SUBJECT: CLINICAL EFFECTIVENESS REPORT

Transcription

1 Meeting of Lanarkshire NHS Board: Lanarkshire NHS Board Kirklands Fallside Road Bothwell G71 8BB Telephone: PURPOSE SUBJECT: CLINICAL EFFECTIVENESS REPORT This paper is coming to the Board: For approval For endorsement To note This paper aims to provide assurance to Lanarkshire NHS Board on the continuing endeavour to provide clinically effective care in NHS Lanarkshire, through provision of the most appropriate treatments, interventions, support and services at the right time to everyone who will benefit, and eradication of wasteful or harmful variation. 2. ROUTE TO THE BOARD This paper has been: Prepared Reviewed Endorsed By the following Committee: or Is a standing item 3. SUMMARY OF KEY ISSUES As recorded at the November 2014 Board meeting, assurance on the quality of patient care will be provided to Lanarkshire NHS Board through themed reports as well as the Corporate Quality Assurance Dashboard. Reflecting the NHS Scotland Quality Ambitions, these will focus (on a rolling quarterly basis) on the topics of patient safety, person centred care and clinical effectiveness. 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

2 The Transforming Patient Safety and Quality of Care Strategy progresses NHS Lanarkshire s quality vision to achieve transformational improvement in the provision of safe, person centred and effective care for our patients and for our patients to be confident that this is what they will receive, no matter where and when they access our services. 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 high. 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 2

3 The Transforming Patient Safety and Quality of Care Strategy provides vision and leadership for NHS Lanarkshire in the delivery of quality healthcare. The strategy described the conditions for quality which include structural and personal governance and accountability for quality. One of the quality goals relates to equality and diversity. 10. EQUALITY AND DIVERSITY IMPACT ASSESSMENT An E&D Impact Assessment has been completed Yes No An assessment has been completed for the Transforming Patient Safety and Quality of Care Strategy. 11. CONSULTATION AND ENGAGEMENT The draft Transforming Patient Safety and Quality of Care Work Programme for 2015/16 was considered at the Healthcare Quality Assurance and Improvement Steering Group on 20 January 2015 and approved at the Healthcare Quality Assurance and Improvement Committee on 11 th June ACTIONS FOR THE BOARD The Board are asked to: 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 Dr Iain Wallace, Medical Director, Telephone: Dr Iain Wallace Medical Director 3

4 SUBJECT: Clinical Effectiveness Report August PROCESS FOR REVIEW, EVALUATION & REPORTING OF NATIONAL & REGIONAL AUDIT AND BENCHMARKING REPORTS. A new process has been developed for review, evaluation and reporting of national and regional audit and benchmarking reports in relation to NHS Lanarkshire s performance. The process of evaluation should generate closer analysis of clinical care and help to drive improvements in the areas being reported. The reporting arrangements will ensure that any risks or issues identified through these reports are highlighted to the appropriate committees and groups as well as any areas of good performance. Meetings have taken place with the Acute & Primary Care Medical Directors to discuss and agree the process and a scoping exercise has taken place to identify potential reports to be included. The Acute & Primary Care Medical Directors have written to Clinical Leads to inform them of the new process & tools, and to confirm that the list of reports is correct and complete. Evaluation tools have been tested out using the following reports: Audit And Benchmarking Report Action plan completed 1. Scottish Arthroplasty Project Biennial Report 2014 Completed by Clinical Lead 2. HepatoPancreatoBiliary Cancers National Managed Completed by Clinical Lead Clinical Network Audit Report Upper GI Cancer Quality Performance Indicators Completed by Clinical Lead Gastric Upper GI Cancer Quality Performance Indicators Completed by Clinical Lead Oesophageal Head & Neck Cancer Annual Report 2013 Completed by Clinical Lead 6. Gynaecological Cancer Annual Report 2013 Completed by Clinical Lead 7. Lung Cancer Quality Performance Indicators Completed by Clinical Lead 8. Lymphoma Cancer Quality Performance Indicators Completed by Clinical Lead 9. Colorectal Cancer Quality Performance Indicators Completed by Clinical Lead 10. Scottish Perinatal and Infant Mortality and Morbidity Not required no outliers Report Audit of Critical Care in Scotland (SICSAG) 2014 Not required no outliers 12. Scottish Renal Registry Annual Report 2013 Partially completed in draft and sent to Clinical Lead for finalisation and sign-off 13. Scottish Confidential Audit of Severe Maternal Morbidity 2012 Partially completed in draft and sent to Clinical Lead for finalisation and sign-off The above evaluation tools and action plans have been discussed at the Acute Clinical Governance & Risk Management Committee / Cancer Management Team Meetings. A summary of some of the reports is provided below. 1.1 Scottish Arthroplasty Project Biennial Report 2014 The second Scottish Arthroplasty Project Biennial Report was published in August This report presents the numbers of arthroplasties for and subsequent medical complications for these patients. The Scottish Arthroplasty Project (SAP) analyses hospital inpatient information to link joint replacement surgery (arthroplasty) patients with subsequent medical complications resulting from each operation. NHS Lanarkshire was reported as an outlier for 3 out of the 21 indicators: Average length of stay for hip arthroplasty in 2013 by NHS Board (2 nd highest average LOS after Western Isles) 4

5 Average length of stay for knee arthroplasty in 2013 by NHS Board (2 nd highest average LOS after Western Isles) Percentage of 2008 hip arthroplasty patients with subsequent revision within five years (one of 2 Boards above the upper confidence limit) An action plan to address the outliers has been developed and discussed at the Acute Clinical Governance & Risk Management Committee. The full Scottish Arthroplasty Project Biennial Report can be found on Scottish Perinatal and Infant Mortality and Morbidity Report 2012 The Scottish Perinatal and Infant Mortality and Morbidity Report (SPIMMR) 2012 was published by Healthcare Improvement Scotland / ISD in March This 2012 SPIMMR is the last to be produced in this format. In January 2013, the Scottish Stillbirth and Infant Death Survey was replaced by a revised UK survey, MBRRACE-UK1 (Mothers and Babies Reducing Risk through Audit and Confidential Enquiries across the UK). The MBRRACE-UK programme of work will include surveillance of late foetal losses, stillbirths and some infant deaths together with a rolling programme of topic specific confidential case reviews of stillbirths and mortality and morbidity cases. The first themed topic is congenital diaphragmatic hernia. Annual reports will be produced with the first report anticipated in NHS Lanarkshire was reported to be within normal limits (within 3 standard deviations from the mean) for all of the indicators reported in the 2012 SPIMMR, therefore, no action plan was required. The full report can be found on the Healthcare improvement Scotland website: child/repr oductive_health/spimmr_2012.aspx 1.3 Audit of Critical Care in Scotland 2015 The 2015 report (reporting on 2014 data) was published on 11 August 2015 and is currently being evaluated. The full report can be found on the SICSAG website: Upper GI Cancer Quality Performance Indicators - Oesophageal The 2013 QPI report for Oesophageal Cancers was published by the Public Health & Intelligence (PHI) Division of NSS in February NHS Lanarkshire currently meets 6 out of the 11 Quality Performance Indicators (QPIs). A review of those where the Board hasn t reached the target has been undertaken and where appropriate improvement work is underway. In 2 of the 5 QPIs which are not met the number of patients involved is small so no definitive conclusions can be drawn. In another - % of patients diagnosed after initial endoscopy - NHS Lanarkshire s performance is 88% (target > 90%) with a national average of 84%. Unfortunately, patients in Lanarkshire tend to have more advanced disease when they present to local services and this affects the proportion of patients who can receive curative as opposed to palliative treatment. The figure is 17% in Lanarkshire compared to 22% for the West of Scotland. An action plan to address the above QPI s has been developed and signed off by the Clinical Lead for Upper GI Cancer. 2. CANCER QPI S & DETECTING CANCER EARLY The Clinical Quality Service continues to support NHS Lanarkshire to participate in the National Cancer Audit Programme. Support includes: Working closely with Cancer Multidisciplinary Teams (MDT) to collect data required for 18 Cancer Quality Performance Indicator (QPI) datasets Ensuring data quality at a local level and co-ordinating quality assurance reviews by the Public Health and Intelligence (PHI) division of NSS. The following reviews have been completed by PHI recently. 5

6 QPI Dataset Data period reviewed Data Accuracy Breast Jan to Dec % Colorectal April 2013 to March % Lung April 2013 to March % Prostate July to Dec % Upper GI Jan to Dec % Lymphoma April 2013 to March % Submission of data for all Cancer QPIs to the West of Scotland Cancer Audit Network in accordance with their Analysis, Reporting and Action Plan Schedule. To date NHSL is on schedule and have submitted all data on time. Provision of quarterly local reports to Cancer MDTs. Reports are currently available for Breast, Colorectal, Upper GI, Renal, Prostate and Lung Compilation of local and regional action plans in conjunction with tumour leads. Compilation of evaluation/benchmarking reports in conjunction with tumour leads. The National Detect Cancer Early programme has set a national HEAT target to achieve a 25% increase in the percentage of breast, colorectal and lung cancer cases (combined) diagnosed at stage 1 by 2014/2015. The Clinical Quality Service provides support in the form of collection of data, quality assurance, submission to ISD and local reporting of performance against the target. The baseline for 2010/2011 for NHSL was 23.9%. NHSL are required to achieve 29.9% by 2014/2015 to meet the HEAT target. Figure 2: Percentage of Stage 1 breast, colorectal and lung cancer cases (combined) at point of diagnosis by quarter. 3. SCOTTISH STROKE CARE AUDIT NATIONAL REPORT The 2015 Scottish Stroke Care Audit National Report was published on 14 th July NHS Lanarkshire demonstrated statistically significant improvements in the percentage of stroke patients receiving an appropriate Stroke Care Bundle. A bundle involves a group of specific interventions/ processes of care that significantly improve patient outcome if done together 6

7 rather than separately and this also improves the consistency with which patients are managed. The Stroke Care Bundle is based on the Scottish Stroke Care Standards (2013) and includes the most important drivers for improving stroke outcomes, i.e. admission to a Stroke Unit, swallow screen, brain scan and aspirin. The NHS Lanarkshire 2014 percentage compliance with the Stroke Care Bundle at 83% was the 2 nd highest reported % compliance in Scotland. See table 1 and Figure 1 below. Table 1: Percentage of NHS Lanarkshire stroke patients receiving an appropriate Stroke Care Bundle by Year % 51% 70% 78% 83% Figure 1: Percentage of NHS Lanarkshire stroke patients receiving an appropriate Stroke Care Bundle by Year Each Health Board set its own trajectory for improvement against the Stroke Care Bundle to be achieved by end of March 2015, and currently Lanarkshire is one of four Boards which are exceeding their target. The full report is available on the Scottish Stroke Care Audit website: 4. MEDICAL AND SURGICAL CLINICAL OUTCOME REVIEW PROGRAMME From 1 April 2015, Scotland joined the Medical and Surgical Clinical Outcome Review Programme. The programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and is run by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). The Medical and Surgical Programme aims to assist in maintaining and improving standards of medical and surgical care by reviewing the management of patients, through the use of national, topic-based, anonymised case note review and assessment of Trust or NHS Board organisational data. This facilitates an assessment of the quality of care and service delivery for patients at both local and national level. The results are published and made available 7

8 in the public domain with reports identifying key messages and recommended actions for improvement relating to the topic area covered. Two programme reports are published per year. The next topic to be commenced will be: Provision of Mental Health Care in Acute Hospitals (to be published in November 2016) This will be followed by: Non Invasive Ventilation (publication date TBC) Cancer in Children (publication date TBC) NHS Lanarkshire have nominated a named Clinical Quality representative as a Local Reporter who will act as a link between the non-clinical staff at NCEPOD and NHS Lanarkshire. The Acute Site Chiefs have also been named as Ambassadors for the programme senior clinicians whose role it is to support Local Reporters and champion the work locally. The Clinical Quality Service will support this programme of work when it is fully rolled out in NHS Lanarkshire. 5. REGISTRATION AND MONITORING OF NHS LANARKSHIRE CLINICAL AUDIT ACTIVITY The Clinical Quality Service developed and continues to support and enhance the on-line Clinical Quality Register which allows registration and monitoring of clinical quality activity in NHS Lanarkshire, which includes Clinical Audit & Quality Improvement projects. The register has an in-built project selection criteria which aids prioritisation of local clinical quality projects supported by the service, acts as an educational tool for clinicians wishing to undertake a clinical quality project (promoting best practice) and improves the quality of clinical quality projects supported by and carried out in NHS Lanarkshire (promotes projects in local and national priority areas). The Clinical Quality Service provides specialist advice and support for local clinical quality projects submitted through the Clinical Quality Project Register. Each project submitted is evaluated by the clinical quality team and feedback provided to project proposers on appropriate clinical quality methodologies. The level of support provided by the service for locally generated projects will vary depending on the appropriateness of the project. In the period July 2014 to July 2015, 225 projects were registered through the Clinical Quality Project Register. 6. IMPLEMENTATION OF SIGN GUIDELINES NHS Lanarkshire has an agreed process in place for notification, dissemination, evaluation, implementation and review of published guidelines. There are currently twelve SIGN guidelines at different stages of the agreed process. The SIGN guidelines noted below are new guidelines published in the reporting period. Guideline Guideline Name Date Current Status No. Published 144 Glaucoma Referral & Safe Discharge March 2015 Completion of 143 Diagnosis and Management of epilepsy in Adults May 2015 Evaluation in Progress Completion of Evaluation in Progress Clinical, Managerial & Executive Leads have been nominated for SIGN Guideline 143 & 144 and evaluation of the guidelines is in progress. The evaluation is carried out in order to form a judgement as to whether the guideline is applicable in NHS Lanarkshire and each guideline is evaluated against the following areas: Current practice, Clinical impact, Resource implications, Financial implications & Organisational barriers. 7. REVIEWS AND INSPECTIONS The Clinical Quality Service provides support to NHS Lanarkshire for all reviews and inspections undertaken by Healthcare Improvement Scotland (HIS) and other bodies including the Care Inspectorate. Recent reviews / inspections supported are detailed below. 8

9 7.1 Joint Inspection of Services for Children and Young People A framework of Quality Indicators for evaluating services for children and young people was published by the Care Inspectorate in The Care Inspectorate joint inspection of Services for children and young people in South Lanarkshire took place between June and August 2014 with the final report being published in February The North Lanarkshire inspection took place between October and November 2014 and the final report was published in June The Care Inspectorate have requested the development of joint action plans for each of the local authority Community Planning Partnerships which clearly details how improvements can be made in the key areas identified by the inspectors. 7.2 Multi-agency Inspection for Adults and Older Peoples Services The Care Inspectorate and Healthcare Improvement Scotland have formally notified NHS Lanarkshire and South Lanarkshire Council (SLC) that they are preparing to undertake a multiagency inspection of adult and older people s services from September The Clinical Quality team have supported the collection and cataloguing of evidence from a health perspective for submission to SLC through the programme lead and NHSL Older Peoples Services Preparation for Inspection Meeting. No formal notification has been received for North Lanarkshire. The inspectors will assess against a set of quality indicators and based on the findings of this inspection, award the service with grades against each. These reports will support improvements in the services people receive and will be used by organisations who are delivering care to improve the services they provide, whether in a health or social care setting. 7.3 Unannounced Care for Older People in Acute Hospitals Inspection to Hairmyres Hospital An unannounced Care for Older People in Acute Hospitals Inspection took place in Hairmyres Hospital between the 28th and 30th July The inspection report and action plan will be published on 23rd September UNICEF Baby Friendly Initiative Health visiting services in Lanarkshire have once again been awarded the prestigious Baby Friendly Award from UNICEF following a re-accreditation visit in May 2015.The international award is given to services that display best standard practices to protect, promote and support breastfeeding and to strengthen mother-baby and family relationships. The health visiting teams in North and South Lanarkshire met all of the criteria for continued Baby Friendly accreditation. The Clinical Quality team continues to support teams with maintenance audits required as part of the initiative including: Health Visiting interview: Staff, Health Visiting interview: Breastfeeding Mother, Health Visiting interview: Bottle feeding Mother and Premises Checklist audit. 8. DASHBOARDS & ASSURANCE Maternity Services Clinical Quality Dashboard A monthly Clinical Quality Maternity Dashboard providing data on Clinical Activity and Outcome Indicators, Workforce Indicators and Patient Experience Indicators is produced by Clinical Quality and circulated widely to key staff to consider areas for potential audit and driving local improvement. Review of the dashboard has recently highlighted an increase in both emergency and elective caesarean section rates in April To investigate this further an audit of casenotes for all caesarean sections undertaken in April will be conducted in August / September The findings of the review will be discussed and shared at the relevant forums to agree the way forward for local improvement in this area. 9. PUBLIC HEALTH AUDIT Social History Audit focussing on Tobacco and Alcohol Use 9

10 There are approximately 115 dentists within 8 sub-groups across Lanarkshire undertaking an audit of Social History, the focus of which is on the recording of social history information in relation to tobacco and alcohol use and the advice given to patients on the associated oral health risks. The aim of the audit is to improve the consistency and standards of recording social history information and advice given. Each of the participants will receive a summary report of their own findings as well as an overall NHSL report to inform and drive improvement in their local area and that of the wider dental service. The final reports will be available in September CONCLUSION The Board is asked to: a) Note this report b) Consider further action required in response 10