Quality and Safety Report Quarter 2 13/14 Clinical Governance Manager Q2 - July - Sept 2013

Transcription

1 Quality and Safety Report Quarter 2 13/14 Clinical Governance Manager Q2 - July - Sept 2013 Q21314 Quality and Safety Report - Public

2 Quality and Safety Report Q2 July September Patient Safety Patient Safety Incident Trends and Actions 1.2 Serious Untoward Incidents 1.3 Inquests 1.4 Clinical Negligence Litigation 2.0 Patient Experience Formal Complaints and Enquiries 2.2 Actions arising from upheld and partially upheld complaints 2.3 Monitoring of complaints process 2.4 Local resolution meetings 2.6 Ombudsman referrals and investigations 2.7 Compliments 3.0 PALS Report PPI activity (including patient information) 3.2 PALS Activity 4.0 Risk Management Staff accidents / incidents 4.2 Risk register 4.3 Non clinical claims 5.0 Effectiveness of Care Quality of Care 5.2 Clinical Audit Appendices 12 1 PALS Concerns - Quarterly Reports 2010/11 2 PALS concerns by category heading 2

3 1. Patient Safety 1.1 Patient Safety Incident Trends and Actions There were a total of 439 patient incidents reported during quarter 2, 9% down on Q actual incidents occurred and 104 near miss incidents were reported. Figure 1 shows a comparison of the actual and near miss incidents reported by quarter during the first two quarters of this year. Actual Near Miss Total Q1-2013/ Q2-2013/ Table 1: Numbers of patient safety incidents reported Q2 Figure 1: Patient safety incidents actual v. near miss The reporting of incidents is slightly down, probably due to a seasonal adjustment. The Trust increased awareness of the need to report incidents / near misses and maintain a sustained reporting culture within the organisation continues. Table 2 below shows the number of actual patient safety incidents reported by the principal cause groups in Q1&2 of this year. Medication incidents have increased in Q2 and remain our highest reported incidents within the Trust followed by Implementation of Care. Patient falls have shown a considerable reduction in Q2. Many reporting areas have returned to their historic norm, with the exception of Implementation of Care where the Monitoring of Patients has been predominantly reported on. It is worthy of note that the majority of patient incidents remain categorised as low harm. Further information is provided below. Medication Falls Med Dev Info/ Record Keeping Clinical Assess Access/ Transfer/ Discharge Treatment Procedure Consent/ Comms Implement /Care Other Total Q1 Incident Q1 Near Miss Q2 Incident Q2 Near Miss Table 2: Actual patient safety incidents by main cause group 3

4 Figure 2 PATIENT INCIDENT TRENDS AND ACTION: Medication: The reporting of medication is the highest category of patient incidents reported with the impact severity remaining consistently low. Trend analysis of reported medication incidents is retrospective and a full quarter has not yet been analysed. Figures are available for the rolling year July 2012 July 2013 (Figure 3) and show incidents in relation to omission, checking and prescribing are the main categories. Documentation errors continue to be monitored and have been highlighted as part of the omissions monitoring where staff have omitted to sign the prescription chart. Checking of prescription charts at handovers has been introduced on all wards to mitigate against this issue. 4

5 Figure 3 Medication incident trends July 2012 July 2013 Patient Falls: The enhanced measures, listed below, seem to have had a qualifying effect on the number of patient falls reported in Q2. The number of patient falls per 1000 bed days has reduced to 1.9, which is appreciably below the Trust target of 3. The falls group will discuss technological aids at their next meeting, which if put into practice may see a further reduction in the number of patient falls. Intentional Rounding Patient Alarm Systems Patient Awareness Physiotherapy Toolkit Falls Co-ordinator Role External Resources (e.g. Age Concern) Place Cards Implementation of Care With 30% of incidents reported relating to Pressure Ulcers and other notable areas describing Pain Management and Fluid control, the majority of this increased criterion recounts a failure to monitor the patient. Further examination of the investigation shows a trend of increased pressure on staff; the main reasons given are shortages of staff and increased workload. Staffing issues are on the Risk Register and this has been escalated to the Q&R committee. The Trust now employs a Recruit & Retention nurse and there is currently a drive to employ staff from the European community. 5

6 Green and Yellow Incidents Green incidents (low harm) continue to dominate, accounting for 90% of incidents reported. Yellow incidents (moderate harm) accounts for 4% of incidents reported and are monitored by the respective Directorate Management Group. The total figure does not reflect the total patient incidents as some are still under review. Heads of Departments remain the decision makers when grading an incident with Risk Management as the Trust gatekeepers. Training continues in order to ensure the correct categorisation of incidents. Orange and Red Incidents inclusive of Serious Incidents (SI s) - The Trust has reported 3 SI s (severe harm) in Q2 and is investigating 5 Orange (moderate harm) incidents. There were 42 incidents where the incident report indicated that the patient was harmed and the being open field was completed in all cases. 1.3 Inquests - The Trust gave witness at 2 Inquest in Q2 13/ Clinical Negligence Litigation New Claims - The Trust has received 8 new requests for disclosure of records in Q2. 2. Patient Experience 2.1 Complaints and Enquiries The Trust received a total of 9 Complaints and 6 Enquires in Q2 13/14. Not all complaints have been fully investigated at the time of this report and so the table below is incomplete. Figure 1 shows the trend of formal complaints and enquiries received by quarter. (* = some complaints from this month are still under investigation) Figure 1 No. formal complaints received in Q2 (July - Sept 2013) Upheld / part upheld Enquiries for further information July Aug 4 2* 1 Sept 3 1* 3 Total Table 1: Numbers of complaints / Enquiries 6

7 Figure 2 shows the primary subject of complaints comparing Q213/14 with the previous quarter. Numbers of complaints received remains small with no trends identified _Figure 2 Figure Actions arising from complaints upheld or partially upheld in Q2 13/14 Directorate Summary of Complaint Outcome Q F Thoracic Medicine Q F Cardiac Surgery Q F Post PTE Surgery Q F Cardiac surgery Dissatisfied with inpatient experience and clinical management Dissatisfied with access to cardiology services and timeframe for cardiac surgery Dissatisfied with after care following PTE surgery Part Upheld Part upheld Action(s) identified - Highlighted actions are outstanding Feedback issues of patient experience to Princess ward staff Feedback issues of patient experience to dieticians Apologies and explanation given no actions identified Upheld Clarify the process of ensuring Occupational Therapy input prior to discharge.(meeting arranged for 24/09/2013) Increase capacity for PEA follow ups Revise the text in the PEA information booklets to accurately reflect the PEA follow up pathway Feedback to the team regarding the importance of returning calls and the impact on patients when this doesn t happen Arrange outpatient appointment for patient to discuss outcome of exercise test - COMPLETED Cancelled procedure Upheld 5 Actions identified 3 Outstanding - Development of patient information regarding the payment process for private patients Reception staff to be reminded that patient confidentiality is to be maintained even when in a public area - COMPLETED VJ staff to ensure that the kitchen door is closed when people are working in there to minimise noise - COMPLETED VJ staff have been asked to consider how to 7

8 Directorate Summary of Complaint Outcome Action(s) identified - Highlighted actions are outstanding make sure that patients are aware of the cleaning schedule for the rooms and that they can influence whether their rooms receive additional cleaning The experiences of Mr C will be shared with VJ ward staff so that they can learn from his experiences and work to prevent similar communication confusion. Table 3: Actions arising from investigation of complaints upheld /part upheld 2.3 Local Resolution Meetings The Trust has facilitated one local resolution meetings in Q2 13/ Ombudsman s Referrals The Trust has one complaint currently with the Ombudsman awaiting the outcome of their preliminary review and notification of investigation. 2.5 Compliments 88 formal compliments were registered with the PALS Department in Q2 13/ Patient Advice and Liaison Service 3.1 PPI Activities The Patient and Public Involvement & Membership (PPIM) Committee and the Patient Experience Panel both met during the quarter. The Pulmonary Fibrosis Patient Support Group (PF) celebrated World Pulmonary Fibrosis Week with a Conference at Duxford where 115 Papworth patients attended, sponsored by the Papworth Pulmonary Fibrosis Patient Support Group and the British Lung Foundation. The Group meets bi-monthly with the next meeting to be held in November The Pulmonary Hypertension Patient Support Group (PH) met on Saturday 7 th September 2013 with over 30 patients and carers attending and a Lecturer from Cambridge University gave a talk about the latest updates in PH research. The Mesothelioma Patient Support Group continues to meet on a monthly basis. There were 7 volunteers appointed during the quarter, one each for the Pre-admission Clinic, Ward Reception, Greeter Desk, Trolley and a joint role for the Heritage Centre/Dementia Friends and 2 for the Gift Shop. We currently have 7 volunteers pending. 3.2 Patient Advice and Liaison Service (PALS) During this quarter, the PALS Service received 569 enquiries from patients, families and carers, compared to 538 for the same quarter last year. As can be seen from the number of contacts by month below, the second quarter was slightly higher than the first quarter with July being the highest month. The details are as follows: 1 st Quarter 2013/14 2nd Quarter 2013/14 April 185 July 207 May 178 August 177 June 175 September 185 The Chart below shows how patients, relatives and carers have accessed the PALS Service during the quarter, with the highest volume of enquiries again coming from personal contact with the PALS Office: 8

9 July August September Face to face Telephone Letter QofS Leaflet The spot check carried out by one of our Volunteers showed that the PALS and Quality of Service information leaflets were both available in all patient areas Concerns Raised The Chart at Appendix 2 shows the concerns by category for the second quarter compared with the first quarter 2013/14. In the Access category, out of the 330 concerns received, 197 (60%) related to assistance with directions around the site from appointment letters. 78 (24%) related to help with accommodation for relatives with Flat 4 of the Relatives Hostel again being completely full throughout the quarter. There were 43 (13%) enquiries relating to parking issues concerning Blue Badge parking, the purchase of weekly tickets and requests for change for the ticket machine. 8 (2%) enquiries related to transport issues with only two being queries about the new arrangements for eligibility for NHS transport. In the Waiting category, out of the 39 enquiries received, 25 (64%) related to enquiries regarding in/out-patient appointments and in particular, questions regarding a date for their procedure. There were also 11(28%) enquiries relating to various issues around diagnostic test results and 3 (8%) related to cancelled procedures. In the Building Relationships category, out of the 15 enquiries received, 2 (13%) related to staff attitude, which was dealt with by the Matrons concerned and the remaining 11 (73%) were compliments received about the PALS Service. In the Information category, out of the 150 enquiries received, 91 (60%) related to requests for general information or advice about services provided by Papworth and the referral process. 35 (23%) enquiries were for assistance for relatives on benefits and reimbursement of travel costs. 3 (20%) related to Freedom of Information Requests, which were passed to Corporate Affairs for a response. 7 (5%) related to the patient background information being incorrect and the letters have been reissued showing the correct information. In the Communication category, out of the 21 enquiries received, 8 (38%) related to requests for clarification of the medical information contained within the discharge letter and copying letters generally. 5 (24%) related to enquiries regarding the release of patient records under the Data Protection Act. 4 (19%) related to enquiries regarding inter-professional communication, mainly regarding letters of referral and 2 (10%) related to poor or conflicting information which were resolved by PALS staff. There were no enquiries received in the Environment category during the quarter. In the Quality of Care category, out of the 14 enquiries received, 5 (36%) related to discharge arrangements which were dealt with by the Matrons concerned. 4 (29%) enquiries related to medication queries which were directed to the Medicines Helpline for clarification. 2 related to clinical care and 2 to food and nutrition (29%) which were dealt with by the Matrons concerned and the Restaurant Manager. There were 3 Quality of Service leaflets received during the quarter, 2 were complimentary expressing thanks for the care and treatment received and these have been passed on to the relevant departments and members of staff. 1 related to access to Wi-Fi on the ward which was dealt with by the IT Manager. 9

10 During the quarter, there were 88 compliments received across the Trust as well as 11 compliments about the PALS Service. There were 10 requests for information about the complaints procedure. There are no outstanding actions for this quarter (Q2 2013/2014). 4.0 Risk Management 4.1 Non Clinical Accidents/Incidents There were 2 RIDDOR reportable incidents in Q2 of this reporting period. Table 1 shows the rate of staff accidents/incidents over the last 9 years. The number of staff incidents in Q2 is trending downwards per 100 WTE; manual handling injuries remain our main concern and this is being monitored via the H&S committee. 04/05 05/06 06/07 7/08 08/09 09/10 10/11 11/12 12/13 Q1 13/14 Q2 13/14 Staff Accidents WTE Rate / 100 No No No WTE data data data Table Risk Register During Q1, 3 new risks have been added to the register, all of which have a residual risk rating of 12 or below. The Medical Records committee and Thoracic Management Group will be responsible for monitoring these risks. 4.3 Non-clinical claims There are currently 2 employee liability claims and one public liability claim with the NHSLA. 5.0 Effectiveness of care 5.1 Quality and Safety Measures A summary of the ongoing monitoring for the Safety Thermometer, WHO safety checklist is presented in appendix 3 (Mortality monitoring will be available in the Q3 report) 5.2 Clinical Audit National Audits National Emergency Laparotomy Audit (NELA) The Trust registered for this National audit in March and submitted the first organisational data in September, the report for this is due in Spring We are currently in the process of piloting the patient audit on-line submission. Case Mix Programme (Intensive Care Network and Research Centre - ICNARC) The Trust has received its first data summary and will present the data once more months have been received to allow for comparison. NCEPOD reports Tracheostomy Care Study All ward level tracheostomy data was submitted for the Tracheostomy Study in May. The full report is now awaited. NSF / NICE Guidance received in quarter & progress A total of 40 NICE guidance documents were published during July, August and September. 13 were disseminated to the relevant leads for review. Please see appendix for a list of applicable guidance and compliance ratings. 10

11 Clinical Audit Training The Audit Department continues to educate staff on the audit process at the Trust and at the Doctors induction. Junior doctors training now meets the recommendations set out in the publication of involving junior doctors in clinical audit (HQIP 2010) Table 1 Training delivered Date Speciality Attendance Training delivered July Trust induction 25 Introduction to clinical audit August Trust induction 20 Introduction to clinical audit September Trust induction 55 Introduction to clinical audit Hospital Wide Clinical Audit Meetings The meeting provides the Trust with assurance that the results and actions from clinical audit, effectiveness and quality initiatives are being disseminated to clinical staff. Attendance in the last 3 months has improved. The agenda for the meetings has been reviewed, at future meetings, as well as the results of clinical audits. The learning from serious investigations will also be shared. Dates of the meetings are now available on the home page of the intranet, and in news bites. Attendance will continue to be monitored. 11

12 PALS Enquiries - Quarterly Reports 2013/14 Appendix 1 1 ACCESS Q1 Q2 13/14 13/ Access to NHS Services Building Access Parking Transport Issues Translation & Interpreting Directions Accommodation Other Accompanying patient on site (meeting, appt. etc.) WAITING 2.1 Out-Patients Appointment Waiting List In-Patient Cancelled Procedure Diagnostic/Treatment Transfer from Other Hospital Other BUILDING RELATIONSHIPS 3.1 Staff Attitude Patient Attitude Staff Verbal Abuse Vulnerable Adolescent Vulnerable Adult Other Compliments Received INFORMATION 4.1 Information/Advice Request Complaints Procedure Signpost to Other Organisation Signpost to Other NHS Trust Nursing/Residential Care Convalescence Benefits PCT Advice DoH Advice Freedom of Information Incorrect Data Info. on hospital services (referral process, treatment) No. of Concerns Received 12

13 5 COMMUNICATION 5.1 Confidentiality Admin & Clerical Error Poor/Conflicting Information Lack of Information Inter-Professional Communication Data Protection Record Keeping Consent Issues Choice Clarification of Medical Information Copying Letters General ENVIRONMENT 6.1 Accommodation Cleanliness Equipment Health & Safety Hygiene Maintenance Noise Security Safety (Personal) Other QUALITY OF CARE 7.1 Clinical Care Discharge Arrangement Pressure Sores Privacy & Dignity Infection Control Medication Pain Management Food & Nutrition Personal Hygiene Other 2 1 Totals:

14 Appendix 2 PALS REPORT SECOND QUARTER 2013/14 Number of concerns by category heading for second quarter 2013/14 compared with first quarter 20013/14: 1st quarter 13/14 2nd quarter 13/ Access Waiting Attitude Communication Information Qlty of Care Environment Brenda Bush PALS Manager October 2013 Q21314 Quality and Safety Report - Public