H ORGANISATIONAL LEARNING REPORT 2011/12 ITEM NO 7

Transcription

1 H ORGANISATIONAL LEARNING REPORT 2011/12 ITEM NO 7 Discussion X Report written by: Julie Hargreaves, Interim Head of Quality Governance Purpose of the report: To provide the Committee with a summary of issues recorded across Hillingdon Community Health relating to incidents, accidents, claims, PALs and complaints in order to identify themes and resulting learning across HCH to improve patient care. RECOMMENDATIONS TO THE COMMITTEE: 1. To note the findings of the report and discuss lessons learnt 2. To debate ways of better capturing learning in the organisation that can be shared will all areas of the organisation effectively Date of meeting: 28 th June 2012 Page No 1

2 ORGANISATIONAL LEARNING REPORT 2011/12 ITEM NO 7 TERMS/ACRONYMS USED IN THE REPORT HCH: Hillingdon Community Health CQC: Care Quality Commission CNWL: Central and North West London NHS Trust DoH: Department of Health NHSLA: National Health Service Litigation Authority RCA: Root Cause Analysis PALS: Patients Advice and Liaison Service NPSA: National Patient Safety Agency NICE: National Institute for Health and Clinical Excellence CEPAG: Clinical Effectiveness and Professional Advisory Group HV: Health Visitors DN: District Nurses SALT: Speech and Language Therapy Contact Name: Julie Hargreaves Contact Tel No: INFORMATION Background 1. Learning from adverse events in the NHS has continued to develop since the publication of key quality documents by the DoH. With the publication of An Organisation with a Memory in 2000 a framework for reporting and learning from adverse events in the NHS was developed. Since its publication the NHS set up national reporting bodies, which have subsequently evolved (e.g. National Patient Safety Agency). NHS organisations have developed their own reporting structures and processes to ensure information is collected, reviewed and changes monitored. This has also included processes for capturing information from other sources such as complaints, PALs, patient feedback and audit in order to identify issues and triangulate themes to support learning across organisations. 2. A key element of a learning organisation is to be able to effectively use information gathered and use that information to ensure the learning is shared and monitored for effectiveness. HCH has developed a governance structure which enables staff to report adverse events through various processes and systems (e.g. incident and accident reporting, claims, complaints received, PALs enquiries and audit activity). The data gathered by the Governance team is analysed and fed back enabling teams to learn lessons and make changes to improve the quality of the services they provide. 3. This report will detail the lessons learnt from governance activity which occurred in HCH during the period 1 st April 2011 to 31 st March It will contain information relating to the aspects of governance shown in diagram one. It also compares information reported in 2010/11 and 2011/12, which is a useful way to identify if changes made as a result of lessons learned, have had an impact. Date of meeting: 28 th June 2012 Page No 2

3 4. This report looks at trends and lessons learnt, but will not give detailed reports about each aspect, as these have been reported regularly throughout the year to either the Quality Governance Group or Senior Management Committee. Individual teams also present governance activity around these five aspects of governance. Diagram One: Aspects contributing to Organisational Learning Clinical Audit Complaints and Claims Organisational Learning Incidents and Accidents PALs Service 5. All aspects of governance in diagram 1 are linked to organisational learning. Also there is a clear link between governance and HCH s strategic and quality priorities. Although the information provided may fall under each of the above separate headings they should not be taken in isolation. Themes across each are identified and triangulated to enable effective learning to occur. 6. All staff undertake mandatory training in a variety of aspects of governance including incident reporting and investigation, PALs, complaints and claims. Incident reporting is an important way in which to gather data to identify learning themes. Likewise themes from PALs and complaints also provide similar learning opportunities. 7. Sharing outcomes from audit activity is also crucial for learning lessons and monitoring how effect change has been as a result of those lessons. The organisation reviews audit activity through CEPAG and reports its findings through the Quality Governance Group. Audit activity resulting in lessons learnt is detailed further in this report. Incidents 8. Incident reporting figures have increased from 2010/11 to 2011/12. Incidents are reviewed by the HCH Quality Governance Group and quarterly by the Senior Management Committee with trends monitored across the year. The total number of incidents during the year (01/04/11 to 31/03/12) are as follows; Total number of incidents 1907 Patient related incidents 1527 Staff related incidents 212 Trust related incidents 158 Public related incidents 9 9. Even though there has been an increase in reporting in 2011/12, it does not necessarily mean more incidents have occured. It may indicate that staff are Date of meeting: 28 th June 2012 Page No 3

4 reporting more and thus showing the development of a more open, learning and sharing culture. Year Quarter 1 Quarter 2 Quarter 3 Quarter / / Incidents and accidents categories are recorded in Appendix 1. This compares data between 2010/11and 2011/12. Incident reporting in 2011/12 had increased, but this could relate to the targets for reporting given to teams in 2010/1. The number of incidents reported in each category has remained largely unchanged, except in pressure ulcer reporting. There was a drive across HCH to increase awareness about pressure ulcer management ad reporting, which could be an underlying reason for the increase in number reported. The following charts break that down by group involved e.g. patient, staff, public or indirectly involving a person. Chart 1: Patients Date of meeting: 28 th June 2012 Page No 4

5 Chart 2: Staff Chart 3: Public Date of meeting: 28 th June 2012 Page No 5

6 Chart 4: Indirect (i.e. not involving patient, staff or public) 11. The highest number of patient incidents reported in 2011/12 were categorised as clinical (1148/1527). When this main category is sub-divided into more detailed categories this indicates that nearly 50% of the clinical incidents related to pressure ulcers (562/1148); this will include all pressure ulcers identified regardless of whether or not they are attributable to HCH. This far exceeded any other category recorded. The next highest sub category related to communication issues = 142/1148; many of which related to issues of patient hospital discharge. 12. Medication incidents were recorded as a separate clinical category, and overall was the next highest recorded specific category (n=132). This is an increase of 8% on 2010/11. However this data information includes all medication incidents recorded regardless of whether or not they were directly attributed to HCH, e.g. identification of a prescribing error by a GP on a home visit. All medication incidents are reviewed by the Community Pharmacist with trends reported through the HCH Quality Governance Group. Also the Community Pharmacist links with other organisations when the incident relates the them. 13. In relation to medication administration errors, three themes emerged which were general medication administration errors, insulin administration errors and low weight Heparin administration errors. A whole medication management programme was therefore developed and put in place to improve medication safety across the whole of HCH. 14. This programme consisted of: Recruitment of a dedicated Community Specialist Pharmacist. Training of specific teams in relation to insulin and low weight Heparin administration Introducing mandatory staff awareness medication training sessions for all staff involved in medicines administration at Induction. Date of meeting: 28 th June 2012 Page No 6

7 Introduction of a drug chart for district nursing services which requires signing by the patient s GP to reduce errors associated with verbal instructions. Introduction of compulsory a half day medicines management training programme which includes the need to successfully complete a competency framework and drug calculation test for all staff involved in drug administration every 3 years. The combination of these measures has led to a reduction in medication errors of 30% between 2010/11 and 2011/ In relation to pressure ulcers the organisation has invested heavily in raising awareness to report and prevent pressure ulcers in order to drive long term improvements. All relevant clinical staff are required to attend mandatory pressure ulcer training. Specialist support is provided by the Tissue Viability Team. 16. All pressure ulcers graded 2, 3 or 4 are recorded on Datix and those graded as 3 or 4 are investigated using a root cause analysis tool (RCA). Initially the grade 3 and 4 ulcers were investigated by the clinical members of the Senior Management Team (SMT). However to assist with learning and sharing information across clinical teams, Team Leaders now lead on these investigations, supported by a member of the Senior Management Team. The action plans resulting from such investigations are reviewed by the HCH Senior Management Team along with what lessons can be learnt. The clinical teams are involved in the development and implementation of actions resulting from the investigations. The action plans are collated centrally by the Governance Team who oversee implementation and learning across the various teams. Learning from pressure ulcers has resulted in the development of trigger boards within the district nursing teams. The boards allow staff to see at a glance the number of patients on their caseload who have pressure ulcers. Basic non identifiable information is recorded and it acts as an aid memoire for staff to monitor risk, ensure agreed actions for individuals have been put in place and enable more effective oversight/supervision of junior staff input by the Team Leaders. 17. In addition, the Patient Safety Manager produces a pressure ulcer trend report on a quarterly basis for clinical teams and the HCH Senior Management Team. This identifies particular trends in relation to causes e.g. unavailability of equipment, poor documentation, communication issues etc. as well as highlighting areas of good practice. As a result of identifying a trend in relation to poor assessment and documentation, the district nursing documentation has been reviewed with new assessment sheets and care plan documentation introduced. Since introduction, there has been a steady decline in issues related to poor assessment and documentation. 18. As a result of all the above changes, HCH has seen more than a 10% reduction in the number of avoidable pressure ulcers between 2010/11 and 2011/ Details of staff and patient accidents are summarised in Appendix 1 Tables A and B. A spike in the number of falls in the Northwood and Pinner Community Unit (NPCU) was noted and this has been carefully monitored throughout the year. Measures were put in place to reduce the occurrence of falls, which included employing additional healthcare assistants to supervise patients and purchasing cushions with alarms. The incidence of falls has declined slightly year on year (68 in 2010/11 compared to 64 in 2011/12). Therefore it would appear the number of falls in the unit is being controlled. Date of meeting: 28 th June 2012 Page No 7

8 20. Although clinical incidents, accidents to patients and staff and medication incidents account for 89% of incidents recorded in 2011/12, it was noted there was still a considerable number of non-clinical incidents (see appendix 1, Tables A, B, C and D). On closer review there are no particular trends noted for this group of incidents. The number reported in each category has not changed significantly from 2010/11 except in the group other within patient and staff groups. These incidents have been reviewed and again there are no significant trends. Incident trends are reviewed bi-monthly by the Quality Governance Group and if there are any changes they are reviewed in more detail. An example of this was highlighted with an increase in one quarter in incidents relating to information governance (breeches in confidentiality). As a result all incidents in this group were reviewed and it highlighted discrepancies and inconsistency with assigning a category to the incident. A number of breeches in confidentiality related to lost RiO cards. These are password protected so even if lost they do not pose a threat to confidentiality. They therefore should have been recorded as loss of Trust property. As a result the governance team review all incidents reported and change the categories if necessary. This information is fed back to teams and it is included in incident reporting training. When the categories have been reassigned the number of breeches of confidentiality reported therefore decreased significantly. 21. A final theme that has been identified in clinical incidents has been that of communication with outside organisations. This has predominantly impacted on the District Nursing Service who, as a result, have undertaken work with the local NHS Acute Trust to improve communication relating to discharge arrangements. The Clinical Lead for District Nursing Services has attended the Out of Hospital Group at the local Trust and the Governance Team have set up links with their counterparts in the Trust to be able to feed back incident data to help understand and learn from the issues experienced by poor discharge information. Also new discharge documentation has been developed this year, which will be evaluated when embedded in practice. Continued monitoring of incidents will track the impact this has had on District Nursing Services. In addition to this Health Visiting Service has also reported communication issues relating to new birth notifications and like the DN Service they are working closely with the local Trust to learn and improve outcomes. PALs and Complaints 22. The PALs Service came under the umbrella of governance in the first quarter of this year and therefore a full year s data in not available. However, the information collated (see appendix 2) gives good benchmark information. It is encouraging to see the number of compliments exceeds the number of complaints received (77 in comparison to 28). The total number of problems/concerns raised was 125 and the top three categories of those concerns were; Issues with appointments 22 Attitude of staff 15 =Aids and appliances 14 =Diagnosis and treatment However when the concerns relate to issues with appointments were examined further, it also identified a trend about communication with patients. As a direct results of calls to the PALs service about waiting in for a District Nurse to arrive, the District Nursing Service changed their practice in relation to patient visits. Now the Date of meeting: 28 th June 2012 Page No 8

9 District Nurses ring the patients to inform them if their visit will be in the morning or afternoon which eliminates uncertainty for the patient and/or carer. Since implementing this change there have been no further calls on this subject to the PALs Service. 22. A further theme relating to appointments identified through the PALs Service was the length of time patents were waiting for podiatry follow up appointments. Following an increase in calls to the PALs Service, a service review took place. A backlog was identified due to a) staff absence and b) increase demand. Additional short term assistance was put in place to reduce the backlog and the service manager also reviewed the number of staff allowed to take leave at any one time thus providing better cover for the service. To date, this has had a positive impact with no further calls through the PALs service. Monitoring will need to be continued to assess sustainability. 23. Overall, the number of formal complaints relating to HCH services is low and has reduced in number from the previous year as highlighted in the table below. It is suggestive of good front line management by staff in resolving issues and a effective local PALs Service. All complaints are centrally managed at the Trust but the investigations are carried out locally and learning, where relevant, is shared across the division. To further raise staff awareness around PALs and complaints, training sessions have been introduced through the induction programme this year. To date, staff feedback has been positive with staff indicating a better awareness of how PALs enquiries and complaints differ. They also understand the importance of early intervention to prevent concerns being escalated. Continued monitoring next year will show if the additional awareness sessions will impact on the number of complaints and concerns received. 2010/ /12 Formal complaints registered with CNWL Complaints fell into the following categories: Quality of care 13 Communication 2 Attitude of staff 1 Access to services 1 Appliances/equipment 1 Aspects of clinical treatment 1 Admin procedures 1 Assessment 1 Other agency issues 7 (not included in central database but logged with PALs see appendix two) 24. No particular trends have been highlighted through the formal complaints received although actions have been implemented, where necessary, in response to particular complaints. Specific changes made as a result within particular services is detailed in Appendix 3. Date of meeting: 28 th June 2012 Page No 9

10 Claims 25. Two clinical negligent claims were recorded during the year, one relating to an incident that occurred during this financial year. The other claim related to treatment received in 2008 and investigation has been passed to the PCT. It remains outstanding. These two claims relating specifically to HCH have been settled and liability for both accepted by the organisation. There were no trends identified in either claim but lessons learned regarding support and information given to patients during difficult times was noted and shared with the team. Patient Feedback 26. HCH takes patient feedback as an important measure of quality and safety and results are reviewed alongside feedback from complaints, PALs and incidents. Feedback is received in a variety of ways through individual service specific survey through to a detailed HCH wide survey undertaken in the autumn. A high percentage of patients consistently rate the quality of the service received as good or excellent. Staff wearing name badges, access to interpreting services and attention to hand hygiene are highlighted as the key areas for improvement. This will inform divisional wide improvement plans during the current year with areas of good practice being identified and highlighted for wider dissemination. 27. Other lessons learnt from the survey showed replies received were not truly representative of the community the organisation serves. Therefore the organisation is reviewing the questionnaire, how the information is collated and how we can achieve a more representative sample. The PALs Service and individual Services also undertake patient experience surveys and after feed back from patients the organisation is looking at how the three surveys can be consolidated without loosing the valuable information recorded for each service. Clinical Audit 28. The clinical audit programme provides valuable information about service performance, gaps and areas of good practice which can then be disseminated and shared across services. 29. During 2011/12, 77 clinical audits took place. This included some mandatory audits such as hand hygiene, record keeping and patient experience surveys as well as some service specific audits focusing on national guidance, standards or best practice. 30. During 2011/12, a half day clinical audit day was launched to enable the results of audits to be shared across services with front line practitioners. This approach was very positively received by staff and as a result two ½ day sessions will now be planned annually. 31. The following tables gives examples of some of the learning achieved through audit in 2011/12: Date of meeting: 28 th June 2012 Page No 10

11 Table One: Learning from Audits Service Audit Background Lessons Learnt Health Visiting Two near misses in 3 months relating to safeguarding children Gaps in practice identified and action plan devised. Re-audit showed full compliance not achieved at first re-audit but did at second audit. Lessons learnt shared across children s services and further audits planned Continence Service Catheter insertion knowledge The audit identified gaps in knowledge. Action plan was devised and a re-audit has shown improvements in practice. It has also resulted in joint assessments to improve problem solving and new documentation is planned to assist with troubleshooting. Podiatry Services Peer Review This audit was presented at the Governance Half Day and after initial nervousness by team members to be involved it has resulted in a change in culture in the team and willingness to openly review practice. Other teams in the organisation were keen to undertake it as a result of their presentation. Paediatric SALT Review of outcomes for 3 teams (pre school needs, school teams, clinic and early years team The results showed good compliance with standards but also identified where future developments were needed. The audit will continue to help share good practice and training will be given to the school special needs team to meet targets District Nurse Service Patient Experience Survey Feedback received was very positive but it also identified gaps in Date of meeting: 28 th June 2012 Page No 11

12 information given related to visiting times. This was also reflected in PALs Service feedback. Therefore patients were given information about their visits occurring in either the morning or afternoon and also that they would be cared for by a team and not necessarily always see the same DN. Calls to PALs relating to this has subsequently gone down. Looked After Children Audit to see if health assessment, information given and the process meets the needs of this group of children Feedback about the assessment was very positive but gaps in information giving were identified. Changes were made to the assessment documentation and the results were shared with other agencies so that they could also learn from the feedback. 32. In the past year HCH has strived to move towards a more integrated approach to all aspects of governance and learning. In that respect the Quality Governance Group has encouraged shared learning across all service by developing a programme where teams come together to share their learning. 33. In a slightly more formal arena, a new service presentation programme was introduced this year, to compliment the bi-monthly service reports submitted to the Quality Governance Group. Up to three services at a time are invited to attend the Quality Governance Group annually to share their activity, performance, challenges, audit results and celebrate their achievements. It provides an ideal opportunity for the three presenting teams to share ideas and learning which can help to develop their services. By Spring 2013 all teams will have presented their services to the Quality Governance Group. This will provide a benchmark against which services can measure themselves for their own specific learning outcomes in the future. It also allows the teams to identify with the Quality Governance Group what issues they need assistance with in order to address learning issues. Summary 34. HCH has shown in the last year it has continued to embrace a learning culture and implement changes to improve services provided. With changes in structures, reporting and how information is shared learning lessons across the organisation with continue to flourish. Date of meeting: 28 th June 2012 Page No 12

13 35. There is evidence from the examples provided above that learning is taking place across the organisation. This is reflected in both the agenda s and minutes of team meetings where learning is now a standing item as well as through the tangible improvements which have been noted to have taken place in response to HCH wide sharing and focused activity. EQUALITY IMPACT ASSESSMENT N/A there is no positive or negative impact from this report. RECOMMENDATIONS. The Committee is requested to: 1. To note the findings of the report and discuss lessons learnt 2. To debate ways of better capturing learning in the organisation that can be shared will all areas of the organisation effectively To note the findings of the report and discuss lessons learnt APPENDICES Appendix One: Appendix Two: Appendix Three: Incident Trends Tables A-D: Incident Categories (Staff, Patients, Public and Indirect) PALs Service Trends Changes to Services as a result of complaints Date of meeting: 28 th June 2012 Page No 13

14 Appendix One: Incident Trends Table A: All Incident Categories Patients Incident Category 2011/ /11 Accident Patient falls Patient injury clinical Patient injury non clinical Clinical Pressure Ulcers Communication Patient care Environment /Hand Safety Fire 2 0 Information Security Medication Medication error Medication incident Prescribing errors Security 4 8 Vehicle 6 2 Violence/Abuse/Harassment 5 6 Other Total Date of meeting: 28 th June 2012 Page No 14

15 Table B: All Incident Categories Staff Incident Category 2011/ /11 Accident Patient falls Patient injury clinical Patient injury non clinical Clinical 0 0 Pressure Ulcers Communication Patient care Environment /Hand Safety Fire 0 0 Information Security 8 6 Medication 0 0 Medication error Medication incident Prescribing errors Security Vehicle Violence/Abuse/Harassment Other Total Date of meeting: 28 th June 2012 Page No 15

16 Table C: All Incident Categories Public Incident Category 2011/ /11 Accident 6 11 Patient falls Patient injury clinical Patient injury non clinical Clinical 0 0 Pressure Ulcers Communication Patient care Environment /Hand Safety 2 3 Fire 0 0 Information Security 0 0 Medication 0 0 Medication error Medication incident Prescribing errors Security 0 0 Vehicle 0 0 Violence/Abuse/Harassment 0 0 Other 1 0 Total 9 14 Date of meeting: 28 th June 2012 Page No 16

17 Table D: All Incident Categories Indirect Incident Category 2011/ /11 Accident 3 0 Patient falls Patient injury clinical Patient injury non clinical Clinical 0 0 Pressure Ulcers Communication Patient care Environment /Hand Safety Fire 1 7 Information Security Medication 0 0 Medication error Medication incident Prescribing errors Security Vehicle 31 1 Violence/Abuse/Harassment 0 0 Other 0 25 Total Date of meeting: 28 th June 2012 Page No 17

18 Appendix Two: PALs Service Trends Type of Contact Number Appreciation 77 Complaints logged by PALS 7 were related to other agencies therefore HCH complaints Information Request 46 Concerns/Problem 125 Quality of care 7 Aids and appliances 14 Discharge arrangements 2 Attitude of staff 15 Diagnosis/treatment 14 Admin processes 3 Access to NHS services 11 Local authority services 2 GP registration 2 Changes to service 6 Appointments 22 Zero tolerance 1 Environmental issues 1 Medical records issues 3 Prescribing medicines 1 Patient transport 1 Funding 1 Charges 1 Treatment waiting times 2 Communication/information 8 Continuing care 4 Contact details 2 Manual handling issues 2 Total number of contacts 276 Date of meeting: 28 th June 2012 Page No 18

19 Appendix Three: Changes to Services a result of complaints Ref Change of Service Changed HCH/ Yes Staff were addressed & up-dated on procedures so that patients are to be informed of any delays. HCH/ Yes A refresher of the all procedures regarding Twilight visits will be spoken about at the next Team Meeting & cascaded to all Nurses. HCH/ Yes Further supervision & training for those personnel concerned regarding implants. HCH/09733 Yes Staff member attended a training session to ensure accurate weighing of babies. Will also be attending a Conflict Resolution training session & has received full info. on the complaints procedure & how clients can access this system if necessary. HCH/09741 Yes New Admin. procedures put in place for better communication with parents. HCH/09756 Yes Team are reviewing the prescribing of anticipatory medication with up-dates. HCH/09757 Yes Staff made aware to offer interpreting service in the first instance. HCH/09799 Yes Staff will be requested to check on patients to ensure they have booked in & have not been missed. HCH/09860 Yes Better communication between staff. Partial Response (THH main complaint) HCH/09861 Yes Gaps identified to be addressed by mandatory training for staff in training & therapy input. Care Pledge to be reiterated to all staff. HCH/09885 Yes Relevant action has been taken with Health Care Assistant, including refresher training for all Nurses regarding medication for clients & info. reiterated that they do not leave instructions for carers to give medication. HCH/09896 Yes A review of Urinary Catheter Policy & include guidance on length of observation time post catheterisation. Practice of Nurse been reviewed & has been assessed as competent HCH/09897 Yes Funding for larger community dietician team & procedures up-dated. HCH/09919 Yes All future requests for palliative care night nurses will be made directly to Harlington Hospice who will liaise with Marie Curie. HCH/09935 Yes New arrangements have been put in place to cover short notice staff absences at our outreach sites for Diabetic Service PCT/ Yes New admin procedures put in place to stop delays in sending out reports. PCT/09671 Yes Care changed from Hillingdon to Ealing due to location of existing GP PCT/09677 Yes Night nurses to be stopped with immediate effect with a view to ongoing reassessment of needs. Total 18 Row(s) Date of meeting: 28 th June 2012 Page No 19