Idea Transcript
Quality Report 2012/2013
Page | 77
Page | 78
Birmingham Women’s NHS Foundation Trust Quality Report 2012/13 Contents Page Part One Statement on Quality from the Chief Executive of the Trust
80
Part Two Priorities for improvement and statements of assurance
82
Participation in National Clinical Audits and National Confidential Enquiries
89
Recruitment into Research Studies
94
Use of CQUIN Framework
95
Care Quality Commission Regulations
96
Data Quality
96
Information Governance Toolkit
96
Clinical Coding Error Rate
97
Emergency Readmission within 28 days
98
Responsiveness to personal needs of patients
100
Recommending the Trust as a provider to Family and Friends
101
Patients admitted that are risk assessed for VT
102
Clostridium Difficile Infection
103
Patient Safety Incidents
104
Part Three - Other Information
106
Supplementary Indicators Patient Safety Clinical Effectiveness Patient Experience
106 107 108
Quarterly of Quality Account Indicators Genetics and Laboratories Gynaecology Maternity Neonatology
114 114 115 116 117
Further National Indicators
118
Annexes 1. Statement from Commissioners 2. Statement of Directors responsibilities
119 121
Page | 79
Part 1 – Statement on quality from the Chief Executive of the Trust Our Vision is: “To be a leading provider of local, regional and national importance, providing a specialist range of distinct but interrelated services, delivering excellent healthcare, education and training and research and to contribute to the health and wellbeing of the people we serve.” Central to our vision is our commitment to improve patient care and the experience it brings
The purpose of this Quality Report is to demonstrate our view of the quality of the NHS services that we provide. The annual reporting guidance for Quality Reports details what we must include to fulfil both the Department of Health and Monitor’s requirements. We have set out in this report how we have performed in terms of priorities for improvement in the past year, and we have detailed what our priorities are for 2013/14. For the coming year we are proposing a new deliberately challenging indicator on multiple pregnancy rates. Real improvements in clinical outcomes will only arise if we set ourselves ambitious targets and continuously strive to deliver high performance medicine. Our Governors have contributed to determining the key priorities for improvement and these have been discussed fully and agreed with our Members Council on 14/05/2013. The completion of the Quality Report has been led by the Trust’s Medical Director and Director of Nursing and Midwifery. However, the document has been developed through involvement with the Trust’s Clinical Directorates, Board of Directors and a number of organisations with whom the Trust works.
Sub title Sub title Sub title Sub title Sub title
In all that we do in relation to quality, understanding patient experience and engaging with women and their families remains central. A new Patient Experience Strategy is being introduced in 2013/14 with a focus on making sure the patient’s voice is heard and the patient experience is paramount in helping us make decisions on how to improve what we do as well as designing new services. Our Trust has also just completed a pilot of customer experience training and trained a number of Customer Care Champions. Our Trust is implementing the new Friends and Family Test regime building on our results from last year that are shown in this report. We actively seek real time feedback from users of all of our service by phone, web and in person. We invite complainants to come in and feedback to staff directly and using the Governors to help us observe care in our clinical area. We have extended the Patient Story to Board initiative to include new ways for patients to record their stories for the board to hear if they can’t attend in person. We are putting all our Sisters, Matrons and Heads of Nursing and Midwifery back into uniform and making sure they are highly visible in all clinical areas so patients can identify and contact them. We have also introduced care rounds on every shift in each clinical area to ensure that patients see and talk to the nurse or midwife in charge of the area and discuss their care needs. Our Director of Nursing and Midwifery and I also do care rounds across a variety of clinical areas in the Trust on a weekly basis in addition to the rest of the Board doing Walkabouts on a monthly basis. As a Trust, we are firmly committed to combating healthcare acquired infections (HCAIs) and have in place a Trust-wide strategy to ensure that our excellent track record is maintained. We have continued to have positive results from the environmental inspections of our hospital. The Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. We participated in three special reviews or investigations by the Care Quality Commission during 2012/13 and in all three we were found to be fully compliant with the standards required.
Page | 80
No document that refers to Quality in the NHS in 2013 is complete without reference to The Mid Staffordshire NHS Foundation Trust Public Inquiry chaired by Robert Francis QC. Our Trust is developing a full and detailed response to each of the relevant recommendations following the Government’s response. This is being carried out by the Executive team with the input of the Clinical Governance, Informatics and Human Resources functions. The final response will be shared through the Patient Outcome Committee as the Board Sub-committee responsible for clinical safety, risk and governance matters. It will then be presented to the Board of Directors in autumn 2013. The Trust will share its findings and plans this with its governors, commissioners and other identified partners. The response will be published as required by the end of 2013. This Quality Report sets out our achievements and also our ambitions to continue to be a leading provider of local, regional and national importance. I am satisfied that our report fairly reflects the quality of services we provide, and that the information that supports the document is correct and auditable.
Professor Ros Keeton
May 2013
Chief Executive
Page | 81
Part 2 – Priorities for improvement and statements of assurance from the board Update on Quality Accounts 2012-13 and Main Priorities for 2013-14 This represents our third set of Quality Accounts at Birmingham Women’s Hospital NHS Foundation Trust (BWNFT or the Trust). In the previous two reports we have kept the same main priorities, however after discussion amongst the clinicians it was proposed to discontinue the indicator regarding actions being completed on time following serious incidents. The reason for this is that whilst we remain dedicated to completing these actions in a timely fashion we believe that the good year on year performance on this has resulted in it being superseded by other priorities within the Trust. Therefore we have replaced this with the aim of achieving multiple pregnancy rates at or below the target of 12% for the coming year. Our other 2 main priorities have not reached our targets and therefore remain clinical priorities. The Management Board of the Trust and the Board of Directors have agreed to these changes. We have initially discussed this with our Governors, who include members of staff and patients, and have then formally discussed these at Members Council, which includes representatives of our wider constituency. At this meeting they were made aware of the rationale of maintaining two of our previous priorities and elevating the multiple pregnancy rate to a main priority. Performance of Quality Priorities from 2012/13 Priority 1 - To aim to improve the detection rate of intrauterine growth restriction (IUGR) to 35% Perinatal mortality has long been recognised as being high in the West Midlands, whilst this is partly accounted for by the population we serve a recurrent theme in our investigation of perinatal deaths is the failure to detect fetal growth restriction. In light of this we have in the past and continue to give a high priority to the detection of IUGR. This last year we have implemented all the planned initiatives in our previous report with the exception of investigating the benefits of using the first trimester biochemical screening results for trisomy 21 as an additional risk factor for IUGR. These initiatives are listed below: The Day Assessment Unit will move to a new purpose built facility that is co-located with Triage and Delivery Suite The administrator of the Guardian System taking up post and their role in developing the electronic record, aiding real time data collection. Constant reminders to appropriate clinical staff regarding continuing growth scans until delivery rather than stopping at 36 weeks of gestation, an important change in practice Increase direct access from community midwives to the Day Assessment Unit, facilitating rapid assessment Increase the number of midwives and doctors able to perform growth scans out of hours Re-examine the criteria for serial growth scans Investigate the benefit of using the results of first trimester biochemical screening for trisomy 21 as an additional risk factor for IUGR Despite this, as can be seen below, progress on this important indicator has been disappointing. Indeed the detection rates appear to have fallen, with a detection rate of 26% for quarter 4, though March’s data showed a 31% detection rate. In light of this we have returned to basics to examine how the original data collected by the perinatal institute was classified and it appears that for the period prior to April 2012 all babies in whom IUGR was suspected at any point were classified as detected by the Perinatal Institute, regardless of whether subsequent tests resulted in reassuring results. This obviously leads to a higher detection rate than our present definition where only babies that are managed as being growth restricted are included within our group of detected babies. Whilst this gives a lower detection rate it is, we believe, a more realistic assessment of our clinical detection rate of this condition. For the purpose of our present data collection the definition of detection is antenatally predicting babies whose customised both weight is below the 10th centile.
Page | 82
2013-14 Initiatives We therefore plan to continue with this data collection over the coming year and as well as continuing to remind people of appropriate guidelines our initiative for the coming year will be: To improve the accuracy of the electronic data collection enabling rapid identification of changes in the detection rate enabling focused training to occur Quality control of ultrasound images used for the estimated fetal weight calculation Further dissemination of these results to a wider audience, published on trust internet page since Q3 2012/3 Compare practice with recently published Royal College of Obstetricians guidelines Further Trusts to be contacted to develop a wider base of benchmarking data. Table 2.1 Percentage Detection Rates of Intrauterine Growth Restriction Date Q1-3
Q4
09-10
09-10
10-11
Jan
Q1
Q2
Q3
Q4
West
12
12-13
12-13
12-13
12-13
Mid 10-11
%
26
31
33
28
18
26
21
26
31
Detected
*Please note that data for 11/12 was only available for the month of January 2012 due to problems with data collection, see last year’s accounts.
Monitoring These results will continue to be monitored by the Clinical Lead for the Day Assessment Unit and the Maternity Services Directorate, being measured electronically and at least in the first quarter validated by manual audit. The results will be reported to the Patient Outcomes Committee on a quarterly basis and will be published on a quarterly basis on the Trust’s Quality Dashboard. In addition, as the electronic data collection becomes more robust, this will enable the lead for the Day Assessment Unit to receive rapid feedback. The Medical Director is the executive sponsor for this metric.
Page | 83
Priority 2 – To ensure that actions are completed on time following Serious Incidents At BWNFT, as with many other organisations within the NHS, the reporting culture of adverse incidents and the standard of investigation of these is constantly improving. This is generally perceived to be a good thing and organisations with higher reporting rates are considered to be indicative of an open and learning culture. We felt that examining the proportion of recommendations that have been implemented on time as a result of investigating these incidents is a valuable indicator of the responsiveness of our service to the inevitable incidents that will occur in a complex health care system. This indicator applied to all directorates and the achievement in each directorate can be seen in Tables 3.93.12. This year we increased our target from last year’s achievement of 88% to 93% by end of Q4 2012/13, a 5% increase. Overall the Trust completion of actions on time for the year was 92.3% (192 of 208 actions). For Q4 there were only 2 directorates with actions to complete and between them all but one was completed on time, giving a completion of 93.3%. It is for this reason that for future years we opted to continue this metric as part of our additional reporting, not as one of our three main priorities. Table 2.2 % of Actions Completed on Time Directorate Genetics and Labs Gynaecology Maternity Neonatology Total
% Actions Completed on Time 2010/11 2011/12 Q4 2012/13 80 100 Nil relevant 75 100 Nil relevant 82 86 100 (7 of 7) 85 98 88 (7 of 8 actions) 82 88 93.3
2012/13 75 100 92 90 92.3
Monitoring Although no longer a quality priority we will continue to monitor the performance by directorate on this standard through their quarterly reporting to the Patient Outcomes Committee. Priority 3 – Increasing the percentage of nursing and midwifery time spent delivering direct care. This is an important measure for the Trust. It assures us that despite the many and varied tasks nurses and midwives carry out during their busy day, that direct patient care remains their focus. It is audited on a monthly basis using a “time and motion study”. a proforma which was developed nationally as one of the tools for the Productive Ward, is completed, which calculates the percentage of time spent on what it classifies as either “direct / indirect care” a recognised audit tool developed for this purpose. Evidence shows that higher percentages of direct care improve: Efficiency of care. Patient experience. Safety and reliability of care Staff well-being and satisfaction with the job they do. The Trust has been working to improve this percentage continuously so it is disappointing to see a decline in the percentage of time achieved in a number of the clinical areas. However, this has prompted a Trust wide review of the time spent delivering direct care undertaken by the Director of Nursing and Midwifery and assisted by the Heads of Nursing and Midwifery. This measure and associated activities will be the subject of a practice improvement project undertaken in conjunction with the Institute of Healthcare Improvement (IHI). In the Midwifery Directorate we have increased the numbers of midwives as a result of a skill mix review (Birthrate Plus) and in 2013/14 will meet the recommended national ratio of 1:28 midwives to women. We are one of the first Trusts to do this and we believe that this, coupled with the improvement work we do, will improve this percentage during the next year.
Page | 84
In the Neonatal Directorate we have also recruited more nurses and have introduced a rolling recruitment and retention programme to ensure consistent levels of skilled neonatal nurses. We are also introducing a new Matrons post to help focus on family orientated nursing care. In the Gynaecology Directorate we have reviewed the way the Sister and Shift Co-ordinator roles work and have introduced initiatives to increase the time nurses can spend on direct patient care. We have also looked at the activities carried out by nurses that are not collected as direct patient care, but should be included, such as the telephone advice and support we offer our patients pre and post discharge. We will also evaluate the impact the electronic patient care records are having on direct patient care to ensure that the nurses are not spending excessive time away from the patient bedside to complete the electronic documentation.
Table 2.3 % of direct nursing and midwifery care. 2012/13 Indicator
Target
2011 12
201213
Q1
Q2
Q3
RAG status for
Q4 year
Gynaecology – 55%
43.5%
45%
43% 42% 39%
Wards 7 and 8
42.5%
Maternity Ward 1
55%
40.5%
40%
28% 55% 56% 44.75%
Postnatal floor
55%
56%
58%
66% 62% 69% 63.75%
Delivery Suite
55%
58%
44%
69% 79% 79% 67.75%
Neonatal
55%
46.5%
44%
47% 30% 44%
42%
2013-14 Initiatives Skill mix reviews of nursing and midwifery staff twice a year Introduction of care rounds in all ward areas Sisters becoming supervisory in clinical areas Evaluate the impact of electronic patient care records on time spent on direct patient care Improvement Project with IHI to improve the nursing and midwifery activity flow to increase the percentage of time spent on direct patient care Monitoring These results will continue to be monitored by the Professional Heads of Nursing and Midwifery as well as the Director of Nursing and Midwifery. The results will be reported to the Patient Outcomes Committee on a quarterly basis and will be published publicly on a quarterly basis on the Trust’s Quality Dashboard. The Director of Nursing and Midwifery is the executive sponsor for this metric.
Page | 85
Main priorities for 2013-14 For the year 2013-14 our three main priorities will be: 1. To aim to improve the detection rate of intrauterine growth restriction to 35% see above 2. To achieve a multiple pregnancy rate at or below the target of 12% 3. To increase the percentage of nursing and midwifery time spent delivering direct clinical care from the benchmark figure, see above We have already described our plans for priorities 1 and 3. Listed below is the plan for our new clinical effectiveness priority for 2013/14. Priority 2 – Achieve multiple pregnancy rates at or below the target of 12% The multiple pregnancy rate is defined by the number of pregnancies with more than one fetal heart identified on ultrasound scan following in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) as a percentage of the total number of pregnancies from IVF and ICSI for the given time period. Multiple pregnancy is a major risk factor for perinatal mortality and morbidity. In recent years the Human Fertilisation and Embryology Authority, HFEA have set a target for the rate of multiple births. This rate has been decreasing year on year and from this year will remain static at 10%. A problem of assessing service changes against a multiple birth rate is that there will be a significant time lag between changes in the processes of assisted conception and birth. At the present time the additional target we have set ourselves is the rate of multiple pregnancies which is more stringent and also more timely in that changes in practice will result in changes in multiple pregnancy rates before the necessary time delay prior to delivery and hence multiple birth. The multiple pregnancy rate will always be higher than the multiple birth rate due to the higher pregnancy loss rate in women with multiple pregnancies. This year’s result of 14% means we have not achieved our ambitious target of 12%; however we did improve our pregnancy rate, see Part 3. In the coming year we aim to decrease our multiple pregnancy rate to 12% whilst maintaining our excellent pregnancy rates.
Table 2.4 Performance against HFEA Target for Multiple Pregnancy Year*
HFEA Target**
BWH Fertility Centre Actual***
2009/10
24%
19%
2010/11
20%
17%
2011/12
15%
13%
2012/13
10%
14%*
Page | 86
Table 2.5 Multiple Pregnancy rate by quarter Multiple Pregnancy Rate % 2011-12
2012-13
Quarter 1
10
Quarter 2
4
Quarter 3
12
Quarter 4
15
Quarter 1
13
Quarter 2
22
Quarter 3
13
Quarter 4
17*
* April to March, except for 2012/13 where the March data is not yet available **Multiple Birth rate target, most recent target began in Oct 2012 ***Multiple Pregnancy Rate 2013-14 Initiatives In order to reduce the multiple pregnancy and live birth rate while maintaining or improving the pregnancy rate the Fertility team will introduce the following initiatives to increase the uptake of singe embryo transfer: 1. Increase the blastocyst culture and transfer rate to help select the most suitable embryo 2. Patients where the female partner is less than or equal to 37 years will have single embryo transfer if one or more top embryos are available, in both their first and second attempt (cf applied to first attempt only at present) 3. Where the female partner is more than 37 years but less than 40 years, single embryo to be transferred if one or more top quality embryo is available for transfer in their first attempt (double embryo transfer at present) 4. Single embryo transfer in all egg donation cycles if one or more top grade embryos available (new criteria) 5. Single embryo transfer in all cases of blastocyst transfer of top grade in a frozen cycle (new criteria).
The principal driver to achieve the multiple pregnancy target while maintaining the pregnancy rate is to select the best embryo by greater application of blastocyst culture and transfer.
Monitoring This metric is monitored on a monthly basis via the performance report and on a quarterly basis will be reported to the patient outcomes committee. The Medical Director is the executive sponsor of this indicator.
Page | 87
Statements of assurance from the board During 2012/13 the Birmingham Women’s NHS Foundation Trust provided and/or sub-contracted 11 relevant health services. The Birmingham Women’s NHS Foundation Trust has reviewed all the data available to them on the quality of care in 11 of these relevant health services. The data reviewed covered all there dimensions of quality and where data collection has impeded this it has been mentioned in the relevant part of the report. The income generated by the relevant health services reviewed in 2012/13 represents 100 per cent of the total income generated from the provision of relevant health services by the Birmingham Women’s NHS Foundation Trust for 2012/13. Table 2.6 Planned Income by Speciality Service
12/13 Planned Income (£)
Maternity
31,073,508
Fetal Medicine
3,408,669
Clinical Genetics
4,675,538
Laboratory Genetics
6,585,558
Gynaecology
11,220,047
Fertility Care
1,182,500
Neonatal Services
10,936,047
Neonatal Transport
1,570,950
Imaging Pathology & Lab Services Physiotherapy
289,615 1,931,341 183,060
Page | 88
Participation in clinical audits and national confidential enquiries During 2012/13 four national clinical audits and two national confidential enquiries covered relevant health services that BWNFT provides. During 2012/13 BWNFT participated in three (75%) national clinical audits and two (100%) national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that BWNFT was eligible to participate in during 2012/13 are as follows: Blood Sampling and Labelling (National Comparative Audit of Blood Transfusion) National Pregnancy in Diabetes (NPID) Audit. This data collection is on-going and will be reported in next year’s accounts when completed National Cardiac Arrest Audit (NCAA) Neonatal intensive and special care (National Neonatal Audit Programme) Maternal, infant and newborn programme (MBRRACE-UK) Medical and Surgical programme: National Confidential Enquiry into Patient Outcome and Death (NCEPOD) o Subarachnoid Haemorrhage The national clinical audits and national confidential enquiries that BWNFT participated in during 2012/13 are as follows: Blood Sampling and Labelling (National Comparative Audit of Blood Transfusion) National Pregnancy in Diabetes (NPID) Audit on-going data collection to be completed by January 2014 Neonatal intensive and special care (NNAP) Maternal, infant and newborn programme (MBRRACE-UK)* Medical and Surgical programme: National Confidential Enquiry into Patient Outcome and Death (NCEPOD) o Subarachnoid Haemorrhage The Trust did not participate in the National Cardiac Arrest Audit (NCAA), as there are very few incidents that meet the inclusion criteria, and the participation fee would not provide value for money for the Trust. An in house audit report is produced on a monthly basis, and the Trust also participated in the NCEPOD Cardiac Arrest Study for Hospitals (report received July 2012). The national clinical audits and national confidential enquiries that BWNFT participated in, and for which data was completed during 2012/13, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry:
Page | 89
Table 2.7 Participation in National Clinical Audit / Confidential Enquiry National Clinical Audit / Confidential Enquiry
Cases Submitted
Blood Sampling and Labelling (National Comparative Audit of Blood Transfusion)
1 (100%) organisational survey
Neonatal intensive and special care (NNAP)
1436/1436 (100%)
Maternal, infant and newborn programme (MBRRACE-UK) These criteria for the National Confidential Enquiry changed in January 2013 and for clarity we have included the same definitions for the entire financial year 2012/13, allowing benchmarking in subsequent years to be more applicable.
(Number/Percentage Reported)
100% laboratory error logs for May – July 2012 23 (100%) follow-up interviews
1 (100%) maternal death (death of pregnant women and women up to one year following the end of the pregnancy (regardless of the place and circumstances of the death)). 8 (100%) late fetal loss (the baby is delivered showing no signs of life between 22+0 and 23+6weeks of pregnancy) 3 of these cases were terminations of pregnancy 35 (100%) stillbirths (the baby is delivered showing no signs of life after 24+0 weeks of pregnancy) 4 of these cases were terminations of pregnancy 41 (100%) neonatal deaths (death of a live born baby (born at 20 weeks gestation of pregnancy or later or 400g where an accurate estimate of gestation is not available) occurring before 28 completed days after birth) 2 of these cases were terminations of pregnancy 2 (100%) post-neonatal deaths (occurring from the 28th day and before 1 year after birth of infants who have not been discharged from the neonatal unit).
Medical and Surgical programme: National Confidential Enquiry into Patient Outcome and Death (NCEPOD):
0/0 cases submitted
Subarachnoid Haemorrhage
Page | 90
The reports of four national clinical audits were reviewed by the provider in 2012/13 and BWNFT intends to take the following actions to improve the quality of healthcare provided: Table 2.8 National Clinical Audit Reports Reviewed National Clinical Audit Action NCEPOD Cardiac Arrest Procedures: Time to Intervene? (June 2012)
This report was received by the Clinical Governance Committee on 6th July 2012. The Trust intends to take the following actions: Revise Do Not Attempt Resuscitation Policies and Resuscitation Procedures
Heavy Menstrual Bleeding 2nd Annual Report (July 2012)
This report was received by the Clinical Governance Committee on 3rd August 2012. The Trust intends to take the following actions: Participate in a case-note review of 20 patients to validate the quality and completeness of patient-reported as well as administrative data Review internal resources available for national audits to improve response rates for future audits
Neonatal intensive and special care (NNAP) Data Completeness Report 2012 (July 2012)
This report was received by the Clinical Governance Committee on 3rd August 2012. The Trust has taken / intends to take the following actions: Q1: 34/35 babies have valid data. This reflects considerable input during the year with monthly walkabout clinical governance and case note rounds, educating nursing staff about the importance of completing paperwork later relied on for the Badger summaries and datasets (including this item on recording baby’s first temperature). Q2 (antenatal steroids) data completeness for the year is 98%. (129/132) This is a considerable improvement and reflects educational processes to junior staff. Q3 (ROP screening.) This is recorded at 60%. Actual figure is much higher (98%) as discussed later in report. Q4 (mothers milk on discharge) Data completeness is 100%. Q5 (documented consultation with parents). The data completeness for the year is 79% up from 73% last year. This reflects nursing and medical staff education. Q6-9: N/A Q10: (encephalopathy, daily consciousness and tone recording) very wide variability in results for NICUs (0% to 100%). BWNFT are benchmarked in the middle.
Bedside Transfusion (National Comparative Blood Transfusion Audit)
This report was received by the Hospital Thrombosis and Transfusion Committee on 22nd April 2013. The Trust intends to take the following actions: 2 patients were not issued with identification wristbands and one patient with a wristband did not have a date of birth recorded on it. Feedback will be provided to staff and a re-audit carried out in 2013.
Page | 91
The reports of 342 local clinical audits were reviewed by the provider in 2012/13 and BWNFT has taken / intends to take the following actions to improve the quality of healthcare provided: Table 2.9 Local Clinical Audits Reviewed Local Clinical Audits
Actions
Genetics and Laboratories Directorate
239 local audits were completed during 2012-13. A sample of actions the Directorate intends to take / have taken are as follows: A variety of Standard Operating Procedures (SOPs) are to be updated As a result of the audit of screening for Downs Syndrome requestors are now informed of incomplete request forms prior to sample analysis Fibronectin Analyser Usage in Triage: -
Staff trained in April 2012,
-
Give users barcodes to use as their user ID,
-
Keep a log book next to the fibronectin analyser to record all information regarding patient testing, quality control, lot numbers, problems and troubleshooting,
-
Laboratory involvement required,
-
Produce a new standard operating procedure
Pathology Quality Management Audits: -
138 audits completed. 277 non-compliances identified of which 18 remain open.
Regional Genetics Laboratories Quality Management System Audits: Gynaecology Directorate
85 Audits completed. 58 non-compliances identified of which 25 remain open.
31 local audits were completed during 2012-13. A sample of actions the Directorate intends to take / have taken are as follows: World Health Organisation Checklist Audit: -
due to poor compliance with full completion of form monthly reporting instigated. 100% of cases audited in March 2013 had a checklist and 100% of checklists used were fully completed. This covered both gynaecology and maternity
Emergency Readmissions: -
Incident form now completed for all readmissions
-
Infection control team review care during first admission of all patients readmitted with potential or actual wound infection.
Infection Control audits: -
Instant referral to estates department to undertake environmental repairs: paintwork, cleaning of fans, ceiling ducts
-
Replacement of covers or mattresses undertaken as necessary but also monitored regularly when making beds.
-
Equipment / bed spaces now clearly marked when cleaned and ready for use on next patient.
-
Flooring replaced in inpatient ward kitchens and gynaecology wards
Page | 92
Local Clinical Audits
Actions
Gynaecology
Perioperative Hypothermia:
Directorate
-
Maternity Services Directorate
Undertaken in response to National Institute of Clinical Excellence Technological Appraisal of use of Inditherm Mattress in preventing inadvertent perioperative Hypothermia. Prospective monitoring of patient temperatures did not show any significant difference when using Inditherm mattress. Results did not support changing current practice.
54 local audits were completed during 2012-13. A sample of actions the Directorate intends to take / have taken are as follows: Various amendments made to the electronic clinical record and paper proformas/documentation to improve record keeping and quality of care: -
Develop an electronic, user friendly, partogram with K2. In the interim, feedback to staff the importance of recording regular maternal observations on the paper partogram.
-
Development of a ‘commencement of Cardiotocograph, CTG, screen’ screen, to include reason for CTG, fetal heart with doppler and maternal heart rate.
-
Fetal Blood Sampling, FBS, screen on K2 to be amended to make easier to document timing of next review and time sample obtained. Remind staff to always use the FBS screen.
-
Current commencement of oxytocin screen on K2 needs amending to reflect current guideline and practise.
-
The vaginal birth after caesarean section, VBAC, guideline and Antenatal VBAC proforma amended to clarify what must be included in a management plan should labour occur early or not as planned.
-
Update current patient handling form and raised Body Mass Index Antenatal proforma to reflect the guideline.
-
External cephalic version, ECV, proforma to be developed to prompt promotion of pros and cons of ECV and correct counselling re: ECV.
Induction of Labour, IOL: -
New IOL pathway developed by multi-disciplinary team to aid documentation. This was launched in September 2012. Pathway to be replicated on the K2 electronic system in the future.
Maternal Early Warning Score (MEWS): -
Neonatal Directorate
Antenatal MEWS chart to be amended to assist staff in identifying the frequency of observations for common conditions of pregnancy. Frequency of observations for postnatal women to be added to the transfer page of the postnatal notes.
18 local audits were completed during 2012-13. A sample of actions the Directorate intends to take / have taken are as follows: Audit on Therapeutic Hypothermia in Hypoxic Babies: -
Improve staff education on cooling criteria and importance of passive cooling
-
Ensure that all cooled babies get their Magnetic Resonance Imaging in the specified timescale
Page | 93
Local Clinical Audits Neonatal Directorate
Actions
-
Improve electronic patient documentation on Badger particularly about the resuscitation and passive cooling information
The Unexpected Admissions Audit found some babies were admitted to the Neonatal Intensive Care Unit, NICU for hypothermia. Actions taken / planned in conjunction with the Maternity Directorate include: -
Hats requested for babies on Delivery Suite
-
Thermometer used for the newborn temperature after one hour is now given to the woman to keep.
-
Review the record keeping around skin to skin care and newborn temperature and respirations following the introduction of a revised labour and delivery record.
Support for Parents: -
Support for Parents pack to be reviewed to ensure correct information is given to parents.
-
Leaflets for many conditions are available in the filing cabinet, staff to be made aware of what information is where and importance of documenting when it is given to parents.
-
Pink sheets to be signed re the provision of information leaflets to parents within 48 hours of admission by nurses and parents.
-
Welcome Meetings commenced for parents to give them information and an opportunity to go through the pink sheets.
Feeding Guidelines Audit: -
Laminated nutrition flow charts and volumes of feed increases charts to be put in blue nursing folders
-
Encourage mothers to begin expressing on day of delivery.
Feeding co-ordinator to become more involved in this where appropriate.
Recruitment into research studies The number of patients receiving relevant health services provided or sub-contracted by BWNFT in 2012/13 that were recruited during that period to participate in research approved by a research ethics committee was 2662. This compares to last year’s figure of 1923, showing an improved recruitment.
Page | 94
Information on the use of the CQUIN framework A proportion of Birmingham Women’s NHS foundation Trust income in 2012/13 was conditional upon achieving quality improvement and innovation goals agreed between Birmingham Women’s NHS foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2012/13 are available online at: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics /Publications/PublicationsPolicyAndGuidance/DH_091443 https://www.gov.uk/government/publications/using-the-commissioning-for-quality-and-innovation-cquinpayment-framework-guidance-on-new-national-goals-for-2012-13 Further details for the following 12 month period are available online at: http://www.england.nhs.uk/wp-content/uploads/2013/02/cquin-guidance.pdf The total value of the income due to CQUIN payments for 2012/13 is £1,736,592. The value achieved for 11/12 that was conditional upon achieving quality improvement and innovation goals was £987,711.
Care Quality Commission Regulations BWNFT is required to register with the Care Quality Commission and its current registration status is registered without conditions. The Care Quality Commission has not taken enforcement action against BWNFT during 2012/13. BWNFT has participated in three special reviews or investigations by the Care Quality Commission relating to the following areas during 2012/13: Table 2.10 CQC special reviews or investigations Special Review / Inspection
Standard(s) Reviewed
Outcome
Outcome 21: Records
Compliant – no actions required
Routine Inspection
Outcome 02: Consent to care or treatment Outcome 04: Care and welfare of people who use services Outcome 09: Management of medicines Outcome 14: Supporting workers Outcome 17: Complaints
Compliant – no actions required
Cause for Concern Inspection
Outcome 6: Co-operation with other providers
Compliant – no actions required
Termination of Pregnancy
Outcome 16: Assessing and monitoring the quality of service provision
Page | 95
Data Quality NHS Number and General Practitioner Registration Code Validity Birmingham Women's NHS Foundation Trust submitted records during 2012/13 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data: which included the patient’s valid NHS number was: o 99.53% for admitted patient care o 99.68% for outpatient care; which included the patient’s valid General Practitioner Registration Code was: o 98.3% for admitted patient care; o 99.2% for outpatient care. The percentage for Accident and Emergency care is not Applicable to the Trust
Information Governance Toolkit attainment levels Birmingham Women's NHS Foundation Trust's Information Governance Assessment Report score for 2012/13 was 75% and was graded Green - satisfactory. All requirements met the minimum target Level 2 resulting in a ‘Satisfactory’ score. There was an overall percentage rise from 71% obtained in 2011/12 to 75% in 2012/13, reflecting movement of 4 requirements from Level 2 to Level 3. The Trust is undertaking a number of actions to improve and maintain this score: review business continuity plans and procedures in detail and audit actual compliance. develop a training plan to ensure IT training is delivered more evenly through the year, thereby reducing the risk on the existing year end rush. strengthen evidence re the disposal of records to ensure Trust wide compliance with the Records Management NHS Code of Practice 2006. continue records review & update evidence so that ALL corporate areas have been audited and a complete inventory has been created which is actively managed.
Page | 96
Clinical coding error rate Birmingham Women's NHS Foundation Trust was not subject to the Payment by Results Clinical Coding Audit during 2012/13 by the Audit Commission.
However the Trust did invite an external auditor to conduct an audit in line with the requirements of the Information Governance Toolkit. They have found the following: Overall HRG error rate 0.78% Primary Diagnoses Incorrect 4% Secondary Diagnoses Incorrect 2.1% Primary Procedures Incorrect 2.04% Secondary Procedures Incorrect 1.43%. These figures should not be extrapolated beyond the sampled services. Coverage of the sample included maternity and gynaecology services only.
Birmingham Women's NHS Foundation Trust will be taking the following actions to improve data quality: 1. Increase the remit of the Data quality group to include all information systems in the Trust 2. Increase the number of data quality indicators for reporting to senior executives and managers within the organisation 3. Use externally generated data quality reports and benchmarking data to improve local quality, and create appropriate plans to manage any issues 4. Continue to run monthly workshops that highlight data quality issues and the underlying processes that drive incorrect data capture. 5. Continually update all policies and procedures that identify good practice with regard to data capture and quality. 6. Create tools to enable users to identify and log errors and manage data quality issues locally and feed these into the incident reporting and risk management systems Data made available via the Health & Social Care Information Centre Below follows a series of indicators benchmarked against other Trusts. In some cases only historical data is available for benchmarking. Summary Hospital-Level Mortality Indicator (SHMI) As specified in January 2013 by the Information Centre for Health and Social Care, specialist Trusts, such as BWNFT are exempt from this indicator.
Page | 97
Emergency readmissions to hospital within 28 days of discharge from hospital The data made available to the NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients aged – (i) 0 to 14; and (ii) 15 or over, readmitted to a hospital which forms part of the Trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period. Numerator The number of finished and unfinished continuous inpatient spells that are emergency admissions within 0-27 days (inclusive) of the last, previous discharge from hospital (see denominator), including those where the patient dies, but excluding the following: those with a main speciality upon readmission coded under obstetric; and those where the readmitting spell has a diagnosis of cancer (other than benign or in situ) or chemotherapy for cancer coded anywhere in the spell. Denominator The number of finished continuous inpatient spells within selected medical and surgical specialities, with a discharge date up to March 31st within the year of analysis. Day cases, spells with a discharge coded as death, maternity spells (based on speciality, episode type, diagnosis), and those with mention of a diagnosis of cancer or chemotherapy for cancer anywhere in the spell are excluded. Patients with mention of a diagnosis of cancer or chemotherapy for cancer anywhere in the 365 days prior to admission are excluded. The BWNFT considers that this data is as described for the following reasons; the rate of readmission of people aged