Clinical Effectiveness Annual Report 1 April June 2018

Transcription

1 Clinical Effectiveness Annual Report 1 April June 2018 Page 1 of 33

2 Contents Page 1. Introduction 3 2. Executive Summary 3 3. Clinical Effectiveness Function 4 4. Clinical Audit Introduction to Clinical Audit 4.2 Level 1 and 2 audits during Future Areas of Work 5. Variance Analysis Tools Introduction to Integrated Care Pathways 5.2 Introduction to Variance Analysis Tools 5.3 Key Pieces of work during Future Areas of Work 6. Standards and Guidelines Introduction to Clinical Guidance 6.2 Process for checking guideline compliance 6.3 Key pieces of work during Future Areas of Work 7. Policies Introduction to Policies 7.2 Key Pieces of work during Future Areas of Work 8. Clinical Effectiveness Additional Project Work Introduction to additional project work 8.2 Key pieces of work during Plan of Work Training Future Plans 11. Comparison with Annual Report 19 Appendices Appendix 1: Process flowchart for reviewing New Guidance Appendix 2: Process flowchart for the review of policies Appendix 3: Plan of Work & Gantt Chart for 2018 Page 2 of 33

3 1. Introduction The purpose of this report is to evidence the assurance processes we have in place across the hospital in relation to patient care. There are 4 main strands to the department; Clinical Audit, Variance Analysis Tools, Standards and Guidelines and Policies. The report covers the period 1 April 2017 to 30 June 2018 to bring it in line with the Clinical Governance schedule. All future reports will cover a 12 month period. 2. Executive Summary Clinical Audit 17 Clinical audits were completed. These aim to give management at The State Hospital assurance that clinical policies are being adhered to within the hospital. All clinical audit reports contain recommendations to ensure continuous quality improvement and action plans are discussed at the commissioning group. Future areas of work include delivering on the current plan of work, providing support across the Forensic Network for all relevant POMH audits and ensuring audit action plans are part of the Clinical Governance agenda. Standards and Guidelines There have been 284 pieces of guidance/reports/standards issued during the reporting year that have undergone relevancy checks by the Standards and Guidelines Co-ordinator. 81 of these had some relevance and a full evaluation matrix was completed for 5 of these. The Continuous Quality Improvement Visit (CQIF) from the Forensic Network in February 2018 was co-ordinated by Clinical Effectiveness with the submission of the self assessment and all relevant evidence. Future areas of work include exploring the feasibility of setting up a Standards and Guidelines Scottish across all the health boards as a support mechanism and leading on the Health and Social Care Standards self assessment when available. Variance Analysis Tools (VAT) All admission, annual and intermediate and discharge case reviews are monitored via a VAT (admission, treatment & rehabilitation and discharge) with reports being supplied monthly to senior management. In addition, detailed reports on individual patients are sent to department heads and senior charge nurses to allow them to have the data to support continuous quality improvement. On a quarterly basis trend data is sent to Hub Leadership Teams with professional attendance at treatment and rehabilitation case reviews being monitored in line with LDP targets. This year annual reports were presented to the Clinical Governance and action plans have been produced for highlighting areas where improvement is required. Going forward the annual reports will be monitored by the Mental Health Practice Steering. The main future area of work will be to look at alternative ways of collecting the VAT data using RiO/Tableau. Policies During 2017 Clinical Effectiveness were approached to oversee policies going forward. It was agreed that we would oversee these with the relevant resources being transferred from the Risk Department to take forward this piece of work. Future areas of work include reviewing the Guidance on the development, implementation, monitoring and review of policies with a view to updating as required and monitoring any delays in the process and feeding this information into SMT. Introduction to Clinical Effectiveness Additional Project Work Last year Clinical Effectiveness supported 26 additional projects, working with approx 36 staff to support them to implement QI approaches and understand more fully the data that they gather. Page 3 of 33

4 This is an important responsive service that is called on frequently to support improvements across the hospital. 3. Clinical Effectiveness Function The Clinical Effectiveness Team consists of four staff members, 3.39 WTE. There is a Team Leader, two Clinical Effectiveness Co-ordinators and a part time Clinical Effectiveness Assistant. The Clinical Effectiveness Department contributes to the achievement of the hospital aims by providing a service which: Develops and manages the implementation of the Clinical Effectiveness Strategy and Programme of Work and monitors progress through the co-ordination of reports to the Clinical Governance and through the production of the Annual Clinical Governance Report Manages a programme of clinical effectiveness and audit activity to evaluate the quality of care against the evidence base to determine whether it meets best practice Works collaboratively to continuously improve the systems, structures and processes of care delivery and improve clinical outcomes Develops performance management systems including clinical key performance indicators to monitor the quality of care delivery Manages a programme of Integrated Care Pathways, based on the key stages of the patient s journey of admission, treatment and transfer, which embed and report on standards of multidisciplinary care delivery Ensures that effective arrangements are in place with national healthcare quality improvement agencies and departments Co-ordinates work coming from NHS Quality Improvement Scotland including self-assessment exercises and submissions, review visits and new evidence base. In addition, the department leads the development of appropriate structures and systems so that the organisation is assured that care is being improved in line with national clinical standards 4. Clinical Audit 4.1 Introduction to Clinical Audit Clinical Audit forms an integral part of the clinical governance framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic measurement against explicit criteria and the implementation of any necessary change(s): Healthcare Quality Improvement Partnership, Best Practice in Clinical Audit, September Re-Audit 1. Select Topic 7. Implement change Making improvements Preparation for audit 2. Agree standards of best practice Measuring level of 6. Make Performance recommendations Selecting criteria 3. Define methodology 5. Analysis and Reporting Page 4 of Pilot and data collection

5 Clinical audit within The State Hospital incorporates both national and local priorities. It is an integral part of the Clinical Effectiveness Department which is accountable to the Medical Director. The Clinical Effectiveness Department provides expertise to clinical specialties to monitor and improve patient care through: Completed audit reports within the hospital are presented at the commissioning group that has approved/requested the audit to enable recommendations and an action plan to be agreed. The department does not currently monitor action plans. This responsibility lies with the commissioning group. As of August 2017 progress reports on clinical audit action plans have been presented to the Clinical Governance within the State Hospital. The Clinical Effectiveness Department maintains a hospital-wide clinical audit database of all clinical audit activity. It also maintains electronic records of completed projects, which include proposal forms, audit tools, data and reports. A member of the Clinical Effectiveness Department is assigned to each project. Clinical audits are prioritised into one of four levels, as per the table below, with Level 1 being given the highest priority. Priority Levels for Clinical Audits Level Level 1 audits external must dos Level 2 audits internal must dos Audit Type NHS QIS Standards (self assessments) Prescribing Observatory for Mental Health (POMH) SIGN NICE Mental Welfare Commission Mental Health Forensic Network Scottish Patient ty Programme Chief Executive Letters (CELs) Clinical Risk Category 1 and Category 2 Reviews Complaints Re-audit 1 2 Level 3 audits hospital priorities Local audits important to the hospital 3 Level 4 audits Clinician personal interest Educational audits 4 Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards of high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes. New Principles of Best Practice in Clinical Audit (HQIP, January 2011) Page 5 of 33

6 4.2 Level 1 and 2 Audits Audit Title Description Priority & Commissioning Prescribing high-dose and combined antipsychotics Prescription Sheet Audit RMO Record Keeping The audit ascertains if The State Hospital and the Forensic Network are compliant with the 3 main standards: 1. The dose of an individual antipsychotic should be within its SPC/BNF limits. 2. Individuals receive only one antipsychotic at a time. 3. Where high-dose antipsychotics are prescribed, there should be a clear plan for regular clinical review including safety monitoring. To audit information recorded on kardexes and assess how compliant it is with guidelines used by the State Hospital, The Use of All, fully detailed on the Intranet. icy%20docs/forms/category%20view.a spx These standards are based on recommendations published in the British National Formulary and are in line with those used in NHS Lothian. To ensure that RMOs see their patients at least once per month and this is documented within RiO. NICE BNF CEL Health Records Findings/Actions include Excellent compliance with the standards within The State Hospital. No requirement for an action plan. Staff to: clearly initial administration sheet (not sign) ensure that each line code is in alphabetical order always enter reason for medication being withheld Patient ty to be asked to look at medication omissions within their workstreams with regular data collection of same Report to be taken to MAC to highlight the results and the current input from Pharmacy to ensure adherence with policy Audit to be repeated in 12 months to ensure all recommendations have been met Data fed into the medical revalidation process for all RMOs Page 6 of 33

7 BBV Audit Audit Title Description Priority & Commissioning PMVA Seclusion Notification audit POMH The use of depot/long-acting injectable (LAI) antipsychotic medication for relapse prevention Recording the use of Controlled Drugs The Infection Control states that when a patient is admitted to The State Hospital a BBV Admission Risk Assessment should be completed on the day of admission. The information can either be obtained directly from the patient or from past notes. Ensure The State Hospital compliance with MWC recommendations that alternatives to seclusion should be considered must be documented on seclusion initiation. Audit that ensures that the practice standards are being adhered to The aim of the audit was to ensure that the process for handling Controlled Drugs within The State Hospital as per The Administration of All is being followed. NHS HIS HAI Standards Infection Control MWC PMVA Review MWC MWC Findings/Actions include Ensure that all patients have an Admission BBV assessment recorded on RiO information on those who do not will be passed to the Senior Charge Nurse for that ward. Ensure that all patients have had an annual BBV assessment carried out in the last year and recorded on the Annual BBV Assessment form on RiO information on those who do not will be passed to the Senior Charge Nurse for that ward. Ensure that all Annual BBV assessments are completed on the BBV Annual Assessment form on RiO. A full review of seclusion notification documentation Side effect recording documentation good compared to other UK sites No depot doses missed Lack of crisis plans but N/A The requirement for 2 members of staff to sign the Administration Sheet after administering a Controlled drug was not adhered to. One ward (16.7%) completed this requirement sometimes where the remaining wards (83.3%) never completed this. The normal response was for one member of staff to sign the Administration Sheet. Within 4 of the 12 Registers the name, form of preparation and strength of the Controlled Drug were only recorded on some pages rather than every page Page 7 of 33

8 Audit Title Description Priority & Commissioning The Healthy Weight Management Plan section of CPA Document The aims were: What is the quality of the documentation of the Healthy Weight Management Plan in CPA reports? Have any ongoing patient specific treatment objectives in relation to the HWMP been documented in the treatment plan? Have discussions and any decisions made been documented under the Weight Management Discussion subtitle? Has the change in weight been documented? How many times are recommendations made in the Junior Doctor s report not documented at all and what are the themes that emerge from these examples? Was the Variance Analysis Tool (VAT) filled out appropriately in relation to the weight management discussion? Physical Health Steering Findings/Actions include Although released via metacompliance in March 2017, staff involved in the Controlled Drugs process should refresh themselves on the content of the r Administration of All and the procedures therein that should be adhered to. Of the 442 clinical staff expected to read the policy via metacompliance, 352 (80%) of clinical staff have been recorded as having done so Correct use of Healthy Weight Management Plan to be included in Junior Doctor induction Ensure that no clinical teams are using old CPA formats Circulate communication about appropriate use of VAT forms re-audit in 6 months time over-all monitoring by Clinical Governance Page 8 of 33

9 Audit Title Description Priority & Commissioning Audit looking at the Guidance on the Use of IM Medication for Acutely Disturbed or Violent Behaviour To ensure the guidance is being adhered to NICE Findings/Actions include Develop an action plan for improvement which will include: Redistribute a staff bulletin to remind staff of the key points in the guidance primarily the recording in the CPA treatment plan objectives on the use of IM PRN. Review and amend the guidance around the local documentation process if necessary T2/T3 audit: Compliance with Consent to Treatment Form Adherence to MWC Guidance Record Keeping Audit Grounds Access This audit aimed to highlight areas of good practice. Moreover the audit aimed to identify areas where practice could be further developed and improved by helping clinicians pin point areas where resources could be focussed. This will be done by measuring compliance in relation to T2/T3. To ensure that staff are complying with their professional standards in relation to record keeping. Monitors the number of patients with grounds access across the hospital to MWC CEL NMC Code of Practice Recommendations included: Process to be improved to ensure all current T2/T3s are beside the patients prescription sheet Reminder given to medical staff of the following points: All patients receiving high dose antipsychotics must have this mentioned on their form Route of administration must be included on the form All regular psychotropic medication must be covered by the form If patient on clozapine, the associated bloods must be included on the form The prescription chart must highlight what form the patient is on As at March % of all nursing shifts had an entry made for each patient on each shift All scanned documents had been scanned onto the correct record Information Governance Re-audit Data produced for Mental Health Practice Steering to allow hubs to have an overall position for Page 9 of 33

10 Audit Title Description Priority & Commissioning Named Advance Statement Medication Trolley Audit Post PMVA Physical Intervention Audit allow clinical teams to have meaningful conversations. Monitors the uptake of named persons for patients within the hospital. Monitors the uptake of advance statements for our patients within the hospital and that advance statements are being complied with by medical, nursing and AHP staff. Ensures that medication is kept in the correct alphabetical and dose order to reduce the number if mistakes made. Audit to check that policy is being adhered to in relation to patients being taken to the floor or secure holds applied Mental Health Practice Steering MWC Mental Health Practice Steering MWC Mental Health Practice Steering Category 2 Review Clinical Risk NICE PMVA Review their hub Findings/Actions include Percentage of patients with named person still falling slightly data handed to Mental Health Practice Steering Staff reminded that the advance statement should be attached in the Mental Health page within RiO A reminder given to Medical Secretaries that the advance statement information on the CPA document must correlate with the information on RiO To prevent any issue with Clozapine medication dispensing a small diagram will be provided with sizing and information for differentiation The Administration of policy should be updated to include the process for laying out the medicine trolley The audit should be included in the weekend check. The wards should be given their progress data over the past 3 years and the opportunity to improve said results. The Clinical Effectiveness Department will conduct this audit in 12 months time Staff to close off all Post Physical Intervention Assessment Forms once completed Information on the Post Physical Intervention Assessment Form and Datix should always correspond The Incident date/time at the top of the Post Physical Intervention Assessment Form should contain the incident date/time and not the Page 10 of 33

11 Audit Title Description Priority & Commissioning PMVA Observation Level Audit Audit to check that Observation is being adhered to within the hospital NICE PMVA Review Findings/Actions include date/time of when the Nurse in Charge commenced the form For all incidents where the patient is taken to the floor, physical observations should be recorded (with a minimum of consciousness level being recorded if the patient is too highly aroused to take BP/pulse/respirations/temperature) Re-train staff to ensure that the sub type Observation Review is used when entering progress notes on RiO regarding patients under observations. There appears to be some confusion between the use of Observation Review and Seclusion Review Reiterate to staff that they should record whether or not the patient s carer is informed of the increase in observation levels within the progress note section of RiO Re-train staff on how to complete the Observation Plan within the PMVA section of RiO with specific emphasis in the decrease in observation level section Reiterate to RMO s that patients on Level 3 observations should be reviewed twice, in person, in the first 7 days of their increase. These should be recorded in the medical section of the progress notes under the Observation Review sub type. Reiterate to staff that for patients on Level 3 observations a daily review should be carried out by SCC each day for the first 7 days of the increase in observation Re-iterate to staff that increases in observation levels must be authorised and the name of the authorising member of staff recorded within the Observation Plan in RiO Page 11 of 33

12 4.3 Future Areas of Work The Clinical Effectiveness Plan of work should be delivered The department will also provide support across the full Forensic Network for the POMH reaudits to allow benchmarking to continue A training plan will be explored that will integrate the clinical audit cycle and quality improvement methodology The Clinical Governance within the hospital will support the delivery of the actions plans as a result of clinical audit 5. Variance Analysis Tools 5.1 Introduction to Integrated Care Pathways An Integrated Care Pathway (ICP) is a pathway out-lining the care that every patient should receive. Within The State Hospital we have Variance Analysis Tools (VATs) that sit alongside the pathway. These record when and if the pathway was followed and if not the reason for this. 5.2 Introduction to Variance Analysis Tools All admission, annual and intermediate and discharge case reviews are monitored via a VAT (admission, treatment & rehabilitation and discharge) with reports being supplied monthly to senior management. In addition, detailed reports on individual patients are sent to department heads and senior charge nurses to allow them to have the data to support continuous quality improvement. On a quarterly basis trend data is sent to Hub Leadership Teams with professional attendance at treatment and rehabilitation case reviews being monitored in line with LDP targets. This year annual reports were presented to the Clinical Governance and action plans have been produced for highlighting areas where improvement is required. Going forward the annual reports will be monitored by the Mental Health Practice Steering. Evidence of Attendance at Case Review - April 2017 March 2018 Hub RMO Nursing KW/AW Arran n=42 Iona n=51 Lewis n=63 Mull n=38 Total n=194 Psych Social Work OT Pharm Diet Skye AC Security Total MDT Attend Patient Carer 90.5% 71.4% 83.3% 83.3% 69.0% 64.3% 0% 0% 50.0% 59.2% 81.0% 16.7% 98.0% 76.5% 52.9% 74.5% 54.9% 47.1% 0% 4.0% 58.8% 51.9% 60.8% 19.6% 98.4% 74.6% 77.8% 87.3% 65.1% 66.7% 6.3% 0% 66.7% 62.8% 76.2% 31.7% 89.5% 78.9% 63.2% 71.1% 76.3% 47.4% 5.0% 0% 60.5% 56.4% 65.8% 23.7% 94.8% 75.3% 69.6% 79.9% 65.5% 57.2% 2.8% 1.0% 59.8% 57.9% 71.1% 23.7% Page 12 of 33

13 Annual MDT Attendance 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% Hospital Wide Arran Iona Lewis Mull 20.0% 10.0% 0.0% April 12 - March 13 April 13 - March 14 April 14 - March 15 April 15 - March 16 April 16 - March 17 April 17 - March 18 The table below compares the percentage of professional reports which were available at the patient s Case Review in 17/18 with the period 16/17 and highlights where there has been an increase/decrease. 2016/ /18 Increase/Decrease Mental State 96.8% 91.2% -5.6% Physical Health 93.1% 89.7% -3.4% Nursing 97.9% 98.5% 0.6% OT 64.8% 76.2% 11.4% Skye Centre 73.6% 74.3% 0.7% Pharmacy 100.0% 95.4% -4.6% Psychology 91.2% 91.1% -0.1% Security 84.6% 96.0% 11.4% Social Work 93.7% 95.9% 2.2% Dietetics 69.2% 16.8% -52.4% 5.3 Key pieces of work The report from the High Secure Mental Health & Learning Disability Forensic Services Review visit stated: The patient Admission Pathway Variance Analysis Tool is considered to be an excellent method of gathering, analysing and acting on the information available to improve service provision across the hospital and highlight areas for attention and improvement. It is recognised that the information gathered informs individual patient care and planning and additionally supports overall provision in informing service level improvements at both committee and governance stages. The reviewers saw the VAT system as excellent information. The Annual Admission VAT Report looked at each individual intervention and on 47 out of 62 occasions (75.8%) there is a decrease in interventions being carried out although VAT form completion remains constant. Page 13 of 33

14 Profession Number of interventions considered in this report Number of interventions where performance improved Performance stayed the same Number of interventions where performance decreased Medical Nursing OT Skye Activity Centre Pharmacy Psychology Security Social Work Dietetics Overall (21.0%) 3 (3.2%) 47 (75.8%) In light of this data the Clinical Governance requested that Hub Leadership s produced detailed action plans on how improvements could be made. In December 2016 the Discharge/Transfer Pathway Variance Analysis Tools (VATs) were introduced across the hospital. There are two Discharge/Transfer VATs in place - one of which should be completed by each member of the Clinical Team at the patient s Discharge/Transfer CPA meeting and the other which is held and completed by the relevant medical secretary on the days leading up to the patient moving on. The Discharge CPA completion data is compared with the completion figures for the Admission CPA and Treatment and Rehabilitation CPA. As can be seen from the table below completion of the Discharge CPA is lower for all professions. As part of the report an action plan was put in place to ensure that Discharge VAT paperwork is completed at all Discharge CPA meetings this will be reviewed on a quarterly basis. Discharge CPA Admission CPA T & R CPA Medical 79.5% 95.8% 95.4% Nursing 81.1% 90.8% 90.7% OT 73.3% 100.0% 95.3% Skye Activity Centre 86.7% 100.0% 100.0% Pharmacy 76.7% 100.0% 98.7% Psychology 76.0% 100.0% 97.9% Security 65.0% 92.9% 92.8% Social Work 82.7% 98.0% 95.8% Dietetics 78.7% 88.1% 99.0% Total 86.7% 94.4% 96.2% 5.4 Future Areas of Work Clinical Effectiveness Department will start to look at alternative methods of collecting and analysing VAT data through RiO and Tableau. Page 14 of 33

15 6. Standards and Guidelines 6.1 Introduction to Clinical Guidance Clinical Guidance reduces variations in practice and provides a focus for discussion among healthcare professionals and patients. Guidance enables professionals from different disciplines to come to an agreement about treatment and devise local policy, against which practice can be measured. Clinical guidelines are systematically developed statements designed to help clinicians and patients decide on appropriate healthcare for specific clinical conditions and/or circumstances. By using clinical guidelines that are developed using the best available research evidence they can improve: Quality of care Clinical outcomes Consistency of care Patient safety 6.2 Process for checking guideline compliance The State Hospital has a robust process in place for ensuring that all relevant guidance published and received by the hospital is checked for relevancy. If the guidance is deemed relevant this is then taken to the appropriate Steering within the hospital (Physical Health, Mental Health and ) for an evaluation matrix to be completed. The evaluation matrix is the tool used within the hospital to measure compliance with the recommendations. A flow chart for this process was approved through Clinical Forum (Appendix 1). There have been 284 pieces of guidance/reports/standards issued during the reporting year that have undergone relevancy checks by the Standards & Guidelines Co-ordinator. From these, 81 were found to be relevant to our patient population, 5 of which required completion of an evaluation matrix. Body Total No of documents reviewed Documents for information Evaluation Matrix required SIGN Mental Welfare Commission Scottish Government HIS Scottish Public Services Ombudsman NICE Association of UK Dietitians British Association of Psychopharmacology Joint British Diabetes Societies & RC Psychiatry Key pieces of work during An evaluation matrix has been completed for each of the following guidance published between 1 April 2017 and 30 June Our compliance is noted in the table below: Page 15 of 33

16 Body Title % Compliance Date Issued SIGN SIGN SIGN Scottish Government The Association of UK Dietitians Risk estimation and the prevention of cardiovascular disease Pharmacological management of glycaemic control in people with type 2 diabetes Pharmacological management of migraine Scotland s National Dementia Strategy The nutritional care of adults with a learning disability in care settings 100% 26/07/ % 29/11/ % 21/02/ % 28/06/2017 Pending completion 16/02/2018 In addition, with the publication of the Mental Health Strategy and the Health and Social Care Standards a significant piece of work was completed to map over the various areas to ensure the hospital is complaint with both these national drivers. The Forensic Network carried out a peer review visit within the hospital in May Clinical Effectiveness led the co-ordination of the self assessment. 6.4 Future Areas of Work Clinical Effectiveness will co-ordinate the self assessment for the Health and Social Care Standards during 2018/19. Two pilot sites are currently testing the proposed assessment tool. Clinical Effectiveness will explore the feasibility of setting up a Standards and Guidelines Scottish across all the health boards as a support mechanism and leading on the Health and Social Care Standards self assessment when available. 7. Policies 7.1 Introduction to Policies During 2017 Clinical Effectiveness were approached to oversee policies going forward. It was agreed that we would oversee these with the relevant resources being transferred from the Risk Department to take forward this piece of work. 7.2 Key Areas of Work A flowchart has been agreed and approved through SMT to ensure the process is consistent and robust. This takes into consideration metacompliance as well as the policy reviews (Appendix 2) Ensure adherence to the corporate document standards A policy front page corporate statement has been agreed for policies that may go out of date Work has commenced on updating the policies spreadsheet with accurate data Timeline points have been added to allow us to monitor how long it takes for all the various stages of the process. This will allow us to highlight where the most frequent delays are in the process Page 16 of 33

17 7.3 Future Areas of Work Review the Guidance on the development, implementation, monitoring and review of policies with a view to updating as required Monitor any delays in the process and feed this into SMT Complete the preparation work that will ensure a more consistent and robust process Ensuring that all clinical policies are included within the clinical audit work programme Formally transfer the resources required from Risk Department 8. Clinical Effectiveness Additional Project Work 8.1 Introduction to Clinical Effectiveness Additional Project Work The Clinical Effectiveness team work across the hospital providing expertise and support to a wider range of projects. Last year Clinical Effectiveness supported 26 additional projects, working with approx 36 staff to support them to implement QI approaches and understand more fully the data that they gather. This is an important responsive service that is called on frequently to support improvements across the hospital. 8.2 Key pieces of work during The table below gives a flavour of the various projects and the support that was given. Project Title Description Lead 24 hour report check This project takes the data from the report for admissions, increased observations levels, readmissions, seclusions, discharges and use of ERBs to allow data analysis into all these elements Nurse Director/PMVA e-control Book Questionnaire Lewis Clinical Team Meetings To evaluate the web based e-control Book that was implemented in Results fed back to Risk Team Leader The project is looking at ways to improve the paperwork that is used for the meetings and automate it where possible from RiO Risk Dept Associate Medical Director Advocacy Survey Analysis of the advocacy survey for the hospital Advocacy/ Centred Improvement Department Patient satisfaction survey Analysis and reports for the patients experience survey Centred Improvement Department Carer Survey Analysis and reports for the carers survey Centred Improvement Department Observations of care Increased observation levels on admission Patients coming back from General Hospitals Analysis and reports for the observations of care (Patients meals) Data analysis for all admissions over a 3 year period to see if more patients were being admitted on level 3 observations and the reasons for this. Rolled out laptop project across all wards. This ensures that shift reports are sent from the general hospital back to 3 times a day PHSG Clinical Forum Director of Nursing and AHPs Record keeping (QI) Analysed and sent reports for all the progress Associate Medical Page 17 of 33

18 Patient Activity Project Carer Involvement DASA Palliative and End of Life Care and Procedure Health Centre Referral Form Pharmacy Health Centre check Physical Activity Forms PRN Reduction Project Shop Project Implementation of Seclusion PMVA Observation Form on RiO Medical Revalidation Quality Strategy Leadership Walkrounds Patient ty Records Management 9. Plan of Work notes on RiO that have not been validated. This is a quality improvement project Supported the group to run reports and feedback to project team requirements for automated reports from RiO Supported a piece of work exploring carer involvement by all disciplines on admission into The State Hospital Supported the implementation phase feeding data back on a daily and then weekly basis to encourage completion of forms on each shift. Also supporting short life working group with data for ongoing discussions that will allow teams to have meaningful conversations about the data Supported the short life working group to agree a new policy for palliative and end of life care Support and analysis for health centre to help improve the referral forms in use Designed a flowchart to be used to ensure the correct process is used when medicines are added to kardex by GP Provided analysis to Skye Centre Administrator during the implementation phase to encourage completion of physical activity form Supported the Iona 2 project with data to show what PRNs were being used on a weekly basis charting same Analysed the use of the nutritional care plan within the shop during the pilot period Provided data during the implementation phase to ensure staff were aware of the new processes, forms etc Supported the implementation phase analysing data until all patients had an observation form completed on RiO Support the process ensuring all relevant VAT and clinical audit data is supplied per RMO Led on the quality strategy for the hospital that was approved through Clinical Governance Supported with the walkround process and admin on the day Led on the workstreams in the absence of Risk Management Facilitator ensuring all local and national data was submitted Ensured systems and processes in place with regards to the records management standards Director PHSG Centred Improvement Department Patient ty Nurse Director Health Centre Physical Health Steering Senior Charge Nurse Supporting Healthy Choices PMVA Review PMVA Review Revalidation Clinical Governance Patient ty Patient ty Record Keeping The plan of work is attached (Appendix 3) and has been approved by the Clinical Governance. This links to the local delivery plan and clinical model as well as national guidance. A Gantt chart is also included in Appendix 3 to show the timeframes for the audits. Page 18 of 33

19 10. Training Clinical Effectiveness Department is included in the hospital s induction programme for variance analysis tools, standards and guidelines and clinical audit. This includes all Junior Doctors and Medical Students. Ad hoc sessions are also held for other professions e.g. Dietitians and Occupational Therapists. Training has also been provided as detailed below: Psychologists Medical Students and Junior Doctors QI Assistant Nursing staff DRAMS database for data collection and analysis Turning evidence base into audit tools for projects and analysis How to use Access database for data input, chart design, report design, SPSP training, how to quality check data How to use excel to make charts 10.1 Future plans Explore ways of training nursing staff with regard to clinical audit/quality improvement methodologies. Promote the support that the Clinical Effectiveness Department can provide to staff. 11. Comparison with Annual Report Audit Future Areas of Work Status Update Achieved A Clinical Effectiveness programme of work will be agreed covering The priority will be clinical audits into all the PMVA policies within the hospital, infection control policies and other clinical policies within the hospital The department will provide support across the full Forensic Network for the POMH re-audits to allow benchmarking to continue. There are 3 audits that will be offered across the Network. These are prescribing high dose and combines antipsychotics, use of depot/la antipsychotic injections for relapse prevention and prescribing valproate for bipolar disorder A training plan will be agreed to train clinical staff on clinical audit using the Healthcare Quality Quest training package The Clinical Governance within the hospital will support the delivery of the actions plans as a result of clinical audit Achieved Achieved On hold Achieved This was approved by the Clinical Governance at their April 2018 meeting All clinical audits completed as per programme of work All 3 audits were supported successfully. POMH audits were also presented at The State Hospital Journal Club. This has been put on hold due to the quality improvement training that is being explored within the hospital The action plans are an integrated part of the CGG agenda at the monthly meetings Page 19 of 33

20 Variance Analysis Tools/Pathways Future Areas of Work Status Update Not Achieved Clinical Effectiveness are currently in discussions with the Senior Team looking at setting targets for each intervention in the Treatment and Rehabilitation VAT with a view to introducing a dashboard monitoring system to allow Senior Charge Nurses and Senior Management Team to see easily when there has been a dip in the intervention being completed Clinical Guidelines No targets were forthcoming from the Senior Management Team to allow us to start exception reporting. The reports that now go to the professional heads should give the detail required for continuous quality improvement Future Areas of Work Status Update Achieved With the publication of the Mental Health Strategy and the Health and Social Care Standards a significant piece of work will have to be completed to map over the various areas to ensure the hospital is complaint with both these national drivers The Forensic Network will be carrying out a peer review visit within the hospital during 2017/18. Clinical Effectiveness will lead the co-ordination of the self assessment Clinical Effectiveness Department will coordinate the self assessment for the Health and Social Care Standards. It is unclear at this time whether this will be in 2017/18 or 2018/19. Two pilot sites are currently testing the proposed assessment tool Achieved Not Achieved The mapping has been completed and both pieces of work were reflected within the Quality Strategy that was approved during 2017 The final report will be produced within the next month. The State Hospital were complimented on their robust evidence collection and self assessment completion This has been held up due to changes following the 2 pilot sites. NHS HIS are still in the pilot phase and no self assessment has been shared as yet Page 20 of 33

21 Appendix 1 List of all guidance and Clinical Effectiveness decisions to Clinical Forum for approval Process flowchart for reviewing New Guidance New Guidance Published SIGN, HIS, MWC and other Guidance assessed for relevancy by Clinical Effectiveness Department and passed to the appropriate hospital group Relevant to TSH Not Relevant to TSH Physical Health Steering Mental Health Practice Steering Other Relevant Is a full Evaluation Required? Yes No Nominate person to complete Evaluation Matrix Matrix returned for group to prioritise actions, where appropriate Minute as not relevant to TSH, already assessed or no evaluation needed. Record on database. Feedback to Clinical Forum Decision Approved by the Clinical Forum Routine monitoring/ Periodic Review CLOSE FILE Page 21 of 33

22 The State Hospital Policies Process Flowchart Appendix 2 1. due for review 6 months prior to review Clinical Effectiveness Department (CED) will the Lead Author and Commissioning group: the current policy for review a blank Equality Impact Assessment (EQIA) a blank Submission form a blank Information Governance form (IG19 Privacy by Design Screening Questions) 2. Reviewing Within 3 months of receipt the Lead Author and Commissioning group must review and refresh the policy. 3. Submission for staff consultation The Lead Author submits the policy for consultation through Clinical Effectiveness Department (CED). 4. Staff consultation process 3 weeks CED will upload the policy along with the consultation feedback form onto the consultation intranet page. CED will contact Head of Communications and E-Health Project Administration & Intranet Officer to promote the consultation via the staff bulletin and intranet home page. 5. Following the 3 week consultation period CED will delete the policy from the consultation page. The Lead Author and Commissioning group will review the feedback and finalise the policy. 6. Submission to SMT The Lead Author sends the finalised policy, Submission form, approved EQIA and Information Governance form to Board Secretary for submitting to SMT. Lead Author copies all documents to CED. 7. Following SMT meeting The Board Secretary will contact the Lead Author with the outcome. If approved the Lead Author will contact CED to confirm policy implementation date. If not approved the policy is sent back to the Lead Author and Commissioning group for further review and depending on SMT feedback the above steps 3 6 may require to be repeated. 8. Following final approval by SMT Staff will be notified of any policy approvals via the SMT bulletin. It will be the Lead Authors responsibility to send the approved policy to CED within 3 days of the SMT meeting for uploading to intranet. CED removes the old version of the policy from the intranet and uploads the new approved policy in PDF format. CED sends all users to staff alerting them the policy is now live and should be adhered to. 9. Metacompliance The approved policy will be considered for meta-compliance timetabling by the Head of Corporate Planning & Business support and the Clinical Effectiveness Team Leader. If approved for meta-compliance CED will the policy in PDF format to the Information Governance & Data Security Officer (IGDSO) IGDSO will upload policy to meta-compliance. Page 22 of 33

23 Clinical Effectiveness Department s Programme of Work - Assurance ( ) and Gantt Chart 2018 Appendix 3 Increase the proportion of care that is evidence based and which is known to be clinically and cost effective (e.g. guidelines, standards, best practice statements) and based on patients needs. Objectives Target/Outcome Source Projected Completion by Identify, appraise and implement new NHS HIS Clinical Guidelines, standards and best practice statements for both mental and physical health problems Assist with all self-assessment and peer review exercises Healthcare Associated Infections (HAI) Continuous Quality Improvement Framework for Medium and High Secure Care Standards Assisting in developing, implementing and evaluating action plans for national guidelines and standards including: PMVA Guidance Infection Control Healthcare Associated Infections (HAI) Medium and High Secure Care Standards NICE and SIGN Guidance The proportion of care that is evidence based is increased. Self assessments accurately reflect the service we deliver. External peer reviews conducted efficiently and effectively. Actions plans are driven forward to ensure continuous improvement Action plans reflect identified weaknesses and are used as vehicles to improving the quality of patient care/services. Progress is monitored and reviewed at regular intervals. Quality Strategy and Clinical Model 3 Main Quality Dimension(s) - Effective Centred NHS HIS - Effective Centred NHS HIS - Effective Organisational Link Risk Register Local Delivery Plan Local Delivery Plan Page 23 of 33

24 Development of electronic integrated documentation Scottish Patient ty Project One integrated electronic document incorporating Treatment Plan, HCR-20 & VAT To ensure that care follows safe evidence base NHS HIS Standards for Mental Health ICPs Local Best Practice Dec 2016 Effective NHS HIS - Effective Local Priority National Priority Page 24 of 33

25 Identify variations in practice (e.g. through clinical effectiveness projects and ICPs) and develop approaches to improve the consistency of care. Objectives Target/Outcome Source Projected Completion by AUDITS/RE-AUDITS Blood Borne Virus Risk Assessment Audit Health Centre Patient Survey Ensure that all patients have the opportunity to have their BBV status checked and also that their risks are assessed at least annually To capture the patients experience of the services delivered by the health centre Patient Partnership & Infection Control PHSG September 2018 and September November 2018 and November Quality Dimensions Related Infection Control Manual n/a Organisational Link NHS QIS HAI Standards and HEI self assessment Local Priority (SLA) Blood Monitoring Audit Hand washing Audit Skye Centre Patient Experience Survey To ensure that patients bloods are used for multiple testing To ensure staff are washing their hands as per policy Patients experience is improved, and services are provided in a fair and equitable fashion PHSG Infection Control PCIT December 2018 Ongoing Infection Control Manual November 2018 and November Centred n/a Local Priority NHS QIS HAI Standards and HEI self assessment Local Priority Clinical Forum Seclusion Audit Management is kept apprised of the number of seclusions and how long these are lasting Clinical Forum July 2018 and July Centred Seclusion Local Priority + SPSP Mental Health Programme Page 25 of 33

26 Named Audit To ensure the correct processes are being followed in respect of changes to the Mental Health Act Social Work December 2018 and December Social Work Audit 2 Tbc Social Work December 2018 Loose Stool To ensure that the Loose Stool Ongoing is being adhered to PMVA Seclusion PMVA Mechanical Restraint Process for Controlled Drugs within TSH audit Audit on the Engaging New Patients Guidance Audit of retention and destruction (clinical aspect) Health Centre Referral Form POMH Use of depot/la antipsychotic injections for relapse prevention Diabetes To ensure that the Seclusion is being adhered to To ensure that the Mechanical Restraint is being adhered to To ensure that the process for storing and administering controlled drugs is being adhered to To ensure that the hospital is meeting the timescales for getting new patients engaged in the hub and Skye Centre To ensure the policy is being adhered to and agreeing action plans where required To ensure that the procedure for referring patients is being adhered to National Benchmarking to ensure best practice is being adhered to To ensure that the hospital is adhering to national guidance Infection Control PMVA Review PMVA Review Mental Health Practice Steering July 2018 Ongoing August 2018 and August October 2018 and October E-Health October 2018 and October Health Centre Carol Ann Topping/ PHSG July October February n/a Local Priority Tbc n/a Local Priority Centred Equitable Infection Control Manual Seclusion SRK Newly Admitted Patients Retention n/a n/a NHS QIS HAI Standards and HEI self assessment Local Priority based on NICE Guidelines Local Priority based on NICE Guidelines NICE (NG46) Guidance Local Priority National Local Priority National Guidelines Page 26 of 33

27 Local PRN Audit Prescription Sheet Audit Key Worker Attendance Audit Child Protection Audit To ensure that patients are not being administered PRN medication unnecessarily To ensure that the Administration of Medication is being adhered to To ensure consistency of systems that capture this information To ensure that procedures are adhered to with regards to child visits within the hospital National Strategy October 2018 and October March 2018 and March Equitable Clinical Forum Ongoing Child & Adult Protection Forum June 2018 and June n/a Keeping Children National Forensic Priority Local Priority Clinical Model Principle 6 + LDP 9.7 Local Delivery Plan 9.4 PMVA Post Physical Intervention PMVA Audit of Observation policy To ensure that the process has been followed in relation to the nursing assessment and related timeframes All patients will be observed as per PMVA Observation policy PMVA Review PMVA Review Ongoing Post Physical Intervention Ongoing Observation Risk Register / Local Delivery Plan 11.3 Risk Register / Local Delivery Plan 11.3 Observation Levels on Admission PMVA Audit of Initial Admission Risk Assessments PMVA Audit of Emergency Prescribing 6 monthly report to Clinical Forum All patents will have an initial admission risk assessment completed on admission Medication in the management of violence policy is adhered to Clinical Forum Ongoing Centred Observation PMVA Review Ongoing New Patient Guidance PMVA/ / NHS QIS Schizophrenia Risk Register / Local Delivery Plan 11.3 January IM Risk Register / Local Delivery Plan 11.3 Page 27 of 33