Quality Account 2009/10
Section 1 - Statement of the Chief Operating Officer on behalf of the
Community Healthcare Arms Length Management Board.
Community Healthcare is the Provider Arm of NHS SE Essex and we deliver
Integrated Community Services to local people in Castle Point, Rochford and
Southend with Local Authority and other NHS colleagues.
We have for many years been developing ways in which to seek patient and stakeholder views, with the objective of using your feed-back to improve the quality of the services we offer. Feedback is received through a number of different sources: direct face to face contact with patients, patient representation at meetings, information through patient surveys as well as from complaints and compliments. In addition some services have held focus meetings to receive information from patients regarding the design of services. The quality of our services is of the utmost importance as it directly affects the outcomes of care and your continued health and well being.
In setting the overall vision and direction for our organization our Board have established key value statements that we explore with our stakeholders at every opportunity. In the increasingly commercial environment for healthcare it is our stated aim to be your choice of community health and care services supporting and enabling you to live the best life possible.
In order that we can meet this aim we need to ensure that every single day of the year:
We aim to design services to meet your needs
We put you at the centre of what we do
We deliver the best quality of care possible
We are approachable and encourage feedback about services provided and take action to improve services on the basis of this feedback.
We provide safe services and have good standards of infection prevention and control.
We do what we say we will
We listen and involve you and your carers. .
We treat everyone with dignity and respect.
This Quality Account is designed to share with you progress made during
2009/10. By the very nature of our wide range of service provision (across 47 services employing over 750 staff) we cannot be sure that we are making substantial and sustained progress unless we establish ways of checking the experience that patients, carers and stakeholders have of our services .
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During 2009/10 we have reviewed each of our 47 different services (Service
Lines) to assess how they have delivered against Care Quality Commission
Requirements to be Safe, Effective and Responsive. In addition we have developed ways of seeking service user feed-back to provide us with greater insight into your experience of our services as the occasion arises.
Some of the questions we ask may seem quite simple such as “would you recommend this service to members of your family?” However such feed-back gives us valuable insight into what we need to do to improve our services and your experience of them.
Many of our service Users are frail and vulnerable and we strive to approach our service users maintaining their privacy, dignity and respect.
All members of the Arms Length Management Board (ALMB) have contributed to the contents of this Quality Account, as have a number of Heads of Service.
Feedback has also been sought from Local Involvement Networks (Lin ks) throughout the year (as regular attendees at the ALMB) and also during the drafting process. The performance indicators that we have used this year to assess service quality have arisen from both National and Local targets.
For ease of reference they are summarized in the table below:
Identifier Measure
G3 Audit of our record keeping
Performance
Achieved
G4a
G4b
G4d
G4e
Hand washing compliance of staff
Care Bundle usage
(evidence based audit tool) for Urinary catheters and
Percutaneous Endoscopic
Gastrostomy Feeds (feeding tubes directly in to the stomach)
Actions following
Methicillin-resistant
Staphylococcus aureus
(MRSA) and Clostridium difficile (C.Diff) occurrences -
Immediate
The risk of our patients to
MRSA
Requirement
100% of services to undertake a quality of record keeping audit of which 90% achieve the required standard.
Hand washing compliance against audit 100%
100% patients with invasive device to have care bundle in place
Recommendations implemented immediately.
Summary data from
MRSA Database to
Achieved
Achieved in inpatient areas
(Cumberlege
Intermediate care
Centre (CICC) and
Parklands)
Achieved
Achieved
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SH2
B1
B2
C1
G4f
G4i
G4l
G4m
G8a
G8b
SH1
C5a
Compliance with MRSA guidance
Our compliance (by staff) of best practice to be bare below elbows
The incidences of C.Diff contracted at Cumberlege
Intermediate Care Centre and
Parklands
The number of patients treated for MRSA be presented to commissioners monthly
100% Percentage compliance with
MRSA guidance. (re screening elective admissions)
!00% Compliance with uniform policy and bare below the elbows.
Report numbers of cases at CICC and
Parklands
The percentage of Community equipment delivered within 7 days to those in Southend
The percentage of Community
Equipment delivered within 7 days to Castle Point &
Rochford
The percentage of the population aged between 15 and 24 screened or tested for
Chlamydia – target 25%
The number of people who have quit smoking for at least
4 weeks
The numbers of patients who have a Long Term Condition and a Personal Care Plan
The prevalence of Mums breast feeding at 6 to 8 weeks
Coverage of Mums breastfeeding at 6-8 weeks
The prevalence of Mums breast feeding at 10 days
The immunization rates of children aged 13-18 who have been immunized with a booster dose of tetanus, diphtheria and polio.
Childhood Obesity - %children in reception year with height
No: of patients commenced on treatment monthly
98.75%
97.2%
Joint target
CHC 8180
PCT 8300
2700 quitters
100% patients to be offered
63%
94%
No KPI
89%
88%
Achieved
Achieved at CICC and Parklands.
(93% Trust wide)
4 – CICC
0 - Parklands
0
98.82%
99.8%
CHC – 8180 screens
2050 total offered to date
2733 quitters
39.62%
99.69%
48.71%
65.48%
92.8%
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C5b and weight recorded
Childhood Obesity - % children in Year 6 with height and weight recorded.
92% 97.0%
Key: Please note numbers in green indicate target achieved, red target not achieved (some joint targets) black indicates actual numbers.
Howard Perry
Interim Chief Operating Officer
24 June 2010
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Part 2 Looking Forward - Priorities for Improvement
Whilst our performance information shows significant areas where we are delivering excellent services, we are mindful that there are areas where we need to improve. These are set out in more detail below. Wherever possible we have compared ourselves with other NHS organizations. Where this has not been possible we have compared ourselves with the previous year’s performance to ensure that we are improving year on year.
Priorities for 2010/11 have been determined by a number of factors; areas where performance has deteriorated, where we have not met national or local targets.
Other priorities have been identified as a result of patient feedback and local risk events and where there are lessons to be learned from national findings such as the Francis Report 2009 (Mid Staffordshire NHS Foundation Trust report).
Whilst many services undertake specific satisfaction surveys we have not previously had a comprehensive and consistent approach to seeking feed-back from patients at the time of their care. However we are in the process of implementing a system called Patient Tracker. This will enable us to seek your views at the time that care is delivered to you in a way that ensures that your responses remain confidential to those directly providing care to you. Patient
Tracker provides us with the opportunity of changing the questions we ask you if there is something specific that we are concerned about or something that is specific to the service you are receiving. The implementation of Patient tracker was a Commissioning for Quality and Innovation (CQUIN) initiative for 2009/10.
The Commissioning for Quality and Innovation payment framework makes a proportion of our income conditional on our service quality and innovation.
The numbers of Mums leaving hospital and breast feeding are well below those appropriate for the health and wellbeing of children. The challenge for
Community Healthcare historically has been that at the first point of contact with the Health Visiting services (between 10 and 14 days), women have already decided not to breast feed and therefore it is not possible to re-establish breast feeding. In conjunction with Southend Hospital we are establishing a new programme of volunteers to assist us in our education of new Mums into the benefits of breast feeding in an attempt to support them in achieving higher levels of breastfeeding. This initiative forms one of the CQUIN targets for 2010/11.
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2.3 Wheelchairs
Whilst we are pleased to report significant improvement in our performance against waiting times for wheelchairs for adults and children, our delivery timescales remain short of those appropriate for local needs. For 2010/11 we have established a joint venture pilot with the Whizz-Kidz organization which is a charity that provides wheelchairs primarily for children and up to the age of 25.
In practice Whizz-kidz will lead the service for local children and Community
Healthcare will focus on the wheelchair service for adults. Working together, we have access to each others best clinical practices and procurement leverage to improve the delivery time and cost of wheelchairs. In addition we will be working with our PCT Commissioners to ensure that the level of service commissioned is appropriate for the number of local people who require wheelchairs.
2.4 Improved Immunization Rates
The Measles Mumps and Rubella (MMR) immunization is a joint target with the public health team (Commissioners) of which children’s services are responsible for some part. Overall the PCT has not met the target for this year which is 92% of 2 year old children receiving the immunisation. South East Essex PCT achieved 88.5%, which is an improvement against 2008/9 achievement of 83.7%.
In order to both address this issue and improve future performance moving forward there is now a sub group for MMR which is commissioner led. The PCT
Commissioners have clarified that the focus for 2010/11 is on improving the uptake for children aged 5 to 18 years. Community Healthcare staff including
Health Visitors and School Nurses are included in the sub group and will contribute to the implementation of the action plan (Appendix 1). However it is useful to note that GP’s who are ultimately responsible for delivering the immunisation programme are not included in the subgroup.
2.5 Executive & Non Executive Directors - Walk the floor, look and learn.
During 2009/10 the Directors
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of Community Healthcare undertook audits of clinical areas to ensure that facilities were clean and fit for purpose. This provided an opportunity for Directors to speak to staff and patients. However the majority of this activity related to infection control and it is recognized - in particular from the experiences of the Board in Mid Staffordshire - that these
‘walkabouts’ need to be more frequent and focus on wider quality issues and
1
It is recognized that Directors of Community Healthcare are not Executive Directors in a legal sense as they are not members of NHS SEE PCT Board. However as they are members of
Community Healthcare Arms Length Management Board (ALMB) they are referred to as
Executive Directors for the purposes of this report. Non Executive Directors of Community
Healthcare ALMB are formal Non Executive Directors of SEE PCT Board.
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staff satisfaction. It is proposed that quarterly ‘walkabouts’ are conducted jointly with Executive and Non Executive Directors.
2.6 Personalised Health Plans for People with Long Term Conditions
High Quality Care for All: The Next Stage Review and the East of England document ‘Towards the Best Together’ committed NHS organizations to offering everyone with a long term condition a personalized health plan. The purpose of a personalised health plan is to support improvements in health quality and mobility through self care. Community Healthcare has not achieved this target and therefore is in the process of developing an action plan in collaboration with GP practices to ensure that this target is delivered by March 2011.
For 2010/11 commissioners are making 1.5% of our contract value available for us to earn if we achieve locally agreed quality improvement and innovation goals.
These goals are set out in the table below.
We will support South East Essex PCT in the transformation of services for people with long term conditions ensuring appropriate care and support for people and their families which enables them to remain within their home and community setting, avoiding admission to hospital. This scheme will include the development of an integrated health and social care team for the Fortis Practice
Based Commissioning (PBC)
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cluster population and the use of technology/home monitoring systems to support patients.
We will create a training programme that will support our frontline staff (those delivering patient care such as District Nurses & Health Visitors) to deliver what are known as “brief interventions” in respect of a range of lifestyle interventions.
This will enable our clinical staff to provide lifestyle advice to local people whilst they are delivering their primary clinical support to patients.
We will (jointly with Southend University Foundation NHS Trust) increase the percentage of women initiating breastfeeding and sustaining breastfeeding. In so-doing we are required to increase patient satisfaction (with regard to support provided to them) and improve the sharing of data between the hospital and ourselves
We will develop a comprehensive internal quality and information framework that will enable us to report in public session our quality progress and in a form that can be shared with commissioners.
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(PBC cluster - a group of GPs who work together to manage services, including managing a budget to buy services from various NHS and other providers to meet the needs of their practice populations).
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We will support the national “Pathfinder Project” by developing a comprehensive patient pathway and service specification for those people suffering from the long term condition of Chronic Obstructive Pulmonary Disease (COPD).
We will pilot the Department of Health developed contract Currency and Pricing options for the Healthy Child Programme, which would link the outcome benefits that patients receive compared with the income we derive from the programme.
Details of performance against 2009/10 CQUIN targets are set out in chapter 3.
Progress with regard to all of the above indicators was monitored through the internal governance arrangements (ALMB Governance structure Appendix 2) and through the Statement of Accountability with the Primary Care Trust Board
(PCT). The internal governance arrangements include non Executive Directors membership on all of the Arms Length Management Board (ALMB) subcommittees. The minutes of all of the sub committees are presented in public to each ALMB meetings. The minutes of ALMB are presented in public to the
PCT Board.
In addition to the above all Directors provided Directorate reports to the ALMB that reported on key performance issues and matters of exception.
The PCT Board remains ultimately accountable for the performance of
Community Healthcare, until April 2011, when it is anticipated that Provider
Services will transfer to an alternative provider.
2.8 Care Quality Commission
Community Healthcare was required to register with the Care Quality
Commission (CQC) as a provider of healthcare services under the Health and
Social Care Act 2008 (Regulated Activities) Regulations 2010.
An initial application for registration, including a declaration of compliance with the Commission’s Essential Standards of Quality and Safety was made in
January 2010; this application was made in consultation with the CQC local advisor for the East of England.
This application identified five regulated activities delivered by the organization:
•
Accommodation for persons who require nursing or personal care
•
Treatment disease, disorder or injury
•
Family Planning services
•
Surgical
•
Nursing care
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Community Healthcare was required to declare compliance with the essential standards of quality and safety at each of the locations where regulated activities are delivered. On the advice of the CQC the initial registration application in
January 2010, all activities were registered at Trust Headquarters (Harcourt
House).
This application was accepted by the CQC on the 23 March 2010, without condition and Community Healthcare has not been the subject of any enforcement measures by the Care Quality Commission.
On 1 April 2010, a successful application was made to the CQC to amend the locations identified for the regulated activities, this amendment facilitated inclusion of primary medical and dental care facilities.
The Clinical Governance Manager and Director of Clinical Services have revisited the guidelines and have mapped the regulated activities and registered locations against the service lines of Community Healthcare. This mapping process identifies that a further amendment to the registered locations should be made to include Podiatric Surgery and this application will be made in June 2010.
Clinical audit within Community Healthcare is supported the by Clinical Audit and
Effectiveness Facilitator, who is a key member of the Clinical Governance Team.
A rolling programme of audits is undertaken across the clinical services throughout the year as the basis of a quality improvement process to improve patient care and experience. In 2009/10 the local audit programme focused specifically on patient experience and infection control practices; in addition,
Community Healthcare participated in the National Audit of Continence Care, the results of which will be available to us in July 2010.
Community Healthcare acknowledges that a broader range of clinical audits is required to reflect our commitment to continuously seeking to improve patient outcomes and experiences. The 2010/11 audit programme will be designed to reflect this and all clinical services are required to identify a minimum of one service specific audit to undertake in addition to the rolling programme supported by the Clinical Governance Team.
Participation in National Audits is actively encouraged by the Director of Clinical
Services. To date in 2010/11, Community Healthcare have registered to participate in the following audits:
•
National Audit of Diabetes Care
•
Falls and Bone Health in Older People
•
Food and Nutrition in the Elderly
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The Clinical Audit and Effectiveness Facilitator represents Community
Healthcare at the quarterly Essex Clinical Audit Forum to ensure the sharing of best practice across the region.
As a Community Provider Community Healthcare is not required to provide data for inclusion in the Hospital Episode Statistics and therefore does not submit returns to the Secondary Users System in the way that acute hospitals are required to. However managing confidential patient information is of paramount importance to us. During 2009/10 South East Essex PCT (commissioner and provider) scored 87% for information Quality and Records Management, assessed using the Information Governance Toolkit. A summary of the findings are set out in the table below:
Overall Scores
Information Governance Management
Confidentiality and Data Protection Assurance
Information Security Assurance
Clinical Information Assurance
Secondary Use Assurance
Corporate Information Assurance
Maximum
Possible
Scores
45
30
42
12
21
12
2008/09
Scores
41
28
41
9
16
9
Target
Scores
2009/10
40
27
39
10
16
9
% of
Maximum
Score
2008/09
91.11%
93.33%
97.62%
75.00%
76.19%
75.00%
% of
Maximum
Score
2009/10
88.89%
90.00%
92.86%
83.33%
76.19%
75.00%
Total 162 144 141 88.89% 87.04%
N.B. Scores have decreased due to the wording being changed for each requirement. Additional evidence required.
Part 3 - Review of Quality Performance
KEY NATIONAL PRIORITIES – In Summary
Healthcare
As previously stated Community Healthcare has performed well in relation to infection prevention and control measures. The PCT achieved the trajectory for
2009/10 of no more than 12 bacteraemias. Hand hygiene compliance in
Community Services (patient reported) is 96% and in inpatient areas 100%. This information is obtained through observational audits and questionnaires completed by Patients every quarter.
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The numbers of mums leaving hospital and breast feeding are well below those appropriate for the health and wellbeing of children. In conjunction with
Southend Hospital we are establishing a new programme of volunteers to assist us in our education of new Mums into the benefits of breast feeding.
The Trust was able to meet the target for smoking prevalence achieving 2733 people who had ‘quit smoking’ for a minimum of 4 weeks.
Community Healthcare exceeded the target of 92% of children in year 6 in South
East Essex having their height and weight recorded. This information was submitted to South East Essex PCT who uploaded the information to the
Department of Health where it was data cleansed prior to publication.
3.5 Chlamydia screening programme
During 2009/10 the Community Healthcare screening team worked hard to reach the increased screening target of 25% of 15 to 24 year olds population. This is a target that is shared with other providers such as GPs and Pharmacists, although the final screening figure reached was just under the 25% target of 9975 screens,
Community Healthcare achieved our proportion of the target and there were a number of other successes along the way. These achievements are set out in more detail below.
The National Chlamydia Screening Programme were keen that 60% of all screens came from ‘Core Services’ namely, GP’s and Pharmacies. During
2009/10, the Contraceptive and Sexual Health Services alone were responsible for 41% of those screened. Of those patients who screened positive within South
East Essex over a 9 month period 96.74% were successfully treated.
The challenge for this coming screening year is to continue the great work already being undertaken flowing through the Contraceptive and Sexual Health
Services and to supplement this with increased screening through the other core services venues of GP’s and Pharmacies. In order to achieve this we have recently employed another member of the team to support these venues with increasing screening targets.
We must not forget the hard work that the Central Screening Office administrative team provides in supporting the 3 other Essex PCT’s with their screening programmes. Their efficient and effective work has been singled out
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for praise by the other commissioning PCT’s and by the regional Chlamydia Coordinator.
The table below provides an at a glance look at Community Healthcare’s performance against key national priorities, more detailed information is provided in the sections to follow.
Indicator Plan Actual Trend
Childhood Obesity Rate
92% 97% Ò
Chlamydia Screening
Four Week Smoking Quitters
22.1% 24.1%
Ò
2700 2733
Ò
(as
15.06)
183 141
Ò
Incidence of Clostridium Difficile
% of infants breastfed at 6-8 weeks 63% 39.62% Not measured
08/09
Information regarding Breastfeeding status at 6-8 weeks from Birth
Immunization rate for children aged 1 who have been immunized for Diphtheria, Tetanus, Polio, Pertussis,
93% 96.8%
Haemophilus influenza type b
95% 96.8% Immunization rate for children aged 2 who have been immunized for Pneumococcal infection
95% 95.1% Immunization rate for children aged 2 who have been immunized for Haemophilus influenza type b, meningitis
Immunization rate for children aged 2 who have been immunized for MMR
92% 88.5%
Key
Ò Target met and improved performance against 2008/9
Ô Below planned target, however improvement against 2008/9 (83.7 %)
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3.6 Commissioning for Quality and Innovation (CQUIN) Incentive
Scheme 2009/10
In 2009/10, the priority areas for quality improvement determined by our commissioners were included within the contract as a Commissioning for Quality and Innovation (CQUIN) Incentive Scheme. The areas covered by the scheme were:
ƒ Data quality improvement in the recording of data collected for the
National Child Measurement Programme;
ƒ Ensuring that all patients with a long term condition being managed within our services had a personal care plan;
ƒ Screening all patients being admitted for inpatient care for MRSA; and
ƒ
Improving our patient feedback mechanisms through the implementation of the “Patient Experience Tracker” system.
We were unable to obtain postcode and ethnicity data for all year 6 children in schools within the Essex County Council area although we did achieve 39% compliance with the first area above. An information sharing agreement is now in place with the authority which will ensure that the data quality is improved in future years. This shortfall has no impact on the quality of services provided, but obviously reduces the quality of detailed reports that we are able to produce on the programme. We were fully compliant however for year 6 pupils on Southend on Sea area, and all reception year children.
All other CQUIN quality improvement targets were fully met.
4. PATIENT SAFETY
4.1 Infection prevention and Control
Community Healthcare staff provide a wide range of clinical services to the local population. These range from health promotion activities, to managing long term conditions such as Chronic Obstructive Pulmonary Disease (COPD), Diabetes and Heart Failure to providing and supporting patients (and their Carers) as they approach their end of life. Effective infection prevention and control standards are essential to ensuring the safety of patients in our care, through avoiding health care associated infections (HCAIs) as well as ensuring an excellent patient experience. Community Healthcare is proud of our infection control achievements, some of which are set out below.
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Studies show that infection rates can be reduced by 10-50% when healthcare staff regularly clean their hands. The introduction of alcohol hand rub has been instrumental in improving hand hygiene compliance in healthcare and is recommended for routine use in the clinical environment where hands are not visibly soiled. Hand rubs at the point of care are critical to increasing the likelihood that staff will clean their hands at the appropriate time.
The National Patient Safety Agency (NPSA) created the ‘clean your hands’ campaign. This was the cornerstone for the placement of near-patient alcohol hand rubs. Health Care Associated Infection (HCAI) is believed to cost the NHS at least £1bn annually and causes at least 5,000 deaths (National Audit Office
(NAO) 2000; NAO 2004). An economic evaluation suggested that 30% of these infections were preventable.
In 2008 the campaign was extended to primary care and the campaign was successfully launched in South East Essex on 1 st
July 2008. The campaign supports efforts to improve hygiene generally within a range of healthcare settings, including, clinics, health centres, and people’s homes, in a bid to reduce infections. It is based on national and international evidence of what works in hand hygiene improvement.
The campaign this year has focused on the World Health Organizations “5
Moments for Hand Hygiene”. The Five Moment approach aims to eliminate unnecessary hand hygiene by ensuring hand hygiene is performed at the right moments within the patient zone. All teaching sessions have included the 5 moments for hand hygiene and an on-going poster campaign has also reinforced this important message.
5 moments for hand hygiene
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Community Healthcare continues to embrace ‘Bare below elbows’. It is a requirement that all staff undertaking clinical practices must be bare below elbows. This has been introduced into both the clinical dress code policy and the
Infection Prevention and Control policy and guidelines. Audit tools which measure compliance with hand decontamination have been amended to incorporate bare below elbows and it is now included as a monthly key performance indicator.
Audits of hand hygiene and compliance with bare below elbows has consistently demonstrate 100% in the inpatient areas and 93% across the Trust throughout
2009/10.
Staphylococcus ( MRSA)
4.3.1 Bacteraemia
Community Healthcare has made a significant contribution to the reduction in the number of patients admitted to hospital with MRSA bacteraemia. The East of
England Strategic Health Authority set a standard of no more than 12 cases of
MRSA bacteraemias across all healthcare providers in South East Essex for
2009/10; this was a reduction from 2009/9 target of no more than 19 cases. The actual number of patients diagnosed with an MRSA bacteraemia for 2009/10 was
5. Of these 5, none were attributed to Community Healthcare. It is thought that this significant achievement has been achieved in part through more collaborative working with the hospital and other providers to gain knowledge and understanding from previous cases in order that lessons are learned and the necessary changes to practice implemented.
4.3.2 Screening patients for MRSA
Mandatory screening of all admissions to intermediate care and of patients undergoing podiatric surgery commenced in April 2009 in line with Department of
Health policy. Performance against this policy is monitored by the PCT commissioners on a monthly basis and has consistently achieved 100%.
In addition all patients with an invasive device in place (such as intravenous lines, urinary catheters and feeding tubes) were screened for MRSA during April
2009/10 to obtain a base line of the number of patients at risk of developing a bacteraemia due to MRSA. This has enabled identification of patients at high risk of infection who require appropriate treatment and has facilitated the ongoing monitoring and treatment of patients who are at an increased risk. This information is recorded on the MRSA high risk database, a summary of which is reported monthly to the Commissioning PCT. All new patients referred to the
District Nursing Service with an invasive device are also screened to establish the need for treatment.
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The table below shows the number of admissions, the number of MRSA screens and the number of positive cases isolated upon admission to intermediate care in-patient settings who require appropriate treatment. The number of positives indicates MRSA infection or colonization, not bacteraemia.
AREA
In-patient admissions Number screened Number positive
Q1 Q 2 Q 3 Q 4 Q1 Q 2 Q 3 Q 4 Q1 Q2 Q3 Q4
CICC
Parklands
51 43 36 60 51
14 9 15 13 14
43 36 60
9 15 13
4
1
9
0
5
0
2
0
Total/Q 65 52 51 73 65 52 51 73
Annual Total 241 241
5 9 5
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In addition to admissions for intermediate care all patients undergoing podiatric surgery are also screened for MRSA. In order to facilitate the screening process the pre-assessment of all patients was implemented by the service.
The table below shows the number of patients undergoing surgery, the number of screens undertaken and the number of positive results detected requiring treatment.
AREA
2
Number of procedures Number screened Number positive
Q1 Q 2 Q 3 Q 4 Q1 Q 2 Q 3 Q 4 Q1 Q2 Q3 Q4
South East
Essex
South West
Essex
59 65 45 59 59 65 45 59
20 20 16 21 20 20 16 21
0
0
0
0
0
1
Total/Q 79 85 61 80 79 85 61 80
Annual Total 305 305
0 0 1
1
These figures demonstrate 100% compliance with mandatory MRSA screening.
4.4 Clostridium
Incidence of Clostridium difficile is also monitored closely and reported as a key performance indicator (KPI) on a monthly basis. A target of no more than 183 cases throughout South East Essex was set. In total 141 cases were reported and of these only 76 cases were attributed to the community as a whole
(including GP practices). This figure demonstrates a reduction in cases on the previous year.
0
0
0
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Of the 76 cases of Clostridium difficile (attributed to community services) 4 cases were attributed to the Community Healthcare in patient facility, the Cumberlege
Intermediate Care Centre (CICC). Thorough root cause analysis was undertaken for each case and concluded that none of these 4 patients acquired infection as a result of cross infection during their in-patient stay at CICC, and each case was individually investigated and determined as unavoidable following review by the
Root Cause Analysis review group. Infection prevention and control measures are monitored by the Community Healthcare Directors through the Infection
Control Committee, Integrated Governance Committee and the Arms Length
Management Board.
There is clearly much work to be undertaken in the community to further reduce the incidence of Clostridium difficile and the work undertaken this year is anticipated to form a solid foundation upon which to drive the incidence of
Clostridium difficile infection down.
4.5 Norovirus
There was 1 outbreak of diarrhoea and vomiting at the Cumberlege Intermediate
Care Centre during 2009/10 which resulted in closure of the unit to admissions, transfers and discharges for 13 days. (An outbreak is defined as two or more patients presenting with the same symptoms connected by time and place). This outbreak was caused by the Norovirus, the most common cause of gastroenteritis outbreaks in healthcare settings. It is a highly contagious virus which causes short lived but severe diarrhoea and/or vomiting. The outbreak affected 11 patients and 11 members of staff. The outbreak policy was observed and the outbreak reported early, this assisted with minimizing the length of time the unit was closed and the number of staff and patients affected. This is the first outbreak in the unit has experienced since 2006.
4.6 Environmental and cleanliness audits
All of the premises from which care is provided are owned by South East Essex
Primary Care Trust (PCT) and so maintenance and cleaning is the responsibility of the PCT, however Community Healthcare has undertaken regular audits of cleanliness of the premises. These are audited against national standards and highlight any area of concern that needs to be addressed. The audit tools used to carry out these audits are nationally accepted tools developed by the Infection
Control Nurses Association in partnership with the Department of Health.
In line with Department of Health initiatives, a compliance categorization has been incorporated into the scoring system to provide a clear indication of compliance. The allocation of compliance levels is based on the scores obtained. For the purpose of these audits the categories have been allocated as follows:
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•
Compliant 90% and above
•
Partial compliance 80 – 90%
•
Minimal compliance 80% or under
During 2009/10 only 10 of the 18 clinic bases where Community Healthcare services are provided (56%) were audited. The remaining 8 audits were not undertaken due to the fact that key staff were diverted to respond the Pandemic
Flu Outbreak. The remainder of clinic audits will be scheduled throughout 2010.
Feedback is given at the time of audit to staff present in the setting. In addition to this a written report is provided to commissioners for action with regard to environmental issues with facilities and estates, and to heads of clinical services which are delivered from the area audited. The report provides recommendations where improvement is required. All audits undertaken will be repeated to ensure actions have been undertaken. Any risks identified which threaten compliance with the provisions of the Code of Practice are reported to the Infection Control Committee and the Integrated Governance Committee for escalation to the Arms Length Management Board.
The following table shows compliance with the audits undertaken within clinic bases.
Clinic site Compliance with environmental cleanliness and environment issues
Compliance with hand hygiene and hand hygiene facilities
88% 96% Hullbridge
Kingsley Ward
Raphael
Victoria
Westcliff
93%
84%
88%
80%
96%
96%
100%
84%
Kent Elms
Leigh PCC
81%
84%
96%
96%
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Shoebury
House
Thorpedene clinic
Warrior House
85%
97%
84%
100%
100%
84%
Within the Cumberlege Intermediate Care Centre environmental and cleanliness audits have also been undertaken against the National Specifications for
Cleanliness in the NHS (2007) and the Revised Cleaning Manual (2009).
The results of the audits undertaken at CICC are tabled below.
Audit undertaken
Compliance
Environment Hand hygiene
96%
Waste management
100% 100%
Body fluid and spillage management
100%
Sharps management
100%
Personal protective equipment
100%
In addition to this annual audit which is undertaken by the infection control nurse, the facilities manager at the Cumberlege Intermediate Care Centre and the
Service Manager undertake monthly cleanliness inspections. Action is taken locally to address any issues identified. The Executive Nurse and Head of
Specialist Services have also undertaken unannounced inspection periodically within the centre. To date inspection outcomes have been held locally, however as of April 2010 this process is to be formally reported to the Deputy Director of
Infection Prevention and Control (Deputy DIPC).
4.7 Mattress integrity audits
Following a National Patient Safety alert issued by the Care Quality Commission which highlighted the need for more robust monitoring systems for mattresses within all NHS organizations, a tool was developed to audit mattress integrity within in-patient settings was developed. Audits have been undertaken quarterly.
In addition to the quarterly audit, mattresses are inspected on discharge of each patient.
4.8 Safeguarding Vulnerable Adults
A vulnerable person is defined as someone who “is or may be in need of community care services, by means of mental or disability, age or illness: and
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who is or may be unable to take care of him or her self, or is unable to protect themselves against significant harm or exploitation” [Who Decides 1997]
Community Healthcare has had an active role in increasing awareness and training, to ensure that staff are well informed about issues of adult abuse, in particular vulnerable older people; and that they know how to take effective action to protect them.
During 2008/9 Community Healthcare took the decision to include safeguarding in all Job Descriptions, this is to ensure that staff are aware of their responsibility in relation to this important issue. This is further clarified in the Trust
Safeguarding policy, and ensures clarity regarding the level of training required according to their role.
Staff work alongside both Essex and Southend Councils’ Safeguarding Leads, ensuring that there is continual development of the workforce, with senior nurses undertaking investigators training, that allows participation in undertaking the more complex investigations.
In February 2010, funding was approved to appoint a dedicated Clinical Nurse
Specialist to support the work in relation to safeguarding adults and ensuring older people are treated with respect and dignity. This post was advertised in
March and the successful applicant is due to commence in post in July 2010.
The Safeguarding Children’s team are responsible for supporting both the organisation and staff to ensure that we keep the children and young people with whom we come into contact safe from harm or abuse. We aim to promote their health and welfare to enable them to achieve their full potential.
The service also provides care and support to children and young people who are unable to remain at home and are ‘looked after’ by Social Services. We ensure that carers are aware of the health and developmental needs of children.
Sadly, sometimes children and young people die unexpectedly and the children’s safeguarding team contribute to the child death review process with our partner agencies (police, education and social services) to help parents or carers understand why their child died.
During 2009/10 there have been 3 instances where children and young people have died or suffered serious harm as a result of abuse by their parents and carers. In these circumstances we have (along with our partners) rigorously reviewed the care that we have provided through a process called Serious Case
Reviews. Serious Case Reviews enable us to learn from these tragic events and
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where possible share good practice with colleagues in an attempt to prevent further child deaths.
During March 2010 the Community Healthcare Services were reviewed by East of England, Safeguarding Intensive Support Team (a multidisciplinary team of professionals with expertise and experience in child protection). The purpose of the review visit was to look at the arrangements for safeguarding children and to provide advice and feedback on any areas for improvement. The visit was extremely productive and confirmed that Community Healthcare has robust safeguarding arrangements in place.
A recommendation from the Intensive Support Team was that the Safeguarding
Policy should be updated to reflect new national guidance (received in March
2010). This work is in progress.
This year Community Healthcare have developed two new services within the safeguarding team the first of which is the Looked after Children specialist nurses team and the Child Death Rapid Response Team which supports families following the death of a child.
In addition we have implemented basic level safeguarding training via e-learning whilst integrating a performance reporting process to monitor that staff have completed it. Our work with the human resources department has ensured that we have robust Criminal Records Bureau (CRB) processes in place and have procedures consistent with national guidance regarding managing allegations of abuse. Safeguarding is everybody’s responsibility which is integral to all new job descriptions within our organisation.
4.10 Improving Care and independence of children and young people with
Asthma
Asthma is a long term medical condition and is the most common chronic disease affecting 13% of children in the UK (Asthma UK 2008). In South East
Essex there are an estimated 9280 children who have asthma attending 112 schools.
A proportion of these children require an inpatient stay during an acute phase of an asthma attack. This hospitalisation is a stressful experience for many children despite unrestricted parent participation and considerable improvements in hospital environments” (Coyne & Conlon 2007). This remains the main driver for providing services for children closer to or in their own home, “The rate of recovery for a child is on average is 30 - 40% quicker at home than in hospital”
(Department of Health, DH 1991).
In March 2009 the East of England Strategic Health Authority invited proposals for innovation monies as part of the National Innovation Awards for Transforming
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Community Services. In response to this opportunity a proposal was submitted by Community Healthcare, supported by the Commissioning PCT to develop an successful and we received a £42k award to pilot the scheme over a 12 month period from April 2009 - March 2010.
This service innovation aimed to extend the scope of the existing (9am-5pm) asthma service and to integrate this within the Paediatric Community Nursing
(PCN) service to provide 24 hour a day access to support, advice and specialist home nursing for children with asthma and their families. Using telephone triage and home visiting by registered nurses the service empowers children, young people and their families to manage asthma at home, in turn preventing unnecessary attendance at or admission to hospital.
With improved and timely access to support, advice and treatment children and young people have also been supported in the preventative management of their condition, leading to a reduction in acute episodes of their illness and therefore improving their attendance at school and social activities.
The service is available to children and young people who have been diagnosed as having asthma or are taking asthma medication. Initial referrals to the paediatric asthma/allergy service are usually received by paediatricians, GPs or other health professionals, but once children have been assessed as being suitable for the pilot families are provided with a pager number and can telephone the nurse ‘on call’ directly .
So far, 200 children have been assessed and can access the service if required.
From the 17 August 2009 when the pilot went ‘live’ until the 28 February 2010 the service was accessed 169 times for urgent advice/treatment of an acute asthma episode. Care provided to these children has resulted in admission avoidance and therefore has not only improved the patient experience but also has avoided waste of resources in the acute hospital. Due to funding there are limitations on the amount of new children that can be recruited to the pilot.
Examples of interventions required:
ƒ 169 patients accessed the on call service (outside of normal working hours)
ƒ 46 of the 169 patients were managed at home through telephone advice only
ƒ
123 of the 169 patients received treatment in their own home, this included assessment and treatment with oxygen, nebulisers and or oral steroids.
ƒ
35% of patients came from 20% most deprived wards (December
2009).
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ƒ
42% were new referrals from parents who contacted the service during an acute asthma attack.
ƒ 494 contacts were completed for children during or after an acute episode.
The pilot study has demonstrated that of those children and families contacting the asthma allergy service for treatment:
82% (139) avoided hospital attendance completely and only
16% (27) required a referral to A&E.
Of those 16% (27) referred to A&E 13 (9%) required admission.
In addition to the obvious enhanced patient experience set out above prompt access to nurses with specialist knowledge in the management of acute episodes of asthma also enhances patient safety. There has also been a significant impact of the scheme on community services:
•
Increasing the knowledge and skills of the paediatric community nursing team
•
Integration of the Asthma/Allergy service into the paediatric community nursing team to provide an integrated approach to service delivery
•
Strengthening collaborative working with Pharmacists and local acute
Consultants in development of pilot.
•
Raising the profile, value and confidence to service users in the ability of community services to deliver care closer to home for children.
Community Healthcare is keen to learn from all patient feedback and this is particularly important when care has not progressed as planned or when things have gone wrong. The Arms Length Management Board (ALMB) is informed of those incidents that meet the criteria set out in the East of England Strategic
Health Authority (SHA) SUI Policy and as such warrant reporting to the Primary
Care Trust Commissioners and SHA; as well as those that although do not meet the above criteria are considered sufficiently serious to bring to the attention of the Board. All SUIs are given a unique identifier. During 2009/10 there were 11 incidents reported.
Once investigations are completed the progress with regard to implementation of recommendations following SUIs is monitored by the Integrated Governance
Committee on behalf of the ALMB.
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4.11 Risk Event Reporting
Following the appointment of a dedicated Risk Manager for provider services in
November 2009, Community Healthcare assumed responsibility for the management of all aspects of risk management and Health and Safety with the exception of those risks associated with premises. Risk management is included in the staff induction programme and there have been a number of local training sessions. This has shown an increase in the number of risks reported and anecdotally it would appear that staff feel better able to identify risks and that the service is more responsive.
We have worked during 2009/10 to enhance our major incident response plans to ensure that we are able to mount an appropriate response and maintain essential services in the event of a major incident.
Community Healthcare has purchased a new risk management reporting / recording system known as Datix. This is a web based system that will store information regarding risk events, complaints, claims, assurance and will enable storage of evidence to support compliance with the Care Quality Commission’s
Essential Standards for Quality and Safety. It is anticipated that this system will address the following objectives:
•
Improve the identification, capture and management of incidents, risks and complaints thereby ensuring that Community Healthcare is focusing on the most important risks.
•
Improve the efficiency and effectiveness of processes in managing risks and complying with best practice for Care Quality Commission and NHS Litigation
Authority standards and inspections.
•
Improve the quality and timeliness of the presentation of risks and related assurances to the Integrated Governance Committee and Arms Length
Management Board, thereby improving assurance that risks are being managed effectively.
The Governance team is in the process of implementing the required changes and will provide training for front line staff.
4.12 Response to Pandemic Flu
In April 2009 Community Healthcare responded to the Pandemic Flu Outbreak.
During this time we worked closely with colleagues in the Primary Care Trust
(PCT) to open ‘Tamiflu’ (drug for prevention and treatment of H1N1 (swine flu) virus) distribution centres, and visited schools and residential care homes.
In addition we delivered the swine flu vaccine to housebound patients, carers and staff in Community Healthcare and Havens Hospices. During this time we
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continued to maintain the delivery of existing services to patients and other health surveillance programmes.
5. PATIENT EXPERIENCE
Whilst many services undertake specific satisfaction surveys we have not previously had a comprehensive and consistent approach to seeking feed-back from patients at the time of their care. However we are in the process of implementing a system called Patient Tracker. This will enable us to seek patient’s views at the time that care is delivered to patients but responses remain confidential to those directly providing care.
Community Healthcare has been involved in a number of developments aiming to enhance patient experience, improve patient safety and improve the efficiency and effectiveness of the service we provide to you. Some examples of these developments are set out below:
5.2 Wheelchairs
Whilst we are pleased to report significant improvement in our performance against waiting times for wheelchairs for adults and children, our delivery timescales remain short of those appropriate for local needs. For 2010/11 we have established a joint venture pilot with the Whizz-kids organization which is a charity that provides wheelchairs primarily for children (up to the age of 25). In practice Whizz-kidz will lead the service for local children and we will focus on the wheelchair service for adults; together we have access to each others best clinical practices and procurement leverage to improve the delivery time and cost of wheelchairs. In addition we will be working with our PCT Commissioners to ensure that the level of service commissioned is appropriate for the number of local people who require wheelchairs.
Health Authority in making services more accessible to younger people. ‘’You’re Welcome’’
The Department of Health has set out principles to help health services become more young people friendly. This initiative known as ‘You’re Welcome’ covers a number of areas to be considered by health care commissioners and health services providers. In February 2009 South East Essex PCT agreed to participate in the You’re Welcome Pilot scheme (DH), with the Eastern Region.
The region shared funding, and each took responsibility for key aspects of the pilot. Staff working at the Kingsley Ward Centre ( The Kingsley-Ward Centre, based in Southend is a service for anyone with a contraceptive, reproductive or
26

sexual health need) agreed to evaluate and pilot an audit tool and feedback the results to the East of England regional network for You’re Welcome.
Working with other health care professionals we worked through the audit tool, highlighting areas of clarity, confusion and how the evidence for criteria would be identified. Any difficulties and anomalies with the tool were fed back at regional meetings. The scoring systems were tried, and once more positives and negatives fed back. Working through this process enabled staff at the Kingsley-
Ward Centre to assess how well placed they were in terms of meeting the quality criteria for "You’re welcome”.
This required assessing services at the Kingsley-Ward centre against ten different sets of criteria within the audit tool, including questions regarding accessibility of the service, the environment, staff training, skills, attitudes and values, health issues for adolescents, confidentiality and mental health services as well as sexual and reproductive health services.
In working through the ten sections it was apparent that many of the criteria were already being reached within the Kingsley Ward Centre. It was subsequently agreed that we would move on to registering for our own accreditation following a visit from the “You’re Welcome” regional lead.
Although delighted to know that we were on the whole providing excellent services to young people it was important to collate data regarding those areas where the Kingsley Ward Centre were not meeting the criteria. Use of this tool indicated that we need to improve on monitoring and evaluation, and involvement of young people. Previously the service undertook annual client satisfaction surveys and responded to comments and suggestions as they arose.
As a result there have been several new developments in young person friendly services e.g. development of a satisfaction survey for 2010, introduction of
‘mystery shoppers’ (people who are not in receipt of this service but pretend to be patients in order to test the service provided), and on-going client feedback systems. In addition a new Kingsley Ward Centre website has been launched.
Development of this website involved young people and staff at local schools and it includes an area for young people to comment on services.
The aim of the DH is that the majority of health services for young people will have achieved “You’re Welcome “quality status by 2020. The Kingsley Ward
Centre are very proud not only of supporting the East of England initiative through evaluating the tool but also that this has enabled the service to be ready to register for “You’re Welcome” on line and start the process ahead of many other healthcare providers of completing the Audit tool in readiness for the verification process.
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5.4 Collaboration between Contraception and Sexual Health Services and Family Nurse Partnership
Community Healthcare provides a service to families known as the Family- Nurse
Partnership (NFP). This is a licensed programme, which is evidence based, and its aim is to provide early intervention for vulnerable first time young parents and their children to reduce the impact of multiple deprivation and improve short and long term health and well-being outcomes for children. It also aims to reduce the short and long term cost of caring for these children and families. It is the first part of the preventative pathway for the 2-5% most disadvantaged children.
Recruitment of clients for the randomized controlled trial commenced in April
2009 and was completed in March 2010, although the monitoring of these clients continues through the research team at Cardiff University. Direct referral to the
FNP has now recommenced from April 2010
One of the key objectives of the Family Nurse Partnership is to increase the length of time from one pregnancy to subsequent pregnancies thus supporting women to have more control over the planning of future pregnancies. In order to deliver this key objective Community Health Care Contraceptive and Sexual
Health Service have worked in collaboration with its Family Nurse Partnership to ensure all Family Nurses have up to date knowledge on Long-acting Reversible
Contraception (LARC) methods. It is hoped that this enhanced knowledge will enable nurses to encourage their clients to consider LARC methods following delivery.
As part of this collaborative programme all FNP Nurses have attended
“Contraceptive Choices” study day supported by East of England Strategic
Health Authority. They have also attended observational sessions in the
Contraception and Sexual Health clinics enabling them to have first hand experience of the process involved during fitting of LARC methods and the required counselling prior to fitting.
This collaborative way of working has enhanced care for clients, facilitating counselling to be done in the community and supporting a fast track system to expedite LARC method fittings.
As a consequence of this collaborative working we are hoping to see an increase in the use of LARC methods in clients on the FNP programme and a decrease in subsequent unplanned pregnancies.
5.5 Speech and Language Therapy (SLT) : Involving Children and their
Parents/Carers
The Children’s Speech and Language Therapy Service considered methods for consulting with its service users and their families, utilising a number of guidance
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documents, including ‘You’re Welcome’ (2009), Bercow Review final report
(2008), NHS Toolkit for patient information (2003) and Putting Patients at the
Heart of Care (2009). Over the next 9 months, the service proposes to gather children’s views and will use a variety of methods, depending on the client group, as it is recognised that the same information gathering method would not be suitable ‘across the board’.
The service plans to complete the ‘You’re Welcome’ quality criteria self assessment tool (DOH 2009) to establish its compliance with the quality criteria considered as best practice for those services working with children and young people by March 2011.
Criteria relevant to the SLT service are:
1. Access to the service
2. Publicity about the service
3. Confidentiality and consent
4. Environment
5. Staff training, skills, attitudes and values
6. Joined up working
7. Monitoring and evaluation and involvement of young
People
Following the completion of the service self audit tool areas of non compliance can be addressed and resolved and the service will be able to regularly self assess to audit its compliance to the considered best practice.
A number of parent/child informal ‘drop in’ sessions will be organised across the
PCT geographical area. These sessions will be advertised by leaflet in local health centres/clinics and by verbal invitation during contact with the Speech and
Language Therapy service. Parents/carers will be asked to give their verbal/written contribution and the children will have a variety of different methods available to access their views (e.g. drawings, talking mats, symbols boards, yes/no cards).
In January 2010, Community Healthcare was approved as a Podiatric Surgery training organization and as such was able to commence recruitment for a suitable trainee. A further two Consultants have applied for tutor status, and when this is approved, it is intended that a further two training posts will be advertised.
Podiatry: Leaflets were developed for GPs to more clearly inform them of the services provided. The leaflets cover such elements as Contact information and
Access Criteria, Musculoskeletal guidelines, Diabetic guidelines, Nail surgery and
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Podiatric surgery, thus ensuring our GPs have up to date relevant information to share with their patients.
The Podiatrist and the Specialist Diabetes Nurses have an agreed pathway in place whereby the Podiatrist can make direct referrals to them for prompt assessment of any patient, where there are concerns about wound healing e.g. diabetic foot ulcers. Any patient with high HbA1c (a blood test that indicates whether or not diabetes is well controlled) and non healing ulcers will be referred to the Specialist Diabetes Nurses in order to gain tighter control of the blood glucose levels. This has been proven to improve healing rates, thus improving the quality of life and improving outcomes for the patients we see.
5.7 End of Life Pilot
In December 2009 the PCT procurement group approved funding to deliver an
End of Life Pilot project in across 2 localities (DN bases in Thundersley and
Leigh) in South East Essex. The aim of this study is to enhance the experience of patients approaching the end of their life and specifically to improve the number of patients who are able to achieve their preferred place of care (place of death).
One of the key benefits of this pilot study is that is a joint project shared with
Community Healthcare, South University Hospitals Foundation Trust and the
Havens Hospices. This will hopefully mean that many of the barriers to prompt and responsive care will be removed and communication across organizations will be improved.
Although changes to the way services are to be delivered are to be determined by the project it is proposed that a central register of patients, deemed to be in their last year of life will be held by a case manager. This individual will then work in collaboration with key clinical staff and equipment providers to ensure that the care of patients is better co-ordinated and better able to respond to the needs of patients and carers as their disease progresses. The project will also enable the
Trust to meet the National Institute for Clinical Excellence Guidance in providing
7 days per week access to Specialist Palliative Care Nurses. In is anticipated that the new service will commence in mid July 2010.
5.8 Integrated working with FORTIS - Practice Based Commissioning
Group (PBCG)
Community Healthcare has also been invited to explore opportunities to reduce the number of emergency admissions to the hospital for patients with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Heart Failure and Diabetes, through working in partnership with Fortis Practice Based Commissioning Group.
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It is anticipated that a case management approach be adopted for these patients and that a triage system similar to that currently in place for elective admissions will be initiated.
The exact model is as yet unclear and exploratory work is in progress.
Information has been requested from the PCT regarding the numbers and identity of patients who are at high risk or re-admission in order that clinical staff can consider alternative methods of support to the patients in order to prevent unnecessary admissions.
5.9 Complaints
2009/10 represents the first year of “Making Experiences Count” where complainants have been encouraged to telephone and discuss their complaint and the outcome they would wish to achieve. This has also presented an opportunity to discuss and agree timescales for the complaint to be investigated and a reply given. Community Healthcare still works to a 25 day deadline to provide a response to the complaint, but should the investigation require further time this will be negotiated with the person making the complaint. All complaints are acknowledged within 3 working days.
Complaints are used where possible to improve services to patients and to highlight any trends arising from those complaints.
Community Healthcare has received a total of 82 complaints for the year April
2009 – March 2010, although 3 were subsequently withdrawn. This figure reflects an increase of 37 complaints compared to the same period last year (45).
The reason for this rise in complaints is unclear and may be attributed to the increased number of patients being seen outside of the hospital. It is hoped that in part this rise is as a result of Community Healthcare assuming responsibility for the handling of complaints and patient feedback directly (previously complaints were managed by the commissioners) thus making the process more transparent and enabling patients to provide feedback.
Service Area
District Nursing 20
PCTMS Practices (Trust managed GP practices)
Health Improvement
9
3
Integrated Services (Canvey Island) 1
Podiatry 12
Wheelchair Service/Equipment 7
Continence Advisory Service
Speech & Language Therapy
Leg Ulcer Club
7
1
1
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Community Dental Service
Cumberlege Intermediate Care Centre
Diabetes Service
1
3
2
Collaborative Care
Children’s Services (including Child
Health Admin)
2
10
TOTAL RECEIVED 79
All of the complaints received during 2009/10 were acknowledged within two working days of receipt and all received a formal response from the Chief
Operating Officer within the agreed timescales as required under the NHS
Making Experiences Count.
Complainants who remained dissatisfied after their complaint had been investigated were offered a resolution meeting with the appropriate manager and or clinical staff.
Learning outcomes and service improvements arising from formal complaints against Community Healthcare during 2009/10 included:
•
Failure to adequately communicate change in provision to patients - changes in continence products systems have now been put into place to prevent products being changed without adequate discussion with patients in the future.
•
Concerns raised about the transfer of patients from the Collaborative Care
Team to Sure Care and Ashley Care, following this administrative procedures have now been implemented to ensure a seamless transfer.
•
As a result of complaints regarding communication between staff and patients on the Special Allocation Scheme a telephone recording system has been purchased to both monitor standards within the service and as a training tool.
5.10 Review by Parliamentary and Health Service Ombudsman
Community Healthcare has had 2 complaints referred to the Health Service
Ombudsman during the period 2009/2010. These related to the Continence
Service and one of the Primary Care Trust managed GP practices. In both instances the Ombudsman determined that Community Healthcare had investigated the concerns and responded appropriately and therefore no further action was required.
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5.11 Claims and Litigation
There are 10 claims currently registered with the National Health Service
Litigation Authority (NHSLA) dating back to 31.01.2007. Of these claims 8 relate to allegations of clinical negligence and 2 relate to personal injury. Community
Healthcare assumed responsibility for managing claims in October 2009 and is currently managing 3 of the above Clinical Negligence claims that are lodged with the NHSLA. These comprise 2 for the District Nursing Service and 1 for
Podiatry.
5.12 Compliments
Community Healthcare has experienced a substantial increase in the amount of compliments received by services this year. This increase is due in part to raised awareness amongst staff to report compliments received within their services.
Compliments are also filtered from patient questionnaires. For the period
2009/2010 642 compliments have been received, this represents an increase of
395 on last years figure of 247.
All compliments are recorded, acknowledged and conveyed to the team or individual concerned, as well as being reported to the Service Director, Arms
Length Management Board and the PCT Board. A selection is also reported on a monthly basis in Provider News.
The table below highlights the service areas which received the compliments.
Annual Compliments 2009/2010
90
80
70
60
50
40
30
20
10
Children's Services
Collaborative Care
Complaints Dept
Community Dental
Continence Service
Diabetes Service
District Nursing
Education & Training
Health Improvement
Heart Failure Team
Leg Ulcer Clinic
Long Term Conditions
Macmillan Nursing
Macmillan Benefits Advice
Occupational Therapy
PCTMS Practices
Podiatry
Rapid Response Team
Speech & Language
Stop Smoking Team
Stroke Team
Wheelchair/Equipment
0
Quarter 1 Quarter 2 Quarter 3 Quarter 4
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6. EFFECTIVENESS
South East Essex PCT Strategic Plan for 2009 – 2014 sets out a clear vision for future developments of local health services. The vision aims to bring together health and social care to deliver more coordinated and joined up services, as well as ensuring that the services are developed to manage more complex care for people at home, thus focusing on preventative or planned alternatives to hospital admission. The Specialist Services Directorate concentrated on service review and planning service redesign, to address the aspirations set out within the
Transforming Community Services documentation, and by so doing, to achieve the PCT’s strategic aims.
6.1 Respiratory Long Term Oxygen Therapy
Over the year, it became apparent that a review was needed of all patients using home oxygen to ascertain the appropriateness of their current oxygen prescription. The commissioners asked Community Healthcare to review 250 patients in receipt of oxygen, who were not known to the service and therefore not in receipt of regular assessment and follow up in accordance with British
Thoracic Society guidelines. This piece of work is now complete and to date savings of £144,000 have been released by means of more appropriate prescribing. This also demonstrates that risk is minimized through patients receiving the correct oxygen and level for their identified need.
It is envisaged that there will be further savings to be realized following reassessment of 45 patients by the Clinical Nurse Specialists over the coming months. This piece of work also identified other groups of patients in receipt of oxygen (Children and palliative care patients) who may require reassessment, and these have been forwarded to the appropriate services for review.
6.2 Wheelchairs
In September 2008 the PCT commissioners and Board agreed a full review of the wheelchair service, which took place between April and September 2009 and concluded that the service, as currently commissioned does not meet all the health needs of the population. The PCT therefore proposes to commission a service to include developments in the following areas:
• Provision of a service that works alongside the rehabilitation teams at the local acute trust, to provide wheelchairs on discharge as appropriate, for
•
• both long and short term use.
An annual contract/review for those patients, whose needs are likely to change over time.
The creation of an effective wheelchair user group, enabling users the means by which they can regularly influence and feed back on service provision.
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•
•
•
•
Regular approved assessor training courses, to enable other healthcare professionals to prescribe wheelchairs, thus reducing the pressure on the wheelchair service.
Improved provision of information to users and carers on handover of equipment.
Enabling approved non NHS organizations to refer directly into the wheelchair service.
The proposed service would be expected to work within the 18 week guidelines and in line with recommendations made within the document
‘Health Care Standards for Wheelchair Services Under The NHS’
The service has worked hard in the meantime to reduce waiting times and improve service delivery for the users. As previously mentioned one initiative was a Joint Venture Pilot between Community Healthcare and WhizzKidz, a charity which provides wheelchairs for children and young adults. The pilot started work on 29 April 2010, and monthly evaluation of the outcomes will be carried out, to include user feedback.
6.3 Chronic Disease Management – Care Pathways
Our approach to managing chronic disease in South East Essex is modelled on accepted Good Practice principles, moving towards commissioning of fully integrated care pathways. Clinical evidence suggests that the key elements to managing pathways are:
6.3.1 Level 1 Supported Self-care
This is where we work collaboratively with colleagues from health and social care to help patients and their carers to develop the knowledge, skills and confidence to care for themselves.
6.3.2 Level 2 Disease specific management
This involves providing patients who have a complex single need or multiple conditions with prompt access to specialist services, using multidisciplinary teams and disease specific protocols and pathways, such as the National
Service Framework for e.g. Heart failure nurse specialist.
6.3.3 Level 3 Case management :
This is where we identify the most vulnerable people, those with highly complex multiple long term conditions, using a case management approach (nominated a dedicated person to plan and co-ordinate care), to anticipate, co-ordinate, and join up Health and Social Care. The key worker is often a nurse, known as a" Community Matron"
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6.4 Knowledge :
Is where we develop the ability to identify at-risk groups within the population, carry out needs assessments, understand resource and activity levels and identify trends (Public Health and Health Improvement Team).
For 2009/10 we invested in developing a pathway approach to areas of COPD,
Heart Failure and Adult Diabetes. In response to increasing activity in the hospital we are increasingly investing in alternatives to hospital care by addressing the three levels of Chronic Disease Management:
Fig 1 -
The Triangle above depicts the Kaiser Permanente
Conditions, and how it is adopted in the three stages described above.
6.5 Diabetes
NHS South East Essex (SEE) in 2009 took the decision to transform the diabetes service by bringing care closer to home. This resulted in investment of
£183,000 to fund an enhanced service for those adults with type II diabetes (non insulin dependent) that would focus on:
ƒ Reducing diabetes follow-up appointments in the hospital and by offering these in community settings
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ƒ
Provide resources to GPs for diabetes management in their surgeries
ƒ Contribute to GP Quality Target (Quality and Outcomes Framework) targets
ƒ Free up hospital medical staff to see patients with more complex diabetes
There were also significant improvements in the way services were provided to patients with Chronic Obstructive Pulmonary Disease. Investment of £153, 000 was made with the aim of improving the quality of care to patients, providing more services closer to home and supporting patients to better self manage their condition to avoid acute episodes of their condition by better recognizing the symptoms of deterioration; thus reducing unnecessary hospital attendance. The above investment funded the following initiatives:
• Recruitment within the Rapid Response Team of 2 additional registered
• nurses and 1 additional nursing assistant to provide proactive and intensive intervention to COPD patients
Provision of 1 monthly session of professional/educational/clinical input
•
• from a Consultant in Respiratory Medicine, to enable the Rapid Response
Team and community matrons to better support and manage the patients with long term conditions.
Training and development for Community Matrons to achieve more effective co-ordination of care (funding carried forward from 2008-
2009)
Maintenance pulmonary rehabilitation classes: we have been asked to provide an additional 2 classes to those who have successfully completed a pulmonary rehabilitation plan six months earlier. The programme is aimed at maintaining or further increasing activity levels, endurance, confidence and general well being and includes on going education and support in self management.
The COPD enhanced service has saved the PCT £115,000 in the first two months of operation. The Commissioners have expressed their appreciation to
Community Healthcare in terms of the success of the newly implemented COPD pathway. The comparison of recent 09/10 COPD Non-Elective Admissions figures with those from 08/09 has demonstrated a significant reduction (24%) for the third quarter (Oct – Dec 09). The commissioners have acknowledged that it is
“reassuring that integrated working, the numerous initiatives around COPD and the work of staff involved in their implementation are contributing to this reduction in admissions, together with an improvement in the patient pathway”.
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6.7 Telehealth
In November 2008 a project was commenced in NHS South East Essex in combination with NHS Direct and Doc@home (equipment provider) to deliver a
Telehealth pilot project to evaluate the benefits of Telemonitoring patients with
COPD (chronic lung condition). Approximately 80 patients monitored during the study.
There are a growing number of technological approaches to support people with long term conditions for instance vital sign monitoring technologies. Typically these systems work on the basis of the user having a device in their own home which they use on a daily, or sometimes more frequent basis. Such devices often ask a range of pertinent health and quality of life questions which the user answers on a key pad or touch sensitive screen. Additionally physiological data can be recorded such as blood pressure, weight, lung function, blood glucose levels and so forth.
Having obtained the appropriate data this is typically transferred through the user’s home or mobile telephone connection using encrypted messaging to a central computer server where it is compared against ‘normal’ profiles for each individual user. Any areas of concern can be reviewed through a secure Internet connection by clinical staff who respond accordingly.
It was anticipated that the clinical evaluation of the project will look at the extent to which these assistive technologies:
•
•
•
•
• promote individual’s long term well-being and independence improve individual’s and their carer’s quality of life improve the working lives of staff are cost effective are clinically effective
The pilot was formally evaluated in February 2010, and the commissioners have agreed to fund and continue for a further six months at such time there will be further review of the service.
Below is some of the feedback received on the use of Telehealth from patients’ carer’s and the community matrons:
Patient feedback - 55 questionnaires sent to patients and 33 returned (60% response rate)
ƒ 85% of patients agreed or strongly agreed that the Telehealth service had helped them understand their condition better
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ƒ
88% of patients agreed or strongly agreed that it had helped them cope better with their symptoms
ƒ 81% of patients agreed or strongly agreed that the Telehealth service had helped to reduce their levels of anxiety
ƒ 73% of patients agreed or strongly agreed that the Telehealth service had had a positive impact on their quality of life
ƒ 91% of patients said they were very satisfied or satisfied with the
Telehealth service
ƒ 84% of patients would like to continue with the service
ƒ 94% of patients said the Telehealth equipment was either very easy or easy to use.
Carers Feedback - 32 questionnaires were sent to Carers and 15 responses were received (46% response rate), responses included the following narrative:
ƒ ‘very pleased with it ‘
ƒ ‘I think it is a wonderful service and saves a lot of worry having this at home’
ƒ A good system and we are contacted when my wife's health gets worse.
ƒ The system is a good daily check on health status.
Community Matron Feedback:
ƒ I can discuss patient’s readings prior to visiting or not visiting.
ƒ Less input/visits to patient on Telehealth.
ƒ
Freed up time to see extra patients who would otherwise be on the waiting list
ƒ I can see it has helped my patients by: Understanding their readings, education and (enabling) discussions with patients’ and that ‘some patients have taken more responsibility for the management of their condition’.
ƒ It ‘reduced patient anxiety and empowered patients’. ‘
ƒ
Patients have more knowledge of saturation levels and how to deal with condition but this depends on patient cognitive ability/perception’.
ƒ ‘With the patients monitoring their own condition, they now know when to call me earlier before a crisis.
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Case Study example October 6 2009
Whilst checking Telehealth recordings remotely I noticed that a patient’s recordings were highlighting a potential health problem, and as a result I phoned him to enquire. His wife informed me that he was not well and they were contemplating ringing the team because they knew his recordings that day were abnormal. A priority visit followed the same day. I undertook to examine the patient and determined that he had an infection that was causing a ‘flare up’ of his COPD. I was able to prescribe the relevant promptly resulting in an improved patient experience and possibly prevented him being admitted to hospital.
Successful Outcome for Long Term Conditions Team and Patient due To
Telehealth because:
ƒ
daily Telehealth monitoring enabled prompt medical treatment for the patient
ƒ prevented a GP visit and or unnecessary hospital attendance
ƒ education has increased the patient’s awareness of his condition and his appreciation of Telehealth and the Long Term Condition Team service.
ƒ provided the team with daily data which would otherwise not have been seen, this lead to a referral to the Respiratory Clinical Nurse Specialist for oxygen assessment.
As a result this patient is a positive advocate of Telehealth and his condition is stable and now involves ambulatory oxygen therapy. The Long Term Condition
Team at Thundersley Clinic are enthusiastic advocates of Telehealth and believe its success in this area is largely due to our patient selection for the pilot and the extensive initial education given to those patients by the team.
6.8 Prompt access to patient information
In line with Department of Health initiatives for a single patient record Community
Healthcare have implemented SystmOne which forms part of the National
Programme for IT (NPfit). SystmOne provides a single clinical information system to enable a reduction in the number of times a patient is required to provide personal data, therefore, improving the patient experience. In addition it enables local management of activity systems which historically have been managed through commissioned services external to the organisation.
It facilitates the creation of a single electronic patient record that can be shared, with the correct permissions, across the different care settings, accessible at the at the point of care. Clinical audits can be carried out across whole patient groups enabling real time data collection to support best practice and identify areas of poor practice.
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Workforce activity data collected at the time of care enables accurate reporting to commissioners of service levels and outcomes. It also allows service managers to identify areas of increased service pressure and reallocate resources accordingly.
It is important that if the implementation of SystmOne is to be successful, front line clinical staff will need to have access to the system accessible at the point of care. Thus the use of mobile systems will be required to record or review information when providing care in alternative settings i.e. in patients’ homes, schools, residential care homes etc. This enables the clinician to record their clinical findings without duplication. In addition, clinical information collected by other services is available to enable a holistic approach to care.
A pilot study in mobile working is currently being carried out in one locality. This will enable the community nurses to access to SystmOne in the patients’ home and will replace the patient held paper record. The key objectives to the pilot are:
•
To improve patient safety and information security by providing access for
Community Healthcare practitioners to the SystmOne, Electronic Patient
Record at the point of care
•
To improve the efficiency of Community Healthcare practitioners by reducing the need for duplication when recording information in the SystmOne
Electronic Patient Record
•
To improve the quality and timeliness of the reporting of Community
Healthcare performance by ensuring all relevant data is collected in the
SystmOne Electronic Patient Record
So far additional benefits appear to be an improvement in communication between staff resulting in a reduction in time spent returning the base to collect work and liaise with other professionals.
6.9 Lone Worker Devices
Community Healthcare is committed to protecting all staff from acts of violence and aggression. It is recognized that staff who work in isolation may need the ability to call for assistance where they may be vulnerable or their personal safety is threatened. As a result Community Healthcare has committed to the provision of lone worker devices, in line with the NHS national initiative (together with the
Counter Fraud Security Management Service). This represents an investment over the next 3 years of nearly £100,000.
Each member of staff considered to be at risk has been allocated a lone worker device. Full details of that staff member are logged at the Alarm Receiving
Centre (ARC) to enable prompt recognition and response to alerts. Staff notify the ARC of visits particularly those considered to be hazardous, stating their current location and the anticipated length of the visit.
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In an emergency situation the staff member can activate a red alert which will prompt an immediate response by ARC.
Community Healthcare staff have responded positively to the implementation of these devices and nationally their success has been proven as a number of successful prosecutions have been brought against perpetrators.
Community Healthcare is proud of its achievement to date however recognizes the need for continuously improving the quality of care provided to patients and ensuring that care is evidence based and those providing care are appropriately skilled and are supported to be ‘life long learners’. In March 2010, 2 Practice
Development nurses were appointed in order to support the Executive Nurse and
Modern Matrons to lead on the changes required to ensure nurses are kept abreast of clinical and professional developments.
There is a great deal of work to be done in relation to raising the profile of nursing in the organization and ensuring that good foundations are in place to support transfer of more acute care in to the Community. Changes to the ways nurses are trained will also pose some challenges for us. In 2009/10 a cohort of nurses who will undertake the majority of their nurse training in the Community commenced in post and we need to respond to ensure that they are appropriately supported but have maximum exposure to all aspects of patient care to ensure that they are fit to practice as registered nurses in the future. We are currently in the process of developing Community Healthcare’s Nursing
Strategy in order to address the above.
7. Priorities for next year
For 2010/11 our priorities focus on enhancing patient experience and seeking feed-back on patient experience of our health care services.
Specifically:
ƒ Patient feedback and involvement – using the Care Quality Commission requirements to meet outcome standards at all registered locations.
ƒ Managing diversity – ensuring that patients are able to regularly and consistently feed-back that they are treated with respect, dignity and privacy independent of their race, colour or religious beliefs. We will also be required to identify how we use all forms of patient feed-back to make service improvements.
ƒ
Understanding healing rates – use clinical best practice and outcome measures to identify appropriate care for those with wound or other tissue pressure damage.
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ƒ
Build on the achievement to date with regard to Safeguarding adults and
Children and identifying dignity champions in all services
ƒ Breast Feeding – the health and well-being of our children can be greatly enhanced by encouraging greater uptake of mums who breast feed their children. We have developed a joint programme with our colleagues in
Southend University Foundation NHS Trust to promote higher levels of maternal satisfaction and increased numbers of Mums who breast feed.
ƒ
End of Life Care – Implementing 7 days per week access to Specialist
Palliative Care Nurses and redesigning services to enable more people to have care (and death) in the place they choose.
ƒ
Ensure that we continue to deliver high quality services to patient during a period of transition.
Work is in hand for 2010/11 is to develop and agree a truly integrated care pathway as part of the DOH COPD Pathfinder Project.
The Specialist Services Directorate has held the first user and carer meeting and intends to develop this system of gaining feedback over the next year.
7.1 FEEDBACK FROM KEY STAKEHOLDERS
In preparing this document Community Healthcare has sought feedback from the local LINks, Southend Unitary Authority Overview and Scrutiny Committee,
Essex County Council Overview and Scrutiny Committee and the South East
Essex PCT.
There has been no feedback to date received from Southend Unitary Authority
Overview and Scrutiny Committee (OSCs) or Essex County Council Overview and Scrutiny Committee. It is recognised that Community Healthcare provided limited opportunity for comments from the OSCs prior to publication of this document.
Community Healthcare is extremely grateful to the LINks and PCT for their comments which are as follows:
Commentary on the report “Community Health Care NHS South East Essex
Quality Account 2009/10” by the South East Essex Locality of the Essex and Southend Local Involvement Network (LINk)
‘Members received the report for comment on 22 nd
June 2010 and were requested to respond with comments by 25 th
June 2010. The speed of response has meant that the LINk has been unable to follow its usual process of producing a draft report which would be approved in a public meeting. This report has been prepared by the Chair, Vice Chair, and a LINk member.
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We note that the Community Health Care report has been requested to be provided 3 months earlier that was anticipated and has not been through the thorough internal review process.
We have restricted our comments to an overall appreciation of the report.
Members response is based on contact with the public in south east Essex, and information gained from attending board meetings of the PCT and Community
Services at which community health issues were reviewed. Members have also reviewed community healthcare issues with the Southend-on-Sea Overview and
Scrutiny Committee of the council.
From members’ knowledge, we are concerned that the report does not adequately reflect the successes of the Community Services team and the high esteem that the public has for the team.
The recent consultation performed by the South East Essex PCT about a possible merger between the community services of south east Essex PCT and those of Mid Essex revealed the overwhelming public support for the services provided by the South East Essex Community Services team. The public responses to the consultation supported local vertical integration of health services so that patients, carers and public could enjoy seamless services. The public perception is that NHS and local government services operate in isolation to the detriment of patient outcome and that Community Services have to pick up the pieces of this disjointed approach.
Members are concerned with some of the non achievements of targets quoted in the report, for example Breast Feeding. Members believe that failure to meet targets is a joint responsibility of the local health services and not limited to
Community Services. We suggest that there needs to be a thorough local review of the causes of this failure as the local hospitals, midwives, and education of mothers during their pregnancies have a role to play in improving take up in addition to Community Services, to achieve a higher take up of Breast Feeding.
Our comment about failures to achieve targets is that we note that Community
Services are aware of their failures and report they are taking action to improve.
We would welcome the report including dates when the improvements proposed will be fully operational.
One service that has been brought to our attention is community podiatry.
Patients have commented very favourably on their experiences of the service.
The only adverse comments made have been on information provided by the service on patient discharge after surgery which does not meet all patients’ needs. We suggest the information provided is revised.
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Members have received good reports of the conduct of community clinical staff and the positive attitudes of staff in contact with the public. We are very encouraged by these reports’.
NHS South East Essex
‘The quality account describes Community Healthcare’s development of quality in detail and I think it is a comprehensive account of quality aspirations and achievements to date. It is difficult to create a document that speaks equally to the public and professionals but feel that the document would benefit from a further review to ensure that where possible jargon is removed in order that the document is more accessible to the public.
This is a very comprehensive and detailed document and I wonder whether it needs as much information and detail included. That of course is a matter for
Community Healthcare and about the style of document you want to present’.
Community Healthcare is extremely grateful for the feedback received from
South East Essex Locality of the Essex and Southend Local Involvement
Network and NHS South East Essex and their on-going support at the Arms
Length Management Board Meetings. Following receipt of feedback changes have been made to the text to ensure that all abbreviations have been explained and to address any questions raised by the LINks in order to make this document more accessible to the public.
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Appendix 1
Action
NHS South East Essex
Measles, Mumps and Rubella (MMR) Sub Group - Action Plan
Red Not in place or not at identified standard required and significant needs/improvements identified
Amber Progress being made but further work/investment required to meet identified need/standard
Green Provision in place and/or good progress being made against assessed need and required standards
Lead Agency Status Issues/Comments/Actions
As soon as possible. Check financial implications to include within the business plan prior to start of the new financial year
Identify the percentage of G/P practices not currently on Systm One. Need to obtain correct data
and finish data Cleaning list
Compile data to include reception children, starting wi
Southend and Westcliff Wards.
Formal request for MMR data required
Child Health
Child Health
PCT
Child Health Explore sending out letters at age 3 years with
Immunisation booklet , together with simplified flyer
Develop a MMR letter to be sent to parents as part of case or in lieu the commissioning case
Explore giving out information in school packs
ƒ Primary school packs
ƒ Council packs for family information service
PCT
PCT
MMR data by age, school and area. Years 1 & 2
Request to AG
Financial implications – letters at 3 years
Liaise with JB health improvement, re flyer
AB
Talking to individual schools regarding MMR
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ƒ Pharmacy
Explore volunteers involvement in working with
Vulnerable families and any subsequent training
Work with G/P practices, and monitoring MMR uptake for individual practices
PCT
PCT
Explore future needs for Systm One in Southend
University Hospital.
MMR at 12 months not currently recognised by
Systm One
Circulate NICE Guidance
PCT
Child Health
Identify learning issues around giving immunisation.
Groups to include:- Practice nurses and Staff nurses
PCT
PCT
Develop a business case for the school based
Programme
Postnatal MMR programme
PCT
PCT
E has conducted one training session
Working with practices to monitor the defaulters and suspended children
Ensure Southend University Hospital send documenta to Child Health following immunisation
Mina to take to Systm One user group
Core Training and yearly update sessions available for 2010- Jan 2011.
Explore possibility of immunisation mentors
Feasibility and financial implications. Written and awa approval
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Appendix 2
ARMS LENGTH
MANAGEMENT
BOARD
INTEGRATED
GOVERNANCE
COMMITTEE
STRATEGIC
DEVELOPMENT
COMMITTEE
PERFORMANCE
COMMITTEE
)
STAFF
INVOLVEMENT
GROUP
CLINICAL
POLICIES
& PROCEDURE
INFECTION
CONTROL
MEDICAL
DEVICES
SAFE-
GUARDING
BUSINESS
DEVELOPMENT
SUB-
COMMITTEE
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