1. Safe Surgery
The WHO Safer Surgery Steering Group set up in March 2015 reported for the first time to QSC. Observational audits are underway to identify gaps and barriers to safe implementation of the checklist. The group is focussing on changing the culture in surgical areas away from a tick box attitude to changes in behaviour by positive interventions, aligning practice with Trust values and sharing best practice such as ‘good catches’. Work has already been undertaken with staff to improve accuracy of records and to ensure staff are empowered to challenge non-compliant practice. A Trust policy is being drawn up.
QSC noted the cross-committee referral from the Audit committee of the internal auditors’ report into compliance with the checklist, from April to September 2014. The audit received an amber/red rating and included one high priority recommendation. QSC agreed that progress with the cultural change needed to embed the essential steps for safe surgery should be added to the safety presentations to be presented to the Board of Directors.
2. Patient Safety & Risk Steering Group
The Steering Group escalated two key areas of concern identified by its sub committees:
2.1 Wrong blood in tube incidents-
The Trust has previously agreed to implement the British Society for Standards in Haematology recommendation that all transfusion requests should be based upon two independent blood samples per patient. QSC supports the prioritisation of the implementation of the two sample initiative to reduce the risk associated with ‘wrong blood in tube’ incidents. The Transfusion committee are be notified that they have the authority to implement the changes to practice.
2.2 Medical device training-
A plan is in development to implement a new process and system for capturing and reporting medical devices training within clinical areas, to improve the accuracy of data on training. It is anticipated that this plan will take 6-12 months to implement. QSC agreed that this should be discussed in detail at the June QSC meeting with the Medical Director for Surgery & Cancer.
3. Claims and Inquests
3.1 QSC received the annual report on Claims and Inquest Management for 2014-15 to provide assurance of monitoring systems to ensure that the trust complies with the Clinical Negligence Scheme for Trusts (CNST) / Risk Pooling Schemes for Trusts (RPST) guidelines including
communication with relevant stakeholders, the dissemination of claims data, learning lessons from claims and action planning to improve patient safety, as set out in the Policy for Handling Clinical Negligence and Risk Pooling Scheme Claims. The report is a summary of clinical negligence and public and employer liability claims and Inquests. It incorporates examples of lesson learned in relation to claims and inquests and a development plan for 2015/16.
There have been 42 in house inquests and 26 out of Trust inquests and there may be other cases where the Coroner has had separate discussions with Trust staff.
3.2 QSC noted the cross-committee referral from the Audit committee of the internal auditors’ report into Inquests and the Trust response. The audit received an amber/red rating. It compares the two methods of management of inquests ‘in-trust’ and ‘out-of-trust’ (the patient dies elsewhere following discharge from UCLH) and concludes that the latter is not as well managed. This is a known risk exacerbated by more coronial inquests which are more searching and which families
and legal representation more commonly attend then previously. QSC agreed that all inquests should be handled in house and have referred to the Executive Board for consideration of resources.
4. Duty of Candour compliance
QSC received a second report on compliance with the Duty of Candour regulations (Health and Social Care Act 2008, Regulations 2014) introduced in November 2014. Compliance with Duty of Candour as reported on Datix is low and the report outlined some of the reasons for low
compliance and proposed actions to improve reported compliance. It was felt that Duty of Candour is being implemented but not being reported on Datix and the true picture is better than that reported.
5. Safeguarding
5.1 Child Safeguarding
In compliance with the Children Act 2004, QSC received the child safeguarding committee annual report for 2014-15. The report reviewed the ongoing work of the committee, evaluated last year’s activities and highlighted areas for improvement over 2015/16.
Key achievements were in training:Compliance with level 1 and 2 training is greater than 90% and additional training to meet NICE guidance requirements for domestic abuse has been successfully integrated with child safeguarding training from quarter 3 and compliance has met CCG CQUIN targets. In addition a Section 11 audit has been completed and presented with an action plan to Camden Child Safeguarding Band and was well received. The Safeguarding policy has been updated and approved.
Key risks are: electronic flagging related to duplicated hospital numbers in which all records may not be flagged.
There has been a decline in compliance of those requiring Level 3 training to 78%. QSC supported the move to stop staff from working with children if level two training is not undertaken within a month. A further risk due to new national guidance recommending that children undergoing an intimate examination need to have a chaperone present was noted.
5.2 Adult Safeguarding
In compliance with Trust policy QSC received the Safeguarding Adults committee annual report for 2014-15. There were four upheld allegations against staff, the same as the previous year.
Key achievements include that divisions have achieved training compliance for level one of 95% and two of 91%, a Learning Disabilities clinical nurse specialist (CNS) and a substantive band 7 Safeguarding Nurse have been appointed, significant improvements have been made in support for people suffering from domestic and sexual abuse and the Trust has achieved the CQUIN target. We have made 103 Deprivation of Liberty (DOLs) safeguard applications. We have provided direct support for 104 high-risk inpatients with learning disabilities to improve their experience whilst in hospital, since December 2014.
Key risks include training, increasing administration burden of applications for DOLs safeguards, impact of changes in DOLs and 2015 Care Act of continued increasing trend in safeguarding referrals, and compliance with statutory changes by the Care Act to “make enquiries” and “Making Safeguarding Personal”.
6. Monitor Quality Governance Framework
QSC received the examples provided by Monitor as a description of the practice at UCLH, and where there is variance, including proposed actions. The QSC asked for clarification and further information on some items. It was agreed that it would be helpful to consider training on quality governance and continuous improvement if it was tailored to what we might require e.g.
Committees working better together. This paper will be updated following these comments and will be signed off at the Audit Committee.
7. Inpatient Survey results 2014
More patients responded to the survey this year compared to last year. The next survey data collection will be brought forward to July 2015.
UCLH were ‘about the same’ compared with other Trusts for all sections. Overall performance was very similar to last year with a slight downward trend on 60% of questions, although not
statistically significant. There was slight improvement on 30% and no change on 10% of questions.
Hospital & ward section showed deterioration in 8 of 11 questions, doctor & nurses sections showed slight downward changes and ‘Leaving hospital’ showed deterioration in questions related to medications and discharge planning. In contrast, operations & procedures performed well. Going forward, the plan is to reinvigorate the patient survey agenda including wide distribution of survey results, to re-energise the existing programmes such as the ‘always’ campaign, to continue “help with meals” recommended actions by the Nutrition group, to make more use of Meridian data at ward level and have working groups to track improvements and/or re-define actions.
8. Complaints
The last quarterly complaints report to QSC indicated a rise in contacts about delays and cancellations and application of the access policy
.
QSC received an analysis of specificcomplaints about delays/DNA, discharge and the referral to treatment targets (RTT). QSC was informed that the total number of all formal complaints UCLH received in 14/15 increased by 7%. When delay and cancellation is the main subject this is 21% higher than the previous year. Whilst some appointment changes are linked to delays or timings of tests, many appear to be linked to administration issues. Delays on the day of outpatients appear to have reduced on general review.
9. Incident reporting external benchmarking
QSC was informed that the National Reporting and Learning System (NRLS)has changed the way in which it calculates and benchmarks incident reporting. UCLH has improved its
benchmarking position with other similar trusts but has maintained its benchmarking position with the Shelford Group trusts which is a ranking of 7 out of 10. CQC and NRLS methodology are now aligned.
In relation to incident reporting, our incident rate previously was 5.44 incidents per 100
admissions. When adjusted for bed days, our reporting rate has increased from 29.6 incidents per 1,000 bed days (Oct 13 to Mar 14) to 32.68 incidents per 1,000 bed days (Apr 14 to Sep 14), or 10%. The QSC noted that incident reporting rate is only one indicator of a safe system and other indicators needed to be used.
11. Trust Quality & Safety performance
QSC received the Performance Book for May 2015.
CVC audit compliance
QSC had requested further information on this indicator, in particular to investigate the low compliance for the month of September 2014.QSC was assured thatin August and September 2014 the audit questions on Synbiotix were amended and investigation has shown that this caused confusion for some wards when completing the audit which led to such a low compliance rate in September. There was no increase in the number of bacteraemia in September and compliance improved and has been sustained in subsequent months.
Cathy Mooney Deputy Director of Quality & Safety May 2015 (On behalf of Sandra Hallett, Director of Quality & Safety)