SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Quarterly

SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST
Quarterly Regulatory Assurance Report – Q1 2011/12
Report to:
Trust Board – 27th September 2011
Report from:
Lesley Stuart - Associate Director for Healthcare Governance and Risk
Sponsoring
Executive:
Judy Gillow - Director of Nursing
Michael Marsh - Medical Director
Aim of Report:
To provide the Trust Board with a high level overview of key regulatory
governance assurance progress, issues and current performance for Quarter
1 (April to June 2011/12)
Review History to
date:
This is the 1st report for the current year; the last (Quarter 4) report to the
QGSG was in April 2011, TEC and Trust Board in May. This report was
approved by QGSG on 20th July 2011 and by TEC on 3rd August.
Assurance
Framework/Strategic
Objective Ref:
This report links to all of the Trust Strategic Objectives
Recommendations:
The Board are asked to review the report and identify any areas requiring
further discussion or scrutiny from the Audit & Assurance Committee, with
particular emphasis on the red and amber areas of performance
1. Strategic Context:
1.1
To address the increasing focus on quality improvement, SUHT Trust Board now receive a
high level quality performance report that reflects the Patient Improvement Framework
(PIF), on a monthly basis. Each month a detailed report of one of the three main
components (safety, experience, outcomes) of the PIF is presented. Alongside these
monthly themes sits this quarterly update report on the regulatory national and local
healthcare governance components.
1.2
This Regulatory Assurance Report and our current initiatives are based around the Darzi
quality triangle, ‘Liberating the NHS’, Monitor’s Quality Governance, CQC Essential
Standards and NHSLA Risk Management Standards requirements. They support the
Trust’s performance shadow reporting for Monitor’s Compliance Framework and the
Quality Governance Strategy already in place. This report will be subject to ongoing
development to ensure alignment with existing and emerging initiatives.
2. PPI:
2.1
The Trust receives feedback from patients as to their views about the service received,
predominantly through surveys, complaints and the PAL Service. CQC requirements and
other recent initiatives (‘no decision about me without me’ – DH 2010) require providers to
place greater emphasis on patient and public engagement and patient outcomes and the
Trust’s governance initiatives and quality reports support this.
3. Specific Detail
3.1
The Regulatory Assurance report aims to integrate quality governance
developments/accreditations through this report and therefore improve the assurance
provided to the Trust Board. The report focuses on a number of regulatory requirements
and other significant areas/issues, some of which were not included in previous reports.
The level of regulatory and accreditation activity is not consistent throughout the year and
therefore the content of this report will vary depending on the issues arising during the
quarter. The Trust Board receive a summarised version of the Regulatory Assurance
Report approved by QGSG and TEC.
Page 1 of 15
4. Risk Register Ref:
This report is linked to a number of risks contained in the risk registers. Information from
this and other reports is used to triangulate with the risk registers.
5. Summary of performance Quarter 1 2011/12
A high level summary of areas to note is given in the conclusions below.
6. Legal Implications:
The quality and safety of patient care is a fundamental expectation. There is potential for
civil claims and/or regulatory action against the Trust if patients are harmed. There is the
possibility of criminal liability where such care is so grossly negligent and/or there has
been a breach of health and safety legislation or compliance with CQC Registration and
regulatory compliance.
7. Conclusion:
Particular areas to note in this report are:
•
•
•
•
•
•
•
NHSLA Risk Management Standards assessment: completion of outstanding policies required
by 17tht August –corporate/divisional leads to pursue this. Evidence of compliance with L1
policies must be collated at the end of September and, where necessary, improvement action
plans must be in place by the end of October. Managers/corporate leads to support criterion
leads collating this evidence and develop action plans where required..
continued concerns regarding radiotherapy and radiotherapy physics teams staffing levels
Newborn Hearing Screening Programme (NHSP) Quality Assurance report
update re Environmental Health Inspection
MHRA confirmation that the Blood Transfusion Department are compliant with their
regulations.
the new style Aggregate analysis and learning report.
progress in relation to the other reports as outlined in the summary
8. Recommendations:
The Board are asked to review the report and identify any areas requiring further discussion or
scrutiny from the Audit & Assurance Committee, with particular emphasis on the red and amber
areas of performance.
Page 2 of 15
The Regulatory Assurance Performance Summary Quarter 1 2011/12
Page Regulatory
issues Q1
2011/12
NHSLA Acute
↔ Risk
Management
Standards
↔
7
↔
↔
↔
↔
NHSLA Risk
StandardsMaternity
Radiotherapy
accreditation
by CHKS
National
Cancer Peer
Review
Programme
CPA HTA
Microbiology
Inspection
Safeguarding
Children.
No full report
this quarter
↔
↔
Safeguarding
Vulnerable
Adults
Radioactive
Substances/
Radiation
Protection
Newborn
Hearing
Screening
Programme
(NHSP)
Quality
Assurance
Q1 overview
Timescales for the project are slipping due to suggestions from the
assessor in respect of further policy revisions. Some areas where it
is unlikely the Trust will meet compliance have been identified, as it
may not be possible to provide a year’s worth of compliance
evidence. Recommendations for action included in report.
Accreditation at L2 achieved. Business plan developed plan to move
to level 3 over next 3 years.
A site visit took place in February. The department has agreed to
develop actions to meet standards by the end of the year. There
were no serious concerns raised. However operational demands and
Trust priorities do not allow the current team to dedicate the time
required to ensure provision of the evidence required to meet the
expectations of accreditation. Staffing remains a concern.
Dept updating the service Operational Policy, Quality Manual and
work programme to address non compliance issues. Also working to
improve functionality and quality of Radiotherapy across Central
South Coast and preparing for Peer review self assessment in
September. Staffing levels and skill mix in radiography and
radiotherapy physics teams continues to be the potential risk for
delivery of a quality service. Plans in place to mitigate the risk.
Full Accreditation achieved. The letter of confirmation and certificate
will be sent at a later date.
Nothing further to report this quarter – issues remain as outlined Continued significant increase in number and complexity of cases
referred to team. Unavoidable reduced team resource. Less planned
CP training sessions scheduled for 2011 whilst priority is given and
current resources targeted at casework and SCRs/IMRs/Partnership
Reviews and whilst further CP Lecturer hours being identified from
other sources. Period of significant change in terms of the rapidly
changing political, legislative and policy landscapes and Munro CP
Review Reports. A rapid response will be required to emerging
guidance and legislation once Eileen Munro Review Report is fully
completed in the next few months and the formal government
response received.
Improvements to processes for reporting, responding to and
investigating alerts made, creating a more robust system for
capturing and disseminating learning has become more established.
Further actions - Review of SGA policy completed and review of
SGA training ongoing. Specified safeguarding week to be confirmed
once new policy complete. Plan Safeguarding Adult audit in Q2.
Continue delivery of LD Action Plan.
Action plan to address the 17 areas identified by the Environment
Agency for improvements has almost been completed; one item is
outstanding. MPE post 10th advert unsuccessful. Looking at
developing stronger links with another Medical Physics department
and use their MPE instead of re-advertising.
All NHSP sites submitted self assessment questionnaires and these
were reviewed by a Summary Review Quality Assurance Team. The
SUHT Audiology Dept at the Royal South Hants Hospital was
deemed acceptable and therefore not identified as needing a ‘site
visit’ on this occasion. The NHSP Quality Assurance Report for
Audiology Southampton identified only one item which requires
action (Develop the use of listening questionnaires with families) and
this is being addressed.
Page 3 of 15
Previous Qtr 1
Quarter 2011/12
R
R
G
G
A
A
A
A
G
G
G
G
G
G
A
A
N/A
G
Page Regulatory
issues Q1
2011/12
PMETB/GMC
↔
↑
↑
↔
↔
↔
↓
↔
Research SUHT Routine
GCP
inspection by
MHRA
Environmental
Health
Inspection
Blood Safety
& Quality
Sterile
Supplies
Claims
performance
Q1 overview
The GMC report 2010 has resulted in the trust being awarded Level
3. Whilst this is an excellent result the GMC report identified
deficiencies in certain aspects of training in SUHT. Meetings with
Post-Graduate Leads for specialties with areas highlighted as less
than optimal have taken place. Action plans have been put into place
and we await the trainee survey result to help direct measures.
Response to MHRA Inspection report was submitted in April 2011,
still awaiting feedback from the Lead inspector. Note - It has since
been confirmed that suggested CAPA (corrective and preventative
actions) are satisfactory. Next inspection July 2011
Following past visits EHO confirmed satisfaction with actions
undertaken and requested that SUHT invite him back for a full formal
review upon completion of refurbishment in July 2011. Medirest will
be contacting the EHO in August to arrange a re-visit to view the
refurbishment.
At MHRA inspection in February failures to comply with the
Regulations and the principles and guidelines of good manufacturing
practice were observed. Following receipt of the action plan and
information on how the non-compliances have been resolved the
MHRA responded confirming that the Blood Transfusion Department
are compliant with their regulations.
Inspection visit early April some areas of good practice and areas for
improvement note but only one CAR. A business case will be written
to support the purchase of a new IMS system. At the next scheduled
audit in September 2011 the SGS audit team will follow up on all
identified non-conformities, minors and observations to confirm
effectiveness of corrective actions taken.
Progress with NHSLA ‘Risk Reports outlined.
The department’s performance compliance continues to be less than
optimum due to resource issues.
Good progress continues to be made but Care Groups need to
review Local Action Plans and Divisions need to have identified
Business Continuity Leads.
Emergency
Planning &
Business
Continuity/Resil
ience
CQC Report
Reports from Standard leads indicate a reduction in compliance
position this quarter; this is mirrored by the slight slippage in the
CQC QRP report (mainly due to negative comments received).
Actions are ongoing to improve this position further and address the
recommendations from the CQC inspection report. The CQC has
given the Trust no overall risk rating higher than yellow in the latest
QRP report.
Appendix A
CQC Current compliance and CQC Quality & Risk Profile
Appendix B This report has been subject to further development in Q1 and
Aggregate
TEC/Trust Board will be requested:
Analysis and
• To comment on the new reporting format
Learning from
• To note the action being undertaken to resolve issues raised
Complaints,
• To ask for further action or assurance on the key themes
Claims &
arising in this report as deemed appropriate.
Incident
To ensure that this report is shared and discussed with Divisional
Management and clinical teams and linked to learning from patient
stories to facilitate understanding that it is everyone’s responsibility
to contribute to improvement
Page 4 of 15
Previous Qtr 1
Quarter 2011/12
A
A
A
G
G
A
G
G
G
A
A
G
G
2A
6Y
9G
2A
9Y
6G
G
G
Appendix A: CQC Compliance summary and Quality Risk Profile Report Q1 2011-12
Outcome 1 – Trust
Q1 assessment –
minor concerns
Sept
2010
October
2010
November
2010
December
2010
Outcome 2 Trust Q1
assessment –
Minor concerns
Sept
2010
October
2010
November
2010
December
2010
March
2011
April
2011
January
2011
Sept
2010
October
2010
November
2010
December
2010
January
2011
February
2011
March
2011
April
2011
Sept
2010
October
2010
November
2010
December
2010
January
2011
June
2011
July
2011
August
2011
May
2011
June
2011
July
2011
August
2011
June
2011
July
2011
August
2011
No QRP
For May
February
2011
March
2011
April
2011
February
2011
No QRP
for
January
May
2011
No QRP
For May
No QRP
for
January
CQC QRP
May
2011
No QRP
For May
No QRP
for
January
CQC QRP
Outcome 5 Trust Q1
assessment
– Minor
concerns
CQC QRP
February
2011
No QRP
for
January
CQC QRP
Outcome 4 Trust Q1
assessment –
Minor concerns
January
2011
March
2011
April
2011
May
2011
No QRP
For May
Page 5 of 15
June
2011
July
2011
August
2011
Outcome 6 Trust Q1
assessment
– Minor
concerns
CQC QRP
Outcome 7 Children Trust Q1
assessment
- Compliant
CQC QRP
Outcome 7 Adults Trust Q4
assessment –
minor
concerns
CQC QRP
Outcome 8
- Trust Q1
assessment
- Compliant
CQC QRP
Sept
2010
October
2010
November
2010
December
2010
January
2011
February
2011
March
2011
April
2011
No QRP
for
January
Sept
2010
October
2010
November
2010
December
2010
January
2011
October
2010
November
2010
December
2010
January
2011
February
2011
March
2011
April
2011
October
2010
November
2010
December
2010
January
2011
July
2011
August
2011
May
2011
June 2011
July
2011
August
2011
No QRP
For May
February
2011
March
2011
April
2011
No QRP
for
January
Sept
2010
June
2011
No QRP
For May
No QRP
for
January
Sept
2010
May
2011
May
2011
June
2011
July
2011
August
2011
June
2011
July
2011
August
2011
No QRP
For May
February
2011
No QRP
for
January
March
2011
April
2011
May
2011
No QRP
For May
Page 6 of 15
Outcome 9 Trust Q1
assessment
– Minor
concerns
CQC QRP
Outcome 10
- Trust Q1
assessment
– Moderate
concerns
CQC QRP
Outcome 11
- Trust Q1
assessment
– Moderate
concerns
CQC QRP
Outcome 12
– Trust Q1
assessment
– Minor
concerns
CQC QRP
Sept
2010
October
2010
November
2010
December
2010
January
2011
February
2011
March
2011
April
2011
No QRP
for
January
Sept
2010
October
2010
November
2010
December
2010
January
2011
October
2010
November
2010
December
2010
January
2011
February
2011
March
2011
April
2011
October
2010
November
2010
December
2010
January
2011
July
2011
August
2011
May
2011
June
2011
July
2011
August
2011
June
2011
July
2011
August
2011
June
2011
July
2011
August
2011
No QRP
For May
February
2011
March
2011
April
2011
No QRP
for
January
Sept
2010
June
2011
No QRP
For May
No QRP
for
January
Sept
2010
May
2011
May
2011
No QRP
For May
February
2011
No QRP
for
January
March
2011
April
2011
May
2011
No QRP
For May
Page 7 of 15
Outcome 13
– Trust Q1
assessment
- Compliant
CQC QRP
Outcome 14
– Trust Q1
assessment
- Compliant
CQC QRP
Outcome 16
– Trust Q1
assessment
– Minor
concerns
CQC QRP
Outcome 17
– Trust Q1
assessment
- Compliant
CQC QRP
Outcome 21
- Trust Q1
assessment
– Compliant
CQC QRP
Sept
2010
October
2010
November
2010
December
2010
January
2011
February
2011
March
2011
April
2011
No QRP
for
January
Sept
2010
October
2010
November
2010
December
2010
January
2011
October
2010
November
2010
December
2010
January
2011
February
2011
March
2011
April
2011
October
2010
November
2010
December
2010
January
2011
February
2011
March
2011
April
2011
October
2010
November
2010
December
2010
January
2011
August
2011
May
2011
June
2011
July
2011
August
2011
May
2011
June
2011
July
2011
August
2011
June
2011
July
2011
August
2011
June
2011
July
2011
August
2011
No QRP
For May
February
2011
March
2011
April
2011
No QRP
for
January
Sept
2010
July
2011
No QRP
For May
No QRP
for
January
Sept
2010
June
2011
No QRP
For May
No QRP
for
January
Sept
2010
May
2011
May
2011
No QRP
For May
February
2011
No QRP
for
January
March
2011
April
2011
May
2011
No QRP
For May
Page 8 of 15
CQC Risk Profile : Inherent, Situational, Population and Uncertainty risk for SUHT
September
2010
Inherent
Risk
The risk attributable to
an organisation by
virtue of its care case
mix
The risk attributable to
the care provider by
virtue
of
its
organisational context
Features in the local
population that have
been shown to affect
care outcomes or
access to care
Assessment of the
completeness
of
population, situational
and inherent risk
Situational
Risk
Population
Risk
Uncertainty
Risk
December
2010
Jan
2011
February
2011
March
2011
April 2011
May
2011
risk
Page 9 of 15
No QRP in the Month of May
Contextual
November
2010
No QRP in the Month of January
Overall
estimate
October
2010
June 2011
Appendix B -Aggregate analysis and learning report from complaints, incidents and claims
Top Themes in Common (December 2010– May 2011)
1. Introduction
3. Changes to report since the last edition:
The purpose of this report is to ensure that there is a systematic review of
incidents, complaints and claims on a quarterly basis. Aggregating the data in
this way serves to ensure that issues, experienced by patients, are reviewed
collectively so that where common themes arise, either by theme or area, they
can be acted upon. This will ultimately support the organisational response to
safety and experience issues by improving practice and ensuring lessons are
learnt.
This report covers an analysis of issues reported in the last 6 months (December
2010 to May 2011 inclusive), the learning identified and actions that are being taken.
The time period allows for a two to three month time lag that currently exists in patient
issues being reported and recorded onto Safeguard (our data management software)
and as a result will mean that any trends seen are statistically significant. As we move
towards the implementation of E-reporting this time lag should reduce and it is
anticipated that trends in corporate themes may change. In addition, the first phase of
implementation of E-reporting is focused on agreeing common and consistent data
fields for each module (i.e. complaints, incidents, claims), which will facilitate greater
comparison between the modules and support further interrogation of the data.
It is envisaged that the reporting process for this report will develop iteratively,
and as a consequence it is recognised that the Trust’s NHSLA policy regarding
Aggregated Analysis and Learning may need to be revised. A further step will
be to triangulate the issues arising in this report with the themes that emerge
as the clinical ward dashboards are embedded.
2. Definitions for this document:
Issue: The term “issue” in this report is defined as either a Concern, Complaint, Claim
or Incident, which has been reported from any of the Trust’s departments or divisions.
Corporate Theme: The “Corporate themes” used for this report have been
established through discussion between the respective managers from the Incidents,
Complaints and Claims departments. Prior to the production of the report the
managers’ meet to review and contextualise any themes that have arisen in the
reporting period. Each issue’s cause code is mapped to a corporate theme in
Safeguard. The list of corporate themes were revised in April 2011, however this may
need further revision as this report develops and the E-reporting Safeguard project is
rolled out.
Page 10 of 15
Time frames of data: This report has been reviewed since the last edition
and the time frames for analysis have been changed from 3 months to 6
months. This is to ensure that trends can be reviewed more effectively.
Reporting:
All data for this report has been taken from Safeguard to ensure all
information reflects the information used in Patient Safety, Patient
Experience and Claims independent reports. However Board members
should be aware of the different reporting periods and the fact that a top
theme in safety, complaints or litigation may be different to a top aggregated
theme/issue.
Table 1: showing the % increase of issues per Division and Trust between
June-November 2010 and December 2010 – May 2011
Complaints
Division
June November
2010
December
2010 - May
2011
Incidents
Claims
Percentage
Variance
June November
2010
December
2010 - May
2011
Percentage
Variance
June November
2010
December
2010 - May
2011
Percentage
Variance
Division A
61
61
0%
1150
1304
11%
44
14
-69%
Division B
121
110
-9%
1244
1656
24%
14
10
-29%
Division C
62
48
-22%
1279
1415
9%
16
24
50%
Division D
115
129
-10%
653
908
29%
34
38
10%
Corporate
5
6
20%
128
230
44%
24
14
-42%
364
354
3%
4454
5513
19%
132
100
-25%
Grand Total
This table provides the percentage increase in issues for this reporting
period (Dec 10 to May 11) from the previous 6 months (Jun 10 to Nov 10).
The average month numbers are also added to put the % variance into
context. The table shows: • An overall increase of 21% in the number of reported incidents
(particularly in Divisions B & D). This reflects a recent drive to improve
incident reporting and coding of patient safety incidents in the Trust to
improve our benchmarked position against other Trusts in the National
rd
Reporting & Learning System (23 out of 24). .
• An increase of 1% in complaints, however periods compare winter and
summer months and seasonal differences are well established.
• A reduction in claims of 25%.
4. Trends of Complaints, Incidents and Claims
5. The percentage of users that experience an issue in SUHT
Graph 1 - Trend of All Issues for April 2009 - May 2011
1400
Graph 2 - % of Users Experiencing Issues
90
80
3.00%
60000
2.50%
50000
2.00%
40000
1.50%
30000
1.00%
20000
0.50%
10000
0.00%
0
1200
Number of Incidents
50
40
600
30
400
20
200
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Apr-11
May-11
Mar-11
Jan-11
Feb-11
Dec-10
Oct-10
Nov-10
Sep-10
Jul-10
Aug-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
Nov-09
Dec-09
Oct-09
Sep-09
Jul-09
Aug-09
Jun-09
Apr-09
0
May-09
0
Jan-10
10
Month
Month
Users
Customer Services
Litigation
There is some correlation to be seen between the number of incidents and
complaints, which would be expected.
There is clear guidance as to the correct processes for managing a complaint and
claim.
There is often a protracted period of time before a claim is made, as such the
reporting period is not the same as when the issue occurred and is therefore not
readily comparable to incidents and complaints.
Out of 54 new claims in total from December 2010 and May 2011 there were: •
•
•
% o f Users Experiencing an Issue
Incident
7 claims linked to an incident report = 13%
6 claims linked to both incident and complaint = 12 %
14 claims linked to a complaint = 27%
27 claims either linked to one, the other or both = 50%. Therefore 50% of cases were not
linked to any previous Trust investigation.
Page 11 of 15
Graph 2 illustrates the percentage of issues raised against the number of users
of the hospital (i.e. patient attendances and admissions). There is a correlation
with the Trust’s activity and the number of issues raised.
Issues reported in May 2011 will increase due to the time lag in reporting on the
Safeguard information system.
Number of Users
800
Number of Customer Services / PALS / Litigation
60
Percentage
70
1000
Key areas highlighted against this corporate theme were: -
5. Analysis of Themes
When analysing issues over the last 6 months, 3 key corporate themes have
been identified which are as follows: -
Treatment
Communication
Patient Monitoring
•
•
•
Analysis of these themes is provided in the next sections of the report.
5.1 Treatment
Corporate theme of Treatment
Customer Services
Incident
Litigation
80
Number of Issues
70
60
50
40
5.1.2. Appropriateness and sufficiency of communication in relation to
admission procedures and Out Patient Attendances.
Patients relatives and carers are reporting: • Inconsistency in being kept up to date with progress on investigations
and treatment
• That there is a need for greater patient and carer involvement in care
and treatment decision-making.
• The administrative clerical point of contact with patients are unreliable
• Issues with attitudes
Actions being taken: • Outpatient improving customer service project (with Price Waterhouse
Cooper)
• Trust wide customer care project to implement zero tolerance approach
to negative attitudes to launch in the autumn and will incorporate launch
of newly developed trust values and customer care toolkit
• Development of an e-learning programme on customer care,
incorporating the trust values and “show you Care” Campaign.
• Project to specifically improve patient experience in outpatient
departments in planning stages.
• Development of a new clinical leadership model with clearly designated
nursing and medical leadership roles at ward level
• Redesign of documentation providing better format for capturing
conversations with patients, family and carers.
30
5.1.2
20
10
01/05/2011
01/04/2011
01/03/2011
01/02/2011
01/01/2011
01/12/2010
01/11/2010
01/10/2010
01/09/2010
01/08/2010
01/07/2010
01/06/2010
01/05/2010
01/04/2010
0
Month
•
Graph 3 - All Incidents, Complaints and Claims with a corporate theme of Treatment between April 2010 to May
2011.
•
•
•
Page 12 of 15
Delays/Lengthy waits for Outpatient Appointments – This is with
regard to both the wait for the Outpatient Attendance and cancellation of
appointments, with particular reference to trauma orthopaedics and
spinal services.
Actions being taken: -:
Capacity plan for these services identifying opportunities for outsourcing
to manage demand.
Choose and book efficiency project.
To aid in the improvement of waits for Outpatient appointments, the
Department of Health’s Intensive Support Team is working with Care
Groups to review their current capacity modelling with the intention of
reducing wait times.
The Trust’s partial booking project and Human Resources policy on
Consultant annual leave will reduce the number of inappropriate follow
up appointments and thus less cancellation of appointments.
5.2.2. Letter content and timeliness
Regarding the appropriateness of letter content and the timeliness of
letters being sent to both patients and GPs.
5.2 Communications
Graph 4 - Corporate theme of Communication
issues reported between April 2010 - May 2011
Actions being taken: •
Custo mer Services
Incident
Litigatio n
50
Number of Issues
45
•
40
35
30
25
•
20
15
As and when issues are raised around inappropriate letter content the
responsible department (whether it is Care Groups or the corporate
Electronic Patient Record support team) have reviewed the letter
content and revised the generic template as appropriate.
Further to this, the Trust Outpatient project will be reviewing the
production, effectiveness and timeliness of letters within the Trust.
This is an ongoing project currently in its infancy.
E-Docs discharge letter sent direct to GP’s. However this is
dependent on GP practices having the right IT infrastructure.
10
5
01/05/2011
01/04/2011
01/03/2011
01/02/2011
01/01/2011
01/12/2010
01/11/2010
01/10/2010
01/09/2010
01/08/2010
01/07/2010
01/06/2010
01/05/2010
01/04/2010
0
5.2.3 Capacity in Wards and Patient actual location
On occasion patients have either not been transferred to wards due to
capacity issues or the location of patients have not been known without
some searching.
Corporate Themes
Actions being taken
Graph 4 - All Incidents, Complaints and Claims with a corporate theme of Communication between April 2010 to
May 2011
Analysing the data for the last 6 months, there is a correlation within the corporate theme
of communication illustrating that a rise in communication themed incidents can impact on
the levels of Complaints being made against the Trust.
•
•
•
The key areas highlighted were: 5.2.1 The Isolation of patients with infection concerns
On occasion communication between departments/wards has meant that patients
with infection concerns are not being appropriately isolated in a timely enough
fashion and in accordance with policy.
Actions being taken: • The Trust’s Infection Protection Team are currently undertaking individual
ward training to help improve awareness around isolation best practice and
policy.
•
Isolation breaches are also reviewed at weekly Delivery Group meetings to
ensure senior management are aware of causes of breaches and can act as
appropriate
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The Trust’s real-time Admission, Transfers and Discharges (ADT)
project will aid in ensuring every patient’s location is known.
The new Patient Improvement Framework (PIF) patient moves work
stream and the continual review of timeliness of discharges will both
assist in releasing capacity so that beds are available as required.
The agreement to 90% capacity by Trust Board and the monitoring of
this.
5.2.4 Consent Issues –
On occasion there have been misunderstandings during consent discussion,
lack of documentation regarding the taking of consent and failure to
document the risks on the consent form.
Actions being taken
•
•
•
•
E Learning package currently being developed with the implementation
of a compliance audit and reinforcing of training for all staff with
delegated responsibility
Consent policy has been reviewed and updated and audit to be
undertaken.
The review of top 10 HRG’s patient information leaflets outlining risk.
5.3
Monitoring
6. Serious Incidents Requiring Investigation (SIRI’s)
Non Excluded SIRI's (to May 11)
Corporate theme of Patient Monitoring issues reported between
April 2010 - May 2011
Special Cause Flag
5
4
3
Litigation
Number
Incident
70
1
0
-1
50
-2
40
Apr 11
Feb 11
Dec 10
Oct 10
Aug 10
Jun 10
Apr 10
Feb 10
Dec 09
Oct 09
Aug 09
20
Jun 09
-3
30
Apr 09
Nu m b er of Issues
60
2
Period
10
Target:
<3 Non excluded SIRI’s/month (i.e. excluding Pressure ulcers,
Communicable diseases, VTE’s and High Harm Falls)
Performance: Using the 2010/11 Target (<3 / mth) SUHT has been compliant
01/05/2011
01/04/2011
01/03/2011
01/02/2011
01/01/2011
01/12/2010
01/11/2010
01/10/2010
01/09/2010
01/08/2010
01/07/2010
01/06/2010
01/05/2010
01/04/2010
0
every month since Apr 2009 except April 2010 (3), Sep 2010 (3) and Feb 2011
Month
SIRI’s by Cas e Type (M ar to M ay 2011)
Graph 5 - All Incidents, Complaints and Claims with a corporate theme of Communication
Between April 2010 to May 2011
HCAI, 11
Pt Saf ety, 3
Falls, 3
Key themes highlighted:
5.3.1
Pressure
Ulcers, 6
Handovers and Handoffs –
A number of issues relate to the absence of either handovers of patient care after
the patient has been to theatre or the handoffs between staff to cover for breaks.
Actions being taken
• The new PIF patient moves work stream will be reviewing best practice
around the handover of patient care to ensure issues are reduced to a
minimum.
• The transfer policy and supporting documentation have been reviewed and
agreed, which support the transfer of key patient information.
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VTE, 30
The Trust’s Significant Incidents Scrutiny Group (SISG) oversees SIRI’s
investigations. SISG provides a monthly report to the Quality Governance
Steering Group on organisational lessons to be learnt. In addition the Divisional
Governance Teams are: • Retrospectively reviewing SIRI’s to look for key themes which are also being
reported to QGSG
• Reviewing for themes across complaints and incidents in specialities
7. Conclusion
Board Members will be requested: o
o
o
o
To comment on the new reporting format
To note the action being undertaken to resolve issues raised
To ask for further action or assurance on the key themes arising in this report as deemed appropriate.
To ensure that this report is shared and discussed with Divisional Management and clinical teams and linked to learning from patient stories to
facilitate understanding that it is everyone’s responsibility to contribute to improvement.
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