Appendix--85 Borders NHS Board CLINICAL GOVERNANCE & QUALITY UPDATE Aim The aim of this report is to provide the Board with an overview of progress in the areas of: Patient Safety Programme within NHS Borders Person Centred activities including Complaints Patient Safety Key Issues Spread of all the key changes (including testing, training, communication) is underway beyond the pilot populations throughout the BGH within the five initial workstreams: general ward, peri-operative, medicines management, critical care and leadership. Two applicants from NHS Borders have been successful in securing places on the SPSP Fellowship programme; Dr Jonathan Kirk and Mr Ronnie Dornan. A Patient Safety Study Day is being held jointly with NHS Education Scotland, in Melrose on 23 rd November, aimed at our frontline staff, to educate clinicians to use their data for improvement purposes. Currently 14 staff members are registered. Healthcare Improvement Scotland (HIS) is visiting NHS Borders on 18 th October as part of their series of Autumn Harvest visits. The visiting team will be led by Ros Gray, Head of Safety, and are, in particular, keen to meet teams from the general ward, perioperative, medicines management and critical care workstreams. There will also be a session on how NHS Borders are preparing for Harm Free Care which will be led by Dr Sheena MacDonald. Information from all the Boards across Scotland will be used to inform the Learning Session 9. Healthcare Improvement Scotland are also visiting NHS Borders on 17 th October for a paediatric site visit. The visiting team will be led by Kirsty Ellis, National Paediatric Facilitator. Registration is now open for Learning Session 9 to be held in Glasgow on the 8 th and 9 th November. As requested in the previous Board meeting, the table below shows the Hand Hygiene compliance for each Community Hospital. This data is collected as part of the Leading Better Care clinical quality indicators. 1
Appendix--85 Hospital Hand Hygiene Compliance Kelso 100% Hay Lodge 95% The Knoll 100% Hawick 100% Sepsis/VTE World Sepsis Day on September 13th was marked in the Borders with a manned information stand in the canteen, local press and roll out of the sepsis six bundle to A + E and ward 4. Teams are implementing the sepsis six intervention successfully in the pilot areas. On going education and training from clinical governance, Dr Ed James and the Critical Care Outreach Team has been targeting all staff groups to ensure successful implementation. The Sepsis intervention is a critical success factor for reducing mortality. Mental Health A successful, initial, national learning session was held in August which was well represented by a travelling team from NHS Borders. Preparatory work is commencing with risk assessment in The Brigs, and with medicines reconciliation in Huntlyburn. Baseline data is in the process of being collected for this national pilot. Primary Care A series of national road shows have been advertised by HIS to educate primary care colleagues on the forthcoming Patient Safety in Primary Care Programme. Management of Significant Adverse Events Healthcare Improvement Scotland (HIS) published a review of NHS Ayrshire and Arran s management of adverse events on 12 th June. The report highlighted areas for national learning and made recommendations for NHS Scotland. In light of this a national framework will be developed to support improvement and a more consistent approach to managing and learning from such events. All Boards must consider the recommendations from the report and the development of the new national framework. Healthcare Improvement Scotland asked each Board to complete a baseline self assessment. This was submitted on 7 th September together with an NHS Borders Improvement Plan. HIS will undertake a rolling programme of reviews and visits to Boards over the course of the next 12 months to ensure that appropriate action is taking place and to help inform the development of the national framework. Patients Rights (Scotland) Act 2011 The Patient Rights Act requires Health Boards to support people to become more involved in their health and health care. The key components of the Act are: 2
Appendix--85 The introduction of the 12-week Treatment Time Guarantee A right for patients to give feedback, comments or raise concerns or complaints and have access to support to do so. The publication of a Charter of Patient Rights and Responsibilities The setting up of Patient Advice and Support Service to support patients to provide feedback or make a complaint. Project leads have been identified and are working closely with the Clinical Governance & Quality Team to support the implementation of the Act. Since the last update there has been significant activity including: NHS Borders local Access Policy has been revised to reflect the changes within the Act. The Policy has been disseminated for consultation with a closing date of 27 September. The Waiting Times Team has developed a series of patient template letters that reflect the new requirements of the TTG. Primary and Community services have contacted all independent contractors to support them with complying with the requirements of the Act. A service specification and service level agreement has been agreed with Citizens Advice Scotland and the Borders Citizens Advice Scotland. There has been a series of information sessions held with the booking staff to ensure they understand and implement the requirements of the Act within the patient booking system. NHS Borders Training and Development department have been actively contributing to the NHS Education for Scotland working group that has developed a project plan to develop the capability of staff providing NHS Services to respond to feedback, comments, concerns and complaints. Publicity material (leaflets, fact sheets, posters, post-its, pens, mouse mats) have been distributed across all of NHS Borders services. Training and Development are distributing publicity material as part of their training Programme. A series of information displays/sessions have been delivered in the BGH and all of the community hospitals. Complaints and Commendations Activity To update NHS Borders Board on the complaints and commendation activity during the period April September. Under the Patient Rights Scotland Act (2011), patients now have a legal right to raise a concern, provide feedback or make a complaint in relation to the care they have received. NHS Boards are required to respond to formal complaints within 20 working days. 3
Appendix--85 NHS Borders 20 Working Day Response Rate for this period is outlined in the table below. Apr May Jun Jul Aug Complaints No of complaints 13 11 16 21 13 11 Sept 20 working day response rate 62% 100% 50% 67% 85% - Commendations No commendations Complaint Themes of 213 176 221 178 256 - As of the 1 April health boards are required to report on the themes of the complaints received, below is a summary of the themes. Complaint Theme April May June July August Clinical Care/Treatment 17 7 10 7 11 Attitude and behaviour 2 1 4 3 3 Communication 0 0 3 1 3 Date for appointment 3 1 2 3 1 Complaints Handling To support the improvement of the complaints process, alternative processes are being tested using the Plan, Do, Study, Act (PDSA) improvement method. This approach is being tested in the Borders General Hospital and in Mental Health services. The process will be revised following the completion of the first test of change. Recommendation The Board is asked to note the current progress in Scottish Patient Safety Programme in NHS Borders, Patients Rights (Scotland )Act 2011 and Complaints activity. Policy/Strategy Implications Consultation The NHS Scotland Healthcare Quality Strategy (2010) and NHS Borders Corporate Objectives guide this report. The content is reported to Clinical Boards through the Clinical Governance Steering Group and to the Board Clinical & Public Governance Committees. 4
Appendix--85 Consultation with Professional Committees Risk Assessment Compliance with Board Policy requirements on Equality and Diversity Resource/Staffing Implications As above In compliance as required. Yes Services and activities provided within agreed resource and staffing parameters. Approved by Name Designation Name Designation Evelyn Fleck Director of Nursing & Midwifery Author(s) Name Designation Name Designation Karen McNicoll Head of Clinical Governance & Quality 5