ORGANISATIONAL AUDIT

[Type text] National Care of the Dying Audit Hospitals (NCDAH) Round 3 This audit is being led by the Marie Curie Palliative Care Institute Liverpool in collaboration with the Royal College of Physicians, and is supported by the Department of Health and Marie Curie Cancer Care ORGANISATIONAL AUDIT Guidance for Completing Your Organisational Audit Proforma April 2011 NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 1 of 13

SHOULD YOU HAVE ANY QUERIES AT ALL ABOUT COMPLETING YOUR PROFORMAS THEN PLEASE DON T HESITATE TO CONTACT OUR EVALUTIONS UNIT ON: 0151 706 2212 or email: evaluations.unit@rlbuht.nhs.uk HOURS: 9.00 5.00PM (Mon Fri) Answering Machine available if the team is unable to take your call and queries will be responded to within 2 working days Organisational audit 1. Auditor This proforma can be completed by any member of staff within your organisation. This person should be in a position senior enough to have access to the required information and would normally be a clinical manager or senior member of the clinical staff. 2. Completion of proforma One organisational audit proforma needs be completed for each Hospital Trust. Please pay attention to the date ranges for each question, as although you will be able to enter some of the Organisational Audit data before the end of the data entry phase, you will not be able to enter all of the required fields. For example, some questions require you to collect information throughout the data collection period (e.g: Number of Deaths in your hospital trust during the data collection period [1 st April 30 th June 2011] ) before you can answer. This means you will not be able to fully submit your data until on or after the 30 th June 2011 (final submission by Friday 8 th July 2011). Data Protection: NCDAH Round 3 Disclaimer All care has been taken to ensure confidentiality within this electronic data submission tool, and therefore Organisations are prohibited to enter any data that may identify an organisation or patient e.g. organisation names, or patient identifiable information. All guidance must be followed for the completion of any electronic proforma. The NCDAH data entry tool has been designed in accordance with the Data Protection Act 1998 and no patient/organisation identifiable information is needed to complete the audit. NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 2 of 13

Section 1: Auditor Details 1.1 (a) Main person responsible for completing the audit form (Organisational Audit Proforma) 1.1 (b) Main person responsible for completing the audit form (Patient Data Audit Proformas) 1.1 (c) Main Second Auditor (Patient Data Audit Proformas) This identifies the professional group of the person who has taken the main responsibility for gathering and coding the data on this proforma. This identifies the professional group of the person who has taken the main responsibility for locating, gathering and coding the data on the Patient Data Audit Proforma. This identifies the professional group of the person who completed the second rating of the first 4 patient data sets for Inter Auditor Reliability. (Patient Data Audit) Section 2: Hospital Trust Demographic Details information. information. information. Please code only one box either : Medical Team; Nursing Team; Audit Team or Other. If you code other please provide the name of the team. Please code only one box either: Medical Team; Nursing Team; Audit Team or Other. If you code other please provide the name of the team. Please code only one box either: Medical Team; Nursing Team; Audit Team or Other. If you code other please provide the name of the team. 2.1 Total number of individual hospital sites under your Hospital Trust as at (1st April 2011) Number of individual hospitals that are under the management of your hospital trust. Accurate information should be available centrally from your hospital information department. 2.2 Total number of beds in your Hospital Trust as at (1st April 2011) The total number of beds in the Hospital Trust as at the 1 st April 2011. For the purposes of this audit this should include all beds in the hospital. Accurate information on total number of beds is generally available centrally from your hospital information department. 2.3 Total number of side rooms in your Hospital Trust as at (1st April 2011) The total number of side rooms in the hospital as at the 1st April 2011. For the purposes of this audit this should include all side rooms in the hospital. Accurate information on total number of side rooms is generally available centrally from your hospital information department. NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 3 of 13

2.3a Total number of wards where at least 1 side room exists as at (1st April 2011) 2.4 Number of Deaths in your Hospital Trust during the financial year (1 st April 2010 31 st March 2011) 2.4a Number of Deaths in your hospital trust during the data collection period (1 st April 30 th June 2011) 2.5 Number of Individual Hospital sites that are currently using generic LCP or in your Hospital Trust as at (1st April 2011) The total number of wards in the hospital that has at least 1 side room within the parameters of the ward. Accurate information on total number of wards is generally available centrally from your hospital information department. The total number of deaths in the hospital in the one year period between 1 st April 2010 and 31 st March 2011. The total number of deaths in the hospital in the one year period between 1 st April 30 th June 2011. Number of individual hospitals that have implemented the LCP into at least 1 hospital that is under the management of the Hospital Trust. Section 3: Spread of LCP or You must provide the total number of deaths, expected and sudden. You must provide the total number of deaths, expected and sudden. 3.1 Length of time (in months) that the generic LCP or has been in use in your Hospital Trust 3.2 Total number of wards in your Hospital Trust, where adult patients may be expected to die, as at (1st April 2011) Time in months that the LCP has been in use in your hospital. This may be the time since you had your pilot data analysed, either by the LCP Central Team, or you may have looked at this data in house. This information will give an indication of how long your hospital has been involved with the LCP. Wards should be included in the count, if they provide inpatient care to patients >18 years. Wards should not be included in the count, if they provide only outpatient services, or only day case admissions. Accurate information should be available centrally from your hospital information department. In order to differentiate those hospital trusts that have only recently implemented the LCP from those that have been using the LCP for a longer time. To provide an estimate of the number of wards where the LCP may be implemented for use within your Hospital Trust. Therefore, you should not include deaths that occur on units such as, maternity, ICU, eye units, paediatrics. For those hospital trusts that have a long association with the LCP it may not now be possible to identify this in months. NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 4 of 13

3.3 Number of The number of wards on which To provide an estimate of wards in your Hospital Trust, where adult patients may be expected to die, currently using LCP generic version 12 or, as at (1st April 2011) the LCP was actually used during the data gathering period for this audit. You can consider a ward as using the LCP if: At least one patient received care at the end of life supported by the LCP on that ward between 1 st April and 30 th June 2011. how widely use of the LCP has spread throughout your Hospital Trust. 3.4 Number of Deaths in your Hospital Trust where care was supported by the LCP generic version 12 or your matched alternative during the data capture period (1 st April 30 th June 2011) The total number of completed LCPs used in your hospital trust during the data gathering period for this audit. Provides information on how often the LCP is being used for patients who die in your Hospital Trust. Section 4: Access to End of Life Care Services to support care in the last hours or days of life This information is unlikely to be collected centrally. However, during the data gathering period you will have set up a system for the retrieval of completed LCPs and made photocopies of them ready for coding. 4.1 Does your Trust have a Hospital Specialist Palliative Care Team (HSPCT)? 4.1a Does your HSPCT include a Consultant in Palliative Medicine? 4.1b Does your HSPCT include Clinical Nurse Specialists as part of the team? 4.1c Does your HSPCT include a Social Worker? The National Council for Palliative Care (MDS Data Manual, 1996) offer the following definition of Hospital Support Teams: Hospital support 'teams' vary in composition from a single specialist nurse to a consultantled multidisciplinary group and go under a variety of titles. The team may be based in the hospital but managed by an independent hospice or other specialist unit; there are many different organisational arrangements. HSPCT includes at least 1 consultant working for at least 1 session per week. HSPCT includes at least 1 CNS in Palliative Care working 1 wte. HSPCT includes at least 1 Social Worker working for at least 1 session per week. The LCP Central Team strongly advise teams implementing the LCP in their Hospital Trust to forge strong links with the Hospital Specialist Palliative Care Team. Such links help to ensure that appropriate ongoing advice and support is available for generalists using the LCP. The answer to this question will enable us to calculate the proportion of participating hospitals that have the opportunity to call upon Specialist Palliative Care expertise from within their own organisation. The European Commission have presented an example of what would constitute an effective Specialist Palliative Care Team A Palliative Care Team should comprise at least three multi professional healthcare professionals (Physician, Nurse, and a Social Worker or NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 5 of 13

4.1d Does your HSPCT includes at least 1 Psychologist) 1 HSPCT include a Psychologist? Psychologist working for at least 1 session per week. 4.1e Does your HSPCT offer a face to face 7 day service (office hours)? 4.1f Does your HSPCT provide telephone support for advice out of hours (for example through the local hospice for support)? 4.2 Does your Hospital Trust have an LCP Facilitator or equivalent? Face to face HSPCT advice and support is available 7 days a week between the hours of 9am & 5pm. The HSPCT provide access to specialist palliative care advice and support via telephone through the night after 5pm. An LCP facilitator is defined, for the purpose of this audit, as any member of staff employed specifically to provide support to implement or sustain the use of the LCP within the hospital. This may be a full time or part time position. To understand what Specialist Palliative Care support is available across Hospital Trusts. The answer to this question will enable us to assess the different levels of direct support for the LCP in each individual participating hospital at a given point in time. If the answer to this question is No, go to Section 5. 4.2 a, b, c If Yes, For each LCP Facilitator (or equivalent) Post as at 1 st April 2011, please provide the following information: i. Whole time equivalent (eg half time = 0.5) ii. Profession of Facilitator (eg Medical, Nursing, AHP) Grade Whole Time Equivalent provides a measure of the level of support. Each half day session worked in this role is equivalent to 0.1. Profession provides information on the type of support available. iii. Permanent or Fixed term contract? Provides a measure of how long such support is likely to continue to be available. iv. Member of Hospital Specialist Palliative Care Team NB: If you have less than 3 posts, leave the remaining fields blank. If you have more than 3 posts, please telephone the Evaluations Unit for extra guidance. Allows us to estimate the amount of LCP facilitators (or equivalent) who are linked directly to the Hospital Specialist Palliative Care Team. NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 6 of 13

Section 5: Your Hospital Trust has a process for making the following leaflets available to families and carers, and healthcare professionals: Are the following leaflets available for use: 5.1 *The LCP Coping with Dying Leaflet or equivalent (for relatives) 5.2 Leaflet explaining the organisation of facilities (for relatives) 5.3 *Bereavement Leaflet ie leaflet explaining the grieving process (for relatives) 5.4 Leaflet explaining local information and help for bereaved relatives on What they need to do next 5.5 Department of Work and Pensions (DWP) leaflet 1027, What to Do After a Death in England and Wales 5.6 *Leaflet explaining the LCP (for relatives) appropriate against each leaflet. Communicating effectively is an important part of end of life care and the LCP requires health professionals to communicate effectively with patients and relatives. The use of supporting literature to reinforce verbal communication is strongly advised. Answers to these questions will establish the level of appropriate supporting documentation that is available to patients, relatives and health professionals alongside the LCP. *= leaflets that can be obtained directly from the LCP Central Team. 5.7 *Leaflet explaining the LCP (health professionals) Section 6: Care of the dying Clinical provision, and protocols promoting patient comfort, dignity and privacy Clinical Protocols/guidelines 6.1 Does your Your Hospital Trust has locally Hospital Trust have guidelines for the prescribing of medications for patients in the last produced medication guidance available, for the prescribing of medications for patients in the last hours or days of life, for the 5 key symptoms. hours or days of life? 6.1a Pain 6.1b Agitation Once the multidisciplinary team have agreed that the patient has entered the last hours and days of life, it is important that medication is written up for these symptoms so that they can be delivered without delay if and when required. NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 7 of 13

6.1c RTS For example, LCP generic 6.1d Nausea & Vomiting version 12 documentation is designed to have locally 6.1e Dyspnoea produced guidance attached to guide health care professionals in prescribing for these symptoms in the last hours or days of life. 6.2 Does your Hospital Trust have guidelines for the assessment and delivery of Mouth Care for patients in the last hours or days of life? Your Hospital Trust has locally produced guidance available, for the delivery of mouth care for patients in the last hours or days of life. Patients in the last hours or days of life may be unable to swallow, or may be mouth breathing, and therefore it is essential that good oral hygiene is maintained. For example, LCP generic version 12 includes a goal and prompts, for the assessment and delivery of good mouth care in the last hours or days of life. 6.3 Does your Hospital Trust have a policy for the decision and documentation of a Do Not Attempt Resuscitation (DNAR) order for patients in the last hours or days of life? Your hospital trust has a policy to aid discussion, decision and documentation of a Do Not Attempt Resuscitation (DNAR) order for patients in the last hours or days of life. To avoid invasive, futile, potentially painful and unnecessary cardio pulmonary resuscitations procedures / interventions being carried out when no clear benefit can be gained. All interventions must be considered to be in the patient s best interest. 6.4 Does your Hospital Trust have a policy to enable the deactivation of Implantable Cardioverter Defibrillators (ICD s) for patients in the last hours or days of life? Your hospital trust has a policy for the deactivation of Implantable Cardioverter Defibrillators (ICD s) for patients in the last hours or days of life. An ICD can alter unstable cardiac rhythms, and the resulting shocks can be physically and emotionally distressing to patients in the last hours or days of life, and their relatives/carers. The need for a policy was highlighted through work conducted by the MCPCIL in collaboration with cardiac colleagues, which resulted in the addition of ICD deactivation as a goal with prompts, to the LCP generic document. NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 8 of 13

Organisational Protocols/Guidelines 6.5 Does your Multi disciplinary/multi Hospital Trust have a formal multi disciplinary/multi professional should include as a minimum 1 senior doctor, and 1 nurse. professional decision making process for diagnosing dying? The decision that a patient is dying, and is now in the last hours or days of life should not be undertaken by 1 single health care professional. The diagnosis and recognition of dying is always a complex process; irrespective of previous diagnosis or history. 6.6 Does your Hospital Trust have a designated mortality meeting to review recent deaths within the Trust? LCP generic version 12 includes a helpful algorithm to support the clinical decision making process regarding the recognition and diagnosis of dying and the use of the LCP to support care in the last hours or days of life. To open up the opportunity to review recent deaths through reflection, and learn from the process. 6.7 Does your Hospital Trust have guidelines for referral to Pastoral care/ Chaplaincy Team for patients in the last hours or days of life? 6.8 Does your Hospital Trust have a policy for carrying out Last Offices/Care of the deceased body in the immediate time after the death of a patient? To ensure that any spiritual need is highlighted and addresses if required. For example LCP generic version 12 includes a goal with prompts, to support the referral/contact with pastoral/chaplaincy personnel if this is required in the last hours or days of life. After the death of a patient, it is important that the patients body is treated with respect and dignity, and that any wishes expressed by the patient or the relatives/carers before death, are listened to and appropriately dealt with. For example LCP generic version 12 includes a goal with prompts to support healthcare professionals at this time. NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 9 of 13

6.9 Does your LCP generic version 12 Hospital Trust have a policy for viewing the body in the immediate time after the death of a patient? includes a goal with prompts to support healthcare professionals at this time. 6.10 Does your Hospital Trust have designated quiet spaces available for relatives or carers, for example: designated prayer room, chapel? LCP generic version 12 includes a goal with prompts to support healthcare professionals at this time. Section 7: Education and Training in Care of the Dying 7.1 Does your programme for care of the dying for Qualified Nursing staff? 7.2 Does your programme for care of the dying for Medical staff? 7.3 Does your programme for care of the dying for Allied Health professional staff (OT, Physiotherapists, Dieticians, Chaplaincy team)? There should be opportunity for regular educational updates. There should be opportunity for regular educational updates. There should be opportunity for regular educational updates. The importance of education and training for all healthcare professionals in care of the dying has been promoted by the Government (DH 2009, End of Life Care Strategy: Quality Markers and Measures for End of Life Care) NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 10 of 13

7.4 Does your There should be opportunity for Often, health care assistants programme for care of regular educational updates. provide a significant amount of the day to day care in the ward environment and are the dying for non qualified clinical staff (e.g. health care assistants)? involved in communication with patients and relatives. Up to date education and training is thus of paramount importance. Section 8. Education and Training for the ongoing use of the Liverpool Care Pathway for the Dying Patient (LCP) or 8.1 Does your There should be opportunity for programme for the generic LCP or for Qualified Nursing staff? regular educational updates. 8.2 Does your programme for the generic LCP or for Medical staff? 8.3 Does your programme for the generic LCP or for Allied Health professional staff (OT, Physiotherapists, Dieticians, Chaplaincy team)? There should be opportunity for regular educational updates. There should be opportunity for regular educational updates. The LCP generic document is only as good as the teams using it. Using the LCP generic document in any environment therefore requires regular assessment and involves regular reflection, challenge, critical senior decision making and clinical skill, in the best interest of the patient. A robust continuous learning and teaching programme must underpin the implementation and dissemination of the LCP generic document. NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 11 of 13

8.4 Does your There should be opportunity for regular educational updates. programme the generic LCP or for non qualified clinical staff? Section 9: Care of the Dying Continuous Quality Improvement 9.1 Has a formal audit of care delivery for patients in the last hours or days of life (for example, an audit of LCP or matched alternative) been undertaken in the last 12 months? 9.1a If yes, is it intended that it will be repeated in the next 12 months or 2 years? 9.1b If yes, were the results fed back to the Trust Board? 9.1c If yes, were the results fed back to the clinical teams? Has data from all or a sample of completed LCPs been brought together to provide a picture of end of life care in your hospital at any time during the last Regular auditing of the data on the LCP is an important element in promoting Continuous Quality Improvement and sustainability. It is important, therefore, to establish the proportion of hospitals in which a system of LCP audit is established. Regular audit is an important element in promoting Continuous Quality Improvement and sustainability. It is important, therefore, to establish the proportion of hospitals in which a robust and ongoing system of audit has been established. The timely feedback of data to members of the management team is an important element in promoting Continuous Quality Improvement and sustainability. It is important to establish the proportion of hospitals in which a robust system of feedback to organisational managers is in place. The timely feedback of data to clinical teams is an important element in promoting Continuous Quality Improvement and If the answer to this question is No, please go to question 9.2 NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 12 of 13

sustainability. It is important to establish the proportion of hospitals in which a robust system of feedback to people working in the clinical environment is in place. 9.2 Are all completed LCPs (or matched alternative ) routinely reviewed? 9.2a If yes, who is responsible for review of the data? 9.3 Are routine action plans produced, to promote improvement in care of the dying in your hospital trust? 9.3a If yes, please indicate how regularly this occurs? 9.4 Has a report been produced for your hospital trust (ie reported in the last 12 months) which assessed the views of carers regarding care of the dying? Is there a system in place for the review of all LCPs used in your hospital? appropriate appropriate: a) 6 monthly b) 12 monthly c) 18 months 2 yearly To establish the proportion of hospitals in which a robust LCP data review process is in place. To establish who is responsible for the ongoing data management of LCP data in your hospital Action plans to facilitate the continuous quality improvement of care of the dying is important, and is an integral part of the NCDAH process. To ensure there is a plan for change is paramount. It is important that this action plan is not just local to the clinical environment, but that managerial buy in has been obtained. User involvement in the delivery of services should be encouraged to ensure that the care delivered is appropriate and responsive to need. Gaining feedback from bereaved carers in a systematic way is therefore vital to maintaining a relevant and appropriate service. If the answer to this question is No, go to question 9.3. If the answer to this question is No, go to question 9.4. Reference 1. The Fifth Framework Programme (2004) Promoting the Development and Integration of Palliative Care Mobile Support Teams in the Hospital. European Commission, Luxembourg NCDAH Round 3 Organisational Audit Coding Guidelines April 2011 Page 13 of 13