Meeting of Lanarkshire NHS Board: 31. 05. 2017 Lanarkshire NHS Board Kirklands Fallside Road Bothwell G71 8BB Telephone: 01698 855500 www.nhslanarkshire.org.uk 1. PURPOSE SUBJECT: QUALITY ASSURANCE AND IMPROVEMENT This paper is coming to the Board: For approval For endorsement To note The purpose of this paper is to provide NHS Lanarkshire Board with an update on development of the Lanarkshire Quality Approach and on progress with quality initiatives across NHS Lanarkshire. 2. ROUTE TO THE BOARD This paper has been: Prepared Reviewed Endorsed By the following Committee: Healthcare Quality Assurance & Improvement Committee 3. SUMMARY OF KEY ISSUES The paper provides an update on the following areas: An update on our work on delivering person-centred, safe, effective and sustainable services in line with the NHS Scotland Quality Strategy. Specifically the paper provides update on: o Achievements in relation to the Person-Centred Health & Care (PCHC) Strategic Prioritised Plan during 2016/17 o Achievements in relation to the Patient Safety Prioritised Plan in 2016/17 and an outline of the priorities that have been identified for 2017/18 o Achievements in relation to the Prescribing Quality & Efficiency Programme in 2016/17 and a description of the work plan for 2017/18 A summary of recent local and national quality events involving NHS Lanarkshire staff 4. STRATEGIC CONTEXT This paper links to the following: Corporate Objectives LDP Government Policy Government Directive Statutory Requirement AHF/Local Policy Urgent Operational Issue Other 5. CONTRIBUTION TO QUALITY
This paper aligns to the following elements of safety and quality improvement: Three Quality Ambitions: Safe Effective Person Centred Six Quality Outcomes: Everyone has the best start in life and is able to live longer healthier lives; (Effective) People are able to live well at home or in the community; (Person Centred) Everyone has a positive experience of healthcare; (Person Centred) Staff feel supported and engaged; (Effective) Healthcare is safe for every person, every time; (Safe) Best use is made of available resources. (Effective) 6. MEASURES FOR IMPROVEMENT The Transforming Patient Safety and Quality of Care Strategy and Work Programme provide measures for improvement. 7. FINANCIAL IMPLICATIONS No financial implications are identified in this paper. 8. RISK ASSESSMENT/MANAGEMENT IMPLICATIONS The Healthcare Quality Assurance and Improvement Committee and Steering Group oversee a corporate risk with controls in relation to achieving the quality and safety vision for NHS Lanarkshire. Corporate Risk 1280 (Maintaining quality of care and prevention of harm and injury to patients) is rated as medium. 9. FIT WITH BEST VALUE CRITERIA This paper aligns to the following best value criteria: Vision and leadership Effective partnerships Governance and accountability Use of resources Performance management Equality Sustainability 10. EQUALITY AND DIVERSITY IMPACT ASSESSMENT An E&D Impact Assessment has been completed Yes An assessment has been completed for the Transforming Patient Safety & Quality of Care Strategy. No 11. CONSULTATION AND ENGAGEMENT 2
The Transforming Patient Safety and Quality of Care Work Programme for 2016/17 was considered at the Healthcare Quality Assurance and Improvement Steering Group on 9 th May 2016 and approved at the Healthcare Quality Assurance and Improvement Committee on 9 th June 2016. 12. ACTIONS FOR THE BOARD The Board is asked to: Note the range of work throughout NHS Lanarkshire to improve the quality and safety of care and services Endorse the governance approach to this work and in particular the assurance being provided by the Healthcare Quality Assurance and Improvement Committee Support the ongoing development of the Lanarkshire Quality Approach Approval Endorsement Identify further actions Note Accept the risk identified Ask for a further report 13. FURTHER INFORMATION For further information about any aspect of this paper, please contact Lesley Anne Smith, Director of Quality. Telephone: 01698 858100. Iain Wallace Medical Director QUALITY ASSURANCE AND IMPROVEMENT 3
1. LANARKSHIRE QUALITY APPROACH PROGRESS REPORT AS AT MAY 2017 1.1 NHS Lanarkshire is committed to delivering world leading, high quality, innovative health and social care that is person-centred. Our ambition is to be a quality-driven organisation that cares about people (patients, their relatives and carers, and our staff) and is focused on achieving a healthier life for all. Through our commitment to a culture of quality we aim to deliver the highest quality health and care services for the people of Lanarkshire. 1.2 We are committed to delivering person-centred, safe, effective and sustainable services in line with the NHS Scotland Quality Strategy. 1.3 Progress on this work is being monitored by the Healthcare Quality Assurance and Improvement Committee. 2. PERSON CENTRED CARE 4.1 We are fully committed to the national Person-Centred Quality Ambition of developing care partnerships between patients, their families and our staff and we continued this work during 2016-2017. 4.2 The overall aim of our Person-Centred Health & Care (PCHC) Strategic Prioritised Plan is that person-centred care is a central component in improving health and care services. Our plan sets out the approach that will enable us to hear the voices of patient and carers to evaluate whether we are delivering safe, effective, person-centred care. This is demonstrated in the way that services are designed and delivered so that: People have a positive experience of care and get the outcomes they expect Staff are valued and supported to work collaboratively People are empowered to be active partners in their care. Gathering and acting on feedback 2.3 We have continued to review and update the ways in which we gather people s feedback. A short-life working group which included public partners from the NHS Lanarkshire Public Reference Forum, our Equalities and Diversity Manager, staff from clinical quality, communications, practice development and the patient affairs department reviewed NHS Lanarkshire s approach to inviting unsolicited feedback, how we collect solicited feedback; and how we use and report on all the feedback we received. 2.4 Following this review we have continued to promote our We are listening brand with both staff and the public to highlight the different ways that unsolicited feedback can be provided. Continual awareness raising amongst different staff groups at meetings and 4
training has engaged staff on the importance of ensuring feedback is received regularly via all the mechanisms available. We have recently included our feedback cards in mental health discharge packs and are also considering their inclusion in Carer packs during 2017. 2.5 In order to increase of how to provide feedback, we have welcome and departure boards displayed throughout NHS Lanarkshire premises outlining the different ways that the public can provide feedback or get in touch. Staff encourage patients and carers to provide unsolicited feedback; if not at point of care then at a later date when they have been able to reflect on their experience. This has resulted in an increase in the amount of unsolicited feedback received. 2.6 Our public partners have continued to work with us to develop and review our feedback mechanisms through the Public Reference Forum (PRF) and the Public Partnership Forums (PPFs). The Public Reference Forum is compromised of people with lived experience, with representatives from Deaf Services Lanarkshire, Deafblind Scotland, Scottish Health Council, People First (advocacy group for people with learning disabilities), Mental Health and Carer organisations. 2.7 Standard 9 of our Care Accreditation Standards System details the requirements for each ward to enable and empower the public to provide feedback and that updates on improvement actions or activities are also displayed: 9.4 Element: Contributing to the organisations objectives 9.4.1 There is a patient feedback board visible for staff and relatives within the area that is clearly being used 9.4.2 Regular updates are displayed on a board visible for staff and relatives, detailing feedback received and actions taken where appropriate 9.4.3 All staff are aware of, and have access to local and national standards 9.4.4 Staff are aware of the mechanisms available for patients and carers to provide feedback and actively encourage it 9.4.5 Corporate feedback tools are clearly visible and accessible for patients and visitors (Care to Comment Card, our customer service) 9.4.6 Information on Patient s Rights and how to provide feedback - comment, compliment, suggestion or complaint-are available 2.8 We have increased the number of staff responding to public feedback on Patient Opinion. Between April 2015 and March 2016, 487 stories were told by patients, relatives and carers and we had approximately 90 staff registered to respond. This increased to 658 stories told and over 120 staff responding during 2016 / 2017. The graph below shows the split between positive and negative stories: 5
2.9. We have continued to publish regular blogs via Patient Opinion detailing service improvements or changes as a result of feedback received through other mechanisms. 2.10 We have agreed to be one of the test Boards in Scotland to trial Talking Mats with Patient Opinion. This is a picture and symbol communication system that can be used by people with communication difficulties. We have identified three areas to try this; learning disabilities, care of the elderly ward in acute hospital and care of the elderly mental health ward. 2.11 Our activities using the Patient Opinion platform continue to be well received by our public partners, Patient Opinion and the Scottish Government. We have continued to present at various events at the request of Patient Opinion and will continue to do so during 2017/18. 2.12 NHS Lanarkshire is currently working on a two-year project with Healthcare Improvement Scotland to improve person-centred care using patient experience feedback. Two models of feedback are being tested: Real-time model feedback gathered during an episode of care Right-time model feedback gathered after episode of care is complete Whilst this work affords us the opportunity to identify good practice and areas for improvement, the learning and outcomes will be shared nationally to inform practice. 2.13 Our Your voice, valuing feedback programme has continued to support staff to enhance their skills in responding to feedback. During the year 708 members of staff either completed an e-learning programme; or attended either a half-day classroom-based session or one or two shorter department- based sessions delivered by our Organisational Development department. We have also continued to deliver awareness training on how to respond to feedback and complaints at medical and nursing staff induction programmes. The training is adjusted to suit each staff group and takes account of their feedback. 4.14 The following is a selection of the actions we took in response to feedback: Patients and the public said. Visiting isn t flexible Conflicting / confusing information for procedure preparation (Colonoscopy) Waiting Room configuration not helpful for communication with staff Unclear on next steps when self referring to maternity physiotherapy Privacy concern when moving between cubicle and consulting room Didn t like the language and terminology used in appointment letter Lack of hospital directional signs Lack of information and communication whilst waiting in Emergency Departments What we have done Testing open visiting in the three acute hospitals and one community hospital Reviewed and updated documentation Seating area reviewed and changed Updated text response with additional information Privacy curtains installed Reviewed and some changes made New signs installed Short Life Working Group with public to develop information. Electronic Display Boards being installed in waiting areas 3. SAFE CARE 6
Prioritised Patient Safety Plan 2016/17 3.1 The Hospital Standardised Mortality Ratio (HSMR) remains the Board s high level indicator of the quality and safety of care provided on our acute hospital sites. It is monitored on a monthly basis and reported regularly via the Integrated Corporate Performance Dashboard to the Planning, Performance & Resources Committee, and in the Quality Report to the Healthcare Quality Assurance & Improvement Committee. Detail of the current position in relation to HSMR was provided in the March 2017 report to the Board. 2.2 2016/17 saw the conclusion of the Patient Safety Reducing Harm Collaborative. The Collaborative that began in June 2014 reached its final milestone with Learning Session 6 on June 6th, 2016. The event was a celebration of what the organisation had achieved to date and also a celebration of the 250 plus staff that have begun a journey to reduce harm in our system. 2.3 During the Collaborative the patient safety team supported front line staff to test changes to improve processes and outcomes for patients. The collaborative focussed on a number of key areas including Falls, Cardiac Arrests, Sepsis, Pressure Ulcers and Catheter Associated Urinary Tract Infection (CAUTI). In our efforts to reduce Falls the pilot teams at Wishaw General Hospital collectively achieved a 34% reduction in all Falls and a 58% reduction in Falls with Harm. Overall, NHS Lanarkshire has achieved a 12% reduction in all Falls on all acute sites and sustained this reduction since January 2015. Reducing deterioration from Sepsis and cardiac arrests has been a safety priority in the organisation since 2013. The work to improve reliability of the SEPSIS 6 process in our Emergency Departments has contributed to a 33% reduction in Sepsis related mortality. NHS Lanarkshire has achieved a 12% reduction in the cardiac arrest rate, sustained from April 2016. An improvement in reducing Pressure Ulcers has remained a challenge for us during 2016. A number of our pilot teams have achieved reliability in process and over 300 days between acquired pressure ulcers however, we have not yet achieved sustained system wide improvement in this area. Our CAUTI pilot teams relentless focus on appropriate catheterisation allowed the pilot teams collectively achieved a 54% reduction in catheter use. This was driven by reliable implementation of the care bundles. Charts demonstrating these improvements are shown in Appendix 1. 2.4 The University of the West of Scotland (UWS) carried out an evaluation of the Patient Safety Reducing Harm Collaborative and produced a report on its findings in January 2017. The evaluation highlighted improved staff ownership, the benefits of clarifying our purpose and the infrastructure put in place to support teams. 2.5 The Patient Safety Strategic Steering Group (PSSSG) commissioned a number of activities during the year including patient safety week, patient climate survey and the development of the patient safety measures report. 2.6 Patient Safety Week took place on 24th 28th October 2016. The aims of Patient Safety Week were to raise awareness of patient safety; share successes to date; encourage staff to identify their patient safety issues and discuss priorities for safety improvement work. Throughout the week the following activities took place across both health and social care partnerships and the three acute hospitals: A local patient safety stand and drop-in area for staff Visits to wards and departments to speak to staff about what matters to you in relation to patient safety 7
Lunchtime sessions hosted by the Patient Safety Team, site chiefs and staff to share successes to date Quality improvement labs with a focus on patient safety hosted by the safety team and safety and quality fellows Asking patients/visitors to share how safe their stay or visit was and what matters to you in relation to patient safety 2.7 A Patient Safety Climate Survey was conducted throughout the month of October as part of patient safety week to allow all members of staff to give their views on patient safety in the organisation. Results of the survey show positive progress in 45% of the responses, no change in 40% and deterioration in the remaining 15%. This was reported to PSSSG in January 2017 and actions to improve on these findings will continue during 2017/18. 2.8 PSSSG requested the development of a single report on patient safety data aligned to the patient safety measurement framework. The report pulls together system wide outcome data and pilot team outcome and process data. The Patient Safety Measures Report is now a standing agenda item at this group and is shared with operational leads via the Acute Clinical Governance and Risk Management Group. 2.9 Patient Safety Leadership Walkrounds continued to be a successful part of our plan to engage with front line staff and have meaningful discussions about patient safety that result in action, if appropriate. A total of 50 walkrounds were carried out in 2016/17. March 2017 saw the first out-of-hours walk round took place in Ward 1 Hairmyres Hospital. Out-of-hours walkrounds will be a feature of the 2017/18 weekly programme. Safety Priorities 2017/2018 2.10 The balance of our efforts in safety in Acute Care and Health & Social Care Partnerships (HSCPs) in 2017/18 will be different to recognise the maturity of the agenda in different parts of the organisation. Acute care has focused on patient safety since 2007 as part of the Scottish Patient Safety Programme and we will continue to ensure the spread and sustainability of these initiatives across all three acute sites. Previous safety programmes in HSCPs have been narrower in approach and limited to General Practice. Accordingly our focus in HSCPs will be on system enablers in the first instance. 2.11 The following priorities have been identified by the Healthcare Quality Assurance and Improvement Committee (HQAIC) for 2017/18. Hospital Standardised Mortality Ratio (HSMR) A new aim has been agreed by the Scottish Government and was announced in June 2016 and has been set as a 10 % Reduction in HSMR by December 2018. A number of work programmes will drive the organisation towards this goal. HQAIC has identified a number of reducing harm aims that will contribute. Reduction in Harm Further reductions in harm from falls, deterioration and medicines have been identified as priorities by HQAIC. The harm reduction work will extend across the care continuum, therefore including both acute care and HSCPs. The aims are: o 50% reduction in falls with serious harm & 30% reduction in falls with harm by March 2018 o 50% reduction in deterioration by March 2018 o 25% reduction in adverse drug reactions by implementing reliable medicine reconciliation at all transitions of care by March 2018 Build on the Reducing Harm Collaborative 8
Spreading the learning from the Patient Safety Reducing Harm Collaborative across the organisation is paramount to ensuring continued reductions in harm. A safety toolkit containing revised change packages including HSCP relevant updates, measurement plans and tools will be made available. Safety Essentials There will be a refreshed approach to the reliable implementation of the Safety Essentials (CEL19 2013) across all inpatient care settings and the provision of assurance at various levels throughout the organisation. We work towards achieving implementation in 95% of all eligible wards and departments by March 2018. System Enablers The work programme includes system enablers which are activities designed to address culture, communication, team working and assist the people carrying out the work. Key systems enablers for 2017/2018 include; building capacity and capability in Quality Improvement methods and Human Factors and Ergonomics, data and measurement infrastructure, improving safety culture and learning from the care we provide. 4. EFFECTIVE AND EFFICIENT CARE Prescribing Quality & Efficiency Programme 4.1 According to ISD figures, NHS Lanarkshire had the highest gross and net ingredient prescribing costs in Scotland for primary care in 2015/16. This situation has persisted for the last four years and prescribing costs have been consistently above the Scottish average even when deprivation is taken into account. A Prescribing Quality & Efficiency (PQE) Programme was therefore established in 2016. 4.2 The PQE Programme aim is to: Continue to focus on improving quality and efficiency across the themes of waste, variation and harm. Seek to contain the costs of prescribing in Primary Care aligned to the targeted incentive scheme and within budget allocation in Secondary Care Continue to develop sustainable governance and improvement infrastructures across the system wide programme to deliver safe, cost effective and person centred prescribing across NHS Lanarkshire. 3.3 Pre work carried out in February 2016 and concluded in early April 2016 was undertaken to understand the then current position of prescribing quality in Lanarkshire and to develop a case for change. This work was based on benchmarking with other health boards, review of the national and local literature/reports and available data; a review of current prescribing systems and process resulted in the identification of a number of areas of work as part of a system wide Prescribing QE programme. The actions taken forward in 2016/17 include: Applying Realistic Medicine approach to Improving the Quality of Prescribing The Chief Medical Officer s report has been used as a catalyst in considering the current prescribing patterns and trends in Lanarkshire. The focus of the programme is to identify medicines which are effective, safe and cost-efficient considering individual patient s factors and as part of the decision making process to consider whether the benefits of treatment outweigh the risks. Optimise the use of medicines o Implement Scriptswitch in primary care to aid cost effective choice of medicines with GP. o Demonstrate that patients views about medicine-taking are explored and their choice considered at the point of prescribing (GP, practice) 9
o Demonstrate adherence to the preferential drugs that all stakeholders should be familiar with through the NHS Lanarkshire Formulary. o Focus on areas where the national therapeutic indicators work or the effective prescribing work highlights variations in practice and performance. o Support the introduction and uptake of biosimilar medicines in gastroenterology and rheumatology. Managing Prescribing Interfaces - Single system prescribing Establish principles and support more effective prescribing across the interface between primary and secondary care. o Establish demonstrable co-ordination of prescribing (medicines reconciliation on admission and discharge) between hospitals and general practice o Establish robust medicines review processes and ensure they are carried out regularly Improving Compliance and Adherence to Medicines Reducing the volume and cost of avoidable waste requires multiple complementary measures aimed at enhancing health and pharmaceutical care quality. Three areas have been taken forward: o Improving medicines waste in our hospital wards through better use of patients own medicines, drugs to follow the patients (reduce missed doses and repeat ordering from hospital pharmacy), better communication with patients and families about pain relief medication following discharge) o Reducing stockpiling of medications at home. o Community Pharmacies working closer with GP practices to reduce waste through a review of managed repeat service. o Establish and demonstrate closer co-operation between the practices and community pharmacy Improving Structures and Process to deliver good governance The PQE Programme has established new or refreshed existing systems and structures to improve governance and prescribing including a reduction in the prescribing of medicines with poor evidence base and/or limited clinical effectiveness and dashboards that display progress against targets for interventions. 4.4 The PQE programme is on track to meet and possibly exceed targets set at the start of 2016/17. The programme has been successful in raising the importance of achieving improvements in Prescribing Quality & Efficiency with clinical staff and ensuring that quality of prescribing is recognised as everyone s concern. Figure 1 Gross Ingredient Cost per 1000 patients compared with all other Health Boards in Scotland and the Scottish average. 10
Figure 2 Savings plan for acute services. Note: The sharp incline in October 2016 is in response to an increase in the acute target. 3.5 The change delivered across the programme has a number of drivers including raising organisational priority of prescribing quality for all prescribers, an ongoing focus by the prescribing management team at hospital and locality level on quality interventions and the enhancement of whole system working, all supported by a resourced programme management approach and structure provided by the Prescribing Quality & Efficiency Programme. 3.6 In 2017/18 the work plan includes: Continuing the focus on improving the quality of Prescribing in Lanarkshire through primary care and hospital sites. The plans will be directed by prescribing data where greatest quality gains can be made. Applying a range of quality improvement methodologies and tools/techniques to identify and tackle waste, variation and harm where this exists. Applying the principles of Health Economics to identify the most appropriate form of economic analysis that will increase our understanding of the possible cost drivers in relation to prescribing and identify appropriate actions to manage these. This work will take an action learning research approach to support a spread of robust, evidenced based planning. 3.7 The PQEP s Strategic Plan for 2017-2020 includes the following areas. Further refine the governance arrangements and supports to deliver the PQE Programme thus putting in place infrastructure fully fit for purpose to sustain the Boards approach to prescribing quality beyond the period of the improvement programme. Ensure that the principles and objectives of the PQE Programme are recognised and embedded within new pathways of care which maximise the contribution of all professions including for, non-medical prescribers, clinical pharmacists in general practice and community pharmacists Implement a communication campaign to continue to raise awareness, educate and encourage the public to value medicines and seek to promote behaviour changes resulting in reduced waste. Continue with our clinical engagement programme through the PQE Programme Clinical Reference Group aiming to identify clinically sounds initiatives, schemes and areas for improvement that lead to the removal of waste, harm and unwarranted variation in prescribing practice. Further develop the Primary Care Incentive Scheme based on the areas where improvement is most required. 11
Further develop the Primary Care PQE Plan which will include a list of cost mitigation schemes to be carried out by the Prescribing Management Team (Pharmacists/pharmacy technicians). Further develop the Acute Division PQE Plan incorporating hospital site based PQE Plans that have been developed utilising each hospital s data and reporting into site based Medicines Quality & Safety Groups Align guidance from national approaches to improve the effectiveness of prescribing alongside cross boundary working, collaboration on standardisation of prescribing. Optimise the supply route for specialist medicines. Options being considered include hospital prescribing and supply, supply via a medicines homecare service, hospital prescribing with community pharmacy supply or GP prescribing with community pharmacy supply. 5. NATIONAL AND LOCAL QUALITY EVENTS 5.1 NHS Lanarkshire was a key contributor at the West of Scotland Person-Centred Health and Care Event held in March 2017. Staff presented and provided posters to share good practice on the following areas of work John s Campaign - Wishaw General Hospital Using right-time feedback to improve person-centred care (discharge process) - Monklands Hospital Improving information & communication - Hairmyres Hospital Person-centred care improvement staff also facilitated workshops with NHS Greater Glasgow & Clyde and NHS Tayside for the East of Scotland event. 5.2 The Chief Executive, Director of Strategic Planning & Performance, Medical Director, Director of NMAHPs and Director of Quality visited South Eastern Trust on 27th May 2017 to learn about their Safety & Quality Approach. South Eastern Trust is one of 5 Health and Social Care (HSC) Trusts which provide health and social services across Northern Ireland. The Trust serves a population of approximately 440,000 people with a budget of around 560 million and covers the local government districts of Ards, North Down, Down and Lisburn. The Trust employs in the region of 12,500 staff. The Group will feedback their findings to Corporate Management Team and the HQAIC in the coming weeks. 5.3 NHS Education for Scotland hosted the 7th National Scottish Medical Education Conference on 4/5 May 2017. The meeting was attended by those involved in medical education, training and appraisal, including students, trainees, trainers, appraisees, appraisers, managers, those working in primary care, secondary care, Universities, Deaneries and Medical Royal Colleges. The aim of the conference was to outline recent developments and explore the many challenges facing undergraduate and postgraduate medical education, training and appraisal, in a time of tightening resources and evolving regulatory requirements. As part of the conference an Awards Ceremony was held and the Award for Innovation in Training was presented to Dr Helen Mackie, Chief of Medicine at Hairmyres Hospital in recognition of the Chief Residents Programme at Hairmyres. 5.4 The International Forum on Quality and Safety in Healthcare is a biannual gathering of healthcare professionals in quality improvement and patient safety. This year s Forum took place in London in April 2017 with the theme of Igniting Collective Excellence. The programme focused on how the power of collaboration can inspire all parties, including patients, families, new healthcare professionals and improvement leaders to deliver top quality, person-centred care in a sustainable framework. The Forum was attended by a number of staff from NHS Lanarkshire and we are currently working to ensure that the 12
learning is shared with as many people as possible through a range of different meetings and events. 5.5 Hairmyres Hospital held their second annual Care Assurance and Accreditation System (CAAS) Study day on the 24th of April. Medical, nursing staff and ward teams presented their work on a range of the standards and there was also a Quality improvement Workshop that focused on data for improvement. An external perspective was provided in two sessions, one by Tommy Whitelaw, who works tirelessly across the country to promote person centred care and the other by Professor Craig White, who is a Clinical Lead for Quality Improvement at Scottish Government. Food tasting sessions were run at lunchtime and feedback was captured in a variety of innovative ways throughout the day. 13
Patient Safety Data 2016/17 Appendix 1