions Helping people to recover from episodes of ill health or following injury Ensuring that people have a positive experience of care Treating and caring for people in a safe environment; and protecting them from avoidable harm Food & nutrition Nursing Care Quality Indicators Asthma Care Health Promotion Food & nutrition Nursing Care Quality Indicators Health Promotion CAMH Service User satisfaction Implementing the Sepsis Care Bundle Food & nutrition Play & activities Emergency department transfers Tertiary inpatient referrals Cancelled operations Friends & Family Test Pressure ulcers Reducing Healthcare Acquired Infections in PICU Reducing rates of C.Difficile Preventing MRSA Reducing MRSA Medication Incidents Acute life threatening events, Cardiac Arrests and Respiratory Arrests Zero avoidable deaths WHO Safe Surgery checklists Extravasation injuries Overview of Quality of Care Complaints We take all complaints about our services very seriously and ensure that the way we respond is tailored to the individual and that we answer all of their concerns. Our Chief Executive is involved in every response and writes personally to each individual. Responding to a complaint can include meetings with clinical staff and senior managers, including the Chief Executive. Formal complaints often originate in a concern raised with PALS (Patient Advice and Liaison Service) which supports families in obtaining the response they need in the best way for them. We encourage people to use our Formal Complaints service and PALS as, if something has gone wrong we want to know about it so we can try to put it right, learn from it and improve. This information, when combined with other quality information about our services, can also help us identify when there are other problems. 40

41 Fortunately, compared to the numbers of patients we see every day, we receive very few formal complaints. Each one is considered in detail and incorporated into our Safety Dashboard and our Quality Report. Figure 23: Numbers of formal complaints per month/per 1,000 admissions (This data is governed by local definitions) Complaints 5 Complaints per 1000 Admissions 0 In order to see whether there are any themes amongst the complaints we receive, we group the issues raised in each complaint into categories. The pattern of complaints received about the 5 main categories is set out below. Figure 24: Pattern of complaints per top 5 categories, 2010/ /13 admissions (This data is governed by local definitions) Waiting, delays & cancellations Staff Attitude Quality of Treatment 5 Communication 0 Q Q Q Q Q Q Q Q Q Other As part of the formal complaints investigation process, we identify any areas in which the quality of the services could be improved, and make appropriate recommendations. These range from reminders to staff about proper practices and behaviour, to fundamental changes in practice and documentation. We regularly follow up on these recommendations to make sure action has been taken. As a result of these recommendations a number of changes have been made, including: Radiology: An area has been identified where families can discuss issues privately; Surgical Day Care: To avoid any discrepancy in recording weight and therefore incorrect calculation of medication, the same member of staff who checks a child s weight now also writes the weight on the drug chart; Communication processes between Radiology and Rheumatology secretaries about appointments have been improved; Heart Investigations Unit: A test results tracking process has been introduced; 41

42 All wards: The handover process has been improved to ensure speciality patients on outlying wards are more clearly identified; All clinical areas: A new discharge form has been designed to prevent failure to follow-up; The Breast-feeding training programme has been re-launched; Learning Disabilities: increased awareness has been raised amongst staff about the importance of the Trust Learning Disabilities Passport and care pathways; The experience of a family will be used as a learning example for doctors in training. In January 2013 the Patient Association published a report: Complaint handling in NHS Trusts signed up to the CARE campaign, which is based on information about the complaint handling systems and processes of a random sample of trusts. Birmingham Children s Hospital was one of the randomly selected trusts and is included anonymously within the report. The Patients Association wrote to us and gave us some positive feedback about what they have seen of our systems and processes, in particular they said: Birmingham Children s Hospital appears committed to being a learning organisation. An example of this is your unique approach of measuring complaints against Trust values within the Quality Report. Incidents We have robust systems for managing incidents and in 2011/12 were awarded NHSLA level 3, the highest level for compliance with the NHS Litigation Authority Risk Management Standards. In 2012 we carried out a Lean process on our investigation management system to ensure it is as efficient as it can be. This means investigations can now be concluded more quickly, which is better for the patients and families involved and allows us to start implementing learning from the incident earlier than we previously could. In 2013 our Internal Auditors gave an opinion of significant assurance about our incident management processes. We encourage all members of staff to report all incidents, errors and near misses so we can make improvements, work out what went wrong, identify themes and drive quality improvements in everything we do. We share learning from incidents through our Safety Circular, a staff publication which provides news on safety issues and changes made as a result of incidents and incident analysis. Our Quality Report - which is published on our website - also includes information about incidents, which any member of staff or the public can read. Some of the major changes we have made as a result of learning from incidents and incident analysis include: Development of a sepsis care pathway; Development of new techniques for weighing patients on PICU to allow us to manage their nutritional status more effectively; New guidance documents to allow more effective checking of medication in theatres when it is prepared by anaesthetists; Revised training approach and new training package for cannula care to minimise the risk from extravasation. 42

43 We monitor the numbers of patient safety incidents and the proportion of those which involve harm. The high levels of incidents involving low or no harm and the very low proportion of incidents that involve more than minor harm provide assurance that we have a good safety culture. Figure 25: Patient Safety Incidents by harm 2011/ /13 Year Total Incidents No Harm Patient Safety Incidents by Harm Category 2011/ /13 Minor, Non Permanent Harm Moderate, Semi Permanent Harm Severe, Severe Permanent Harm Catastrophic, Death 2011/ <80% <19% >1% <1% <1% 2012/ % 22.21% 1.0% 0.05% 0.4% The following will help us ensure we sustain and improve this positive position: We carry out an annual safety culture survey of all our clinical staff We carry out regular audits of incident reports to identify any staff groups, wards or departments that may not be reporting all incidents. A lower than expected number of reported incidents is one of the measures we use to identify possible issues on wards or departments through our Safety Dashboard. We have set up a Safety Hotline which trainee doctors can use to report any safety concerns and obtain advice. We have set up an advice service specifically for trainee doctors (Trainee Advice and Liaison Service TALS), which mirrors the processes of our Patient Advice and Liaison Service (PALS). We will introduce a facility which allows staff to report an incident direct into our online incident reporting system via a mobile phone. Implementation of actions arising from reviews of incidents is robustly monitored. Incidents are analysed to identify themes and significant safety issues. Our Safety Strategy is updated annually with new safety goals that address issues highlighted by single incidents and analysis of incidents. 43

44 Progress against the Safety Strategy goals is monitored by a quarterly report. Never Events Never Events are very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place. There are 25 defined Never Events, 4 of which are not relevant to BCH due to the services we provide. We have developed processes to prevent these Never Events happening. In 2012/13 no Never Events were declared at Birmingham Children s Hospital. Mortality Data about mortality can be presented in a number of ways. By monitoring all the data we can obtain an overall picture. At page 94 we report the number of inpatient deaths and the number per 1,000 admissions (a simple calculation to overcome any variations in admission numbers over time). This data helps us compare data over time, but is less helpful in comparing hospitals with each other, as some hospitals treat different types of patients with very different types and complexities of illness. In order to account for this the Standardised Mortality Ratio (SMR) has been developed. This is the ratio of the actual number of deaths in a hospital within a given time period, to the number that might be expected if the hospital had the same death rates as a larger reference population. If we remain in the green section of the graph in figure 26 this indicates that our mortality rates are within acceptable ranges. If we move into the red section this is a warning of possible concerns which must be investigated. The graph for February 2013 in figure 26 shows that we remained in the green section, as we did throughout 2012/13. There was an increase in the number of deaths in March 2013, however, so we have commissioned an independent review to make sure we are not missing anything. We also monitor rates of mortality in the PICU and in cardiac and liver services. All this data is reported in our monthly Quality Report to the Board and is examined closely to see if there are any concerns. The Board also sees the most important information - a summary of the circumstances leading to the death of every patient that dies at BCH. Figure 26: SMR Funnel Plot February

45 Patient Feedback Listening to what our children, young people and their families tell us about their experiences at BCH and their views about our services is vital in making sure we continue good practice, and make changes where improvements are needed. It is really important that we gather this feedback in lots of different ways so we can make sure we are taking account of everyone s views. We call this our Patient Experience Toolbox, and we load all the information we obtain into our Patient Experience Database which helps us identify themes or areas that need closer attention. It also helps us make sure that we can let our staff know when we receive really good feedback. The toolbox includes patient surveys, quality walkabouts, patient stories, mystery shoppers, focus groups, feedback cards and direct feedback like letters and comments. Combining this with information about patient experience from other sources such as PALS contacts and formal complaints - provides an overall picture of individual wards and departments and of the whole Trust. It also helps us see what we do well and identify areas for improvement. As a result of this work we have set new quality objectives and made service improvements in areas like food, play, communication, environment and patient information. As well as looking at what we need to improve, it is also important to look at what patients and their families tell us we do well. This provides vital learning about how we can improve other areas, and it is important to take this into account when we are thinking about changing something. Sharing positive feedback with staff about the work that they do also supports and motivates them to deliver the highest quality of care that they can. What are people talking about? This Word Cloud demonstrates by their size the most frequently used words in all the patient feedback we received in 2012/13. The larger the word, the more frequently it has been used. 45