Quality Account 2009-2010
High quality care for all
“This is a happy place where we don’t feel frightened. The members of
staff have smiling faces and have taken away our fear of dying. There
is mutual support here and everyone understands what we are talking
about. The members of staff have the time to listen and to treat us as
individuals. We feel safe and our dignity is respected. We feel
supported by the staff and the volunteers.”
Patients’ Forum 24th February 2010
1
Part 1
Chief Executive’s Statement
Together with the Board of Trustees, I would like to thank all of our staff and
volunteers for their achievements over the past year. Despite the current economic
climate, the hospice has continued to provide a high quality service and remain
financially sound. We have achieved this by providing high quality, cost-effective
services to our patients and their families.
Quality is high on the agenda for the hospice. The Douglas Macmillan Hospice has
been a leader and innovator in the hospice movement and now has a fully developed
independent clinical governance function. This has enabled the hospice to focus on
the quality of the services provided. Once again this year, our regulators have
assessed the treatment and care provided by the hospice as being of high quality.
Following submission of our self-assessment in November 2009, the Care Quality
Commission identified no shortfalls in the services provided by the hospice. This is a
tribute to the hard work of every member of staff working for the Douglas Macmillan
Hospice.
The hospice has a culture of continuous quality monitoring, in which any shortfalls
are identified and acted upon quickly.
I am responsible for the preparation of this report and its contents. To the best of my
knowledge, the information reported in this Quality Account is accurate and a fair
representation of the quality of healthcare services provided by our hospice.
The safety, experience and outcomes for all our patients and their loved ones are of
paramount importance to us. We continue to actively seek the views of our service
users.
Michelle Roberts
Chief Executive
30th May 2010
2
Part 1
1.1
Priorities for improvement 2010-2011
The Douglas Macmillan Hospice (DMH) is fully compliant with the National Minimum
Standards (2002). As such, the Board did not have any areas of shortfall to include in the
priorities for improvement for 2010-2011.
The Board looked at how the hospice could extend its services to better meet the needs of the
local population. The Board then looked at development opportunities for service improvement.
Following consultation with the staff and the Patients’ Forum, and dependent upon obtaining
funding, the DMH confirmed the top three quality improvement priorities for 2010 to 2011 to be:
Future planning Priority 1
A community care unit
The hospice has put in an application to the Department of Health to support this
project, which will provide an innovative new intermediate care unit. If funded, this
facility would play a significant role in improving the quality, accessibility, flexibility
and integration of palliative and end of life (EOL) care in North Staffordshire. It will
be managed by the Douglas Macmillan community palliative care team, and will
improve integration and availability of palliative care services across primary and
secondary care. The unit will assist in preventing inappropriate EOL admissions to
hospital, which occur as there is no other form of intermediate care for palliative
patients.
Future planning Priority 2
A new spiritual area, bereavement suite and reception area.
The hospice is applying for a capital grant to fund this project, which is driven by the
requirements of our patients and their families. This project brings together the main
functions of the hospice around one new user-friendly access and circulation area.
The Patients’ Forum continues to highlight the fear service users experience when
coming to the hospice for the first time. All principal functions will be off the new
reception area which will make the first visiting experience much less intimidating.
In addition, the location of the bereavement suite close to reception will allow
3
bereaved relatives to access the service without needing to enter any clinical areas
which may hold difficult memories or associations for them. Also, it will enable
visitors who are returning to the hospice to collect certificates and belongings to do so
in a more private way which respects their privacy and dignity much more effectively
than currently.
The new chapel/spiritual area will provide an area all patients, which is purpose built
and is away from the hustle and bustle of the main building.
Future planning Priority 3
Provision of a 24/7 specialist palliative care advice line service
The hospice is applying for PCT funding to provide a Palliative Care Nurse Specialist
(PCNS) on duty at the hospice continuously 24 hours a day for 7 days each week.
This includes all bank holidays (including Christmas Day). This is not an on call
service, it will be provided by an experienced and trained nurse specialist from the
hospice. These members of staff will continuously rotate into the day-team in order to
keep their clinical skills fully up to date and to be familiar with the current end of life
care case load.
1.2
Priorities for improvement 2009-2010
The Douglas Macmillan Hospice (DMH) is fully compliant with the National Minimum
Standards (2002). As such, the Board did not have any areas of shortfall to include in the
priorities for improvement for 2009-2010.
The hospice had a series of ongoing initiatives to enable the hospice to offer a more
comprehensive service to the local community, whilst remaining within the limitations of the
current financial constraints. All plans for improvement have been identified through needs
assessments of the local community and direct patient involvement. As far as possible, we
have discussed all initiatives with the hospice’s Patients’ Forum.
The quality improvement priorities for 2009-2010 were as follows:
4
Improvement Priority 1
Consultant posts
A needs assessment of the local community has shown that there is a shortfall in the
number of consultants. The hospice has been working with the local health economy
to address this shortfall. Priority was given to the appointment of a hospital-based
consultant and a community-based consultant.
Hospital-based post:
An appointment to the hospital-based post was made on 23rd September 2009.
The hospice consultant and the hospital-based consultant work as a team, with
the new consultant providing cover at the hospice for two sessions.
Community-based post:
The hospice will hold the contract for a community-based consultant post. This
post is currently being advertised.
The outcomes of having these posts in place will be evaluated by providing a
dataset to the PCT.
Improvement Priority 2
Volunteer respite sitting service
.
A volunteer respite sitting service has been developed by the Hospice at Home
Service to provide additional support to patients and respite for carers. The Patients’
Forum was asked for views on how this service should be developed. These views
will be incorporated into the service configuration. Following a successful pilot, the
service commenced in January 2010. There are tight referral and selection criteria.
The outcomes of this service are being monitored by the Clinical Governance
Committee.
5
Improvement Priority 3
To ensure that the hospice has a team of healthcare professionals
who are skilled at undertaking audit
Audit is becoming increasingly important as a source of evidence used to reassure
the Care Quality Commission that hospices are meeting current regulatory
requirements. To achieve ownership by staff, it is preferable that the clinical staff
themselves carry out audit and influence change management. However, for this
to be successful, it is essential that staff have a clear understanding of the audit
process and the need to take this process to completion. With this in mind, the
Douglas Macmillan Hospice, has trained an audit team. The team consists of
Registered Nurses and Nursing Assistants, and is led by the Clinical Governance
Manager. Following each audit, an action plan was agreed with named people
given responsibility for completing the actions within an agreed timescale. This
team has driven quality in a number of areas including infection control.
The outcomes of the work of this group were published in the British Journal of
Nursing in November 2009 (Flanagan, 2009).
The outcomes of this team make a significant contribution to the quality agenda of
the hospice.
6
Part 2
Statements of assurance from the board
The following are a series of statements that all providers must include in their Quality
Account. Many of these statements are not directly applicable to specialist palliative care
providers.
Review of services
During 2009/10 the DMH provided five NHS services.
The services were as follows:
•
In-Patient Unit
•
Day Hospice
•
Out Patients
•
Hospice at Home
•
Palliative Care Nurse specialist Service
The DMH has reviewed all the data available to them on the quality of care in all of these
NHS services.
The income generated by the NHS services reviewed in 2009/10 represents 100 per cent of
the total income generated from the provision of NHS services by the DMH for the reporting
period 2009/10.
Participation in clinical audits
During 2009/10, no national clinical audits and no national confidential enquiries covered
NHS services relating to palliative care. The DMH only provides palliative care.
During that period the DMH was not eligible to participate in any national clinical audits and
national confidential enquiries of the national clinical audits and national confidential
enquiries.
As the DMH was ineligible to participate in the national clinical audits and national
confidential enquiries, and for which data collection was completed during 2009/10, there is
no list below alongside the number of cases submitted to each audit or enquiry as a
percentage of the number of registered cases required by the terms of the audit or enquiry.
7
The reports of six local clinical audits were reviewed by the DMH during 2009/10. The
DMH intends to take the following actions to improve the quality of healthcare provided.
•
Put in place the processes to enable respite patients to continue to self-medicate
following admission to the In-Patient Unit.
•
Ensure that medical gases are prescribed and administered in accordance with national
guidelines.
•
Streamline the administrative and documentation processes associated with
decontamination.
Research
The number of patients receiving NHS services provided or sub-contracted by DMH in
2009/10 that were recruited during that period to participate in research approved by a
research ethics committee was 0. There were no appropriate, national, ethically approved
research studies in palliative care in which we could participate.
The hospice has carried out a local, ethically approved, qualitative research study (Cartlidge
and Read, 2010), which explored hospice staff’s perceptions of their own professional needs
whilst caring for a person with an intellectual disability who required palliative or terminal
care in the DMH. This research concluded that appropriate education and training remain
essential preparation for hospice workers when caring for someone with an intellectual
disability.
Quality improvement and innovation goals agreed with our commissioners
DMH income in 2009/10 was not conditional on achieving quality improvement and
innovation goals through the Commissioning for Quality and Innovation payment framework.
What others say about us
The DMH is required to register with the Care Quality Commission and its current
registration status is unconditional. The DMH has no conditions on registration.
The Care Quality Commission has not taken any enforcement action against the DMH during
2009/10.
8
The DMH is subject to periodic reviews by the Care Quality commission and its last review
was November 2009. The last on-site inspection was on 5th February 2009.
The DMH has no actions to take as no points were made in the CQC’s assessment. The
hospice was fully compliant and rated as low risk.
The DMH has not participated in any special reviews or investigations by the CQC during the
reporting period.
Data quality
The DMH did not submit records during 2009/10 to the Secondary Uses Service for inclusion
in the Hospital Episode Statistics which are included in the latest published data.
In accordance with agreement with the Department of Health, the DMH submits a National
Minimum Dataset (MDS) to the National Council for Palliative Care. The DMH provides the
MDS to the local PCTs.
The DMH score for 2009/10 for information Quality and Records Management was not
assessed using the Information Governance Toolkit. This toolkit is not applicable to
palliative care.
9
Part 3
Quality overview
The National Council For Palliative Care : Minimum Data Sets For
Palliative Care 2008-2009
DMH
National Median
In-Patient Unit
% New patients
% Occupancy
% Patients returning home
Average length of stay- cancer
Average length of stay- non-cancer
% Day case admissions
86.1
74.6
47.5
12.3
9.9
0.9
89
78.4
46.8
14.0
12.0
0
Day Hospice
% New patients
% Places used
61.2
66.5
62.2
60.8
70.0
8.1
68.4
8.1
8.1
5.0
Community: Palliative Care Nurse Specialist
% New patients
% New patients with a non-cancer
diagnosis
Visits per completed series
The National Minimum Dataset for 2008-2009 compares the DMH with the national median
values. Since 2006-7, the In-Patient Unit has reduced its average length of stay (LOS) from
13.6 day to 12.3 days for cancer patients and 9.9 days for non-cancer patients. In addition,
the DMH is treating patients as Day Cases and, following treatment, enabling the patients to
return home. The reduction in the LOS, and treatment on a Day Case basis, has resulted in a
percentage occupancy which is lower than the national median value. This slight increase in
bed availability is enabling the hospice to look at the possibility of increasing the provision of
respite.
The percentage of new Day Hospice patients is similar to that of the national median value.
The percentage of Day Hospice places used is relatively high. The DMH is currently
evaluating the Day Hospice service with the aim of increasing the numbers of new patients
who can access this service.
10
The percentage of new patients being referred to the Community Palliative Care Nurse
Specialist Service, and the percentage of non-cancer patients referred, is in line with the
national median. Patients receive an average of 8 visits per completed series, which is 60%
higher than the national average.
In addition to the limited number of suitable quality metrics in the national dataset for
palliative care, we have chosen to measure our performance against the following metrics:
Indicator
Total number of new referrals to the DMH
Total number of patients admitted to the In-Patient Unit
(IPU)
% of patients who went home
Number of beds
% Occupancy
2008-
2007-
2006-
2009
2008
2007
1419
1254
1323
633
591
618
47.5
49.7
52.1
28
28
28
74.6
72.4
Not
recorded
(NR)
Total number out-patient attendances
Total number of attendances by patients at the Day
Hospice
Total number of contacts with patients by the
community service
Total number of Hospice at Home sessions provided
213
143
129
3326
3308
3447
32, 734 32,218
NR
2,254
2,063 NR
Total number of complaints
6
4
4
The number of complaints which were upheld in full
0
0
0
The number of complaints which were upheld in part
1
0
3
The number of serious patient safety incidents
(excluding falls)
Slips, trips and falls
0
0
0
116
79
105
1
3
1
9
8
7
0
0
0
The number of patients who experienced a fracture or
other serious injury as a result of a fall.
The number of patients know to be infected with MRSA
on admission to the IPU
Patients infected with MRSA whilst on the In-Patient
Unit
11
Indicator
The number of patients know to be infected with
Clostridium difficile, Pseudomonas, Salmonella, ESBL
or Klebsiella pneumonia on admission
Patients who contracted these infections whilst on the
IPU
Number of Patients admitted to the IPU with pressure
sores
Number of Patients who developed pressure sores whilst
on the IPU
Unplanned transfers from the IPU to another hospital
Length of stay on the IPU (days)
Percentage of audits completed on schedule
Percentage of audits which resulted in an improvement
in the quality of care.
2008-
2007-
2006-
2009
2008
2007
4
3
8
0
0
0
106
112
102
7
8
9
5
7
12
12.1
12.0
13.6
100%
100%
100%
100%
100%
100%
The hospice receives approximately 1400 referral per year to its services. These
referrals are assessed by the Palliative Care Nurse Specialist Service and the
appropriate support put in place to suit the individual needs of the patient and their
family.
The hospice receives many letters of thanks and compliments.
The number of
compliments far outweighs the number of complaints. One relative felt so positively
about her experience that she sent a letter to the Nursing Standard (July 22: 23 (46);
2009 pg 33). Many families and friends show their appreciation of the care provided
to their loved one by funding over 70% of our services.
The quality of the service provided is of paramount importance to the hospice. All
letters of complaint received are investigated thoroughly and note taken of any trends.
Where shortfalls are identified, immediate action is taken to minimise the risk of
recurrence. The hospice has reached resolution with every complainant.
Through the complaints process, the hospice identified a need which is not being met
in the local community i.e. the provision of a respite sitting service to help carers.
Although this was not a service which the DMH provided, the hospice took note of
the shortfall in future planning and is putting in place a volunteer respite sitting
service.
12
The hospice admits between 600-650 patients to the In-Patient Unit per year. Of
these, 47.5% of patients went home. Although many of our patients are vulnerable,
they wish to retain their independence for as long as possible. The hospice
philosophy is to support patients and to allow them the freedom to move around the
unit. Every patient is risk-assessed on admission and provided with the appropriate
level of support, such as a nurse call system and putting the more vulnerable patients
in vision of the nursing station. The number of minor slips, trips and falls is fairly
consistent at 5 falls per occupied bed per year. The literature provides figures of 5.7 –
6.2 falls per occupied bed per year in hospices and palliative care units (Goodridge,
2002; Pearse, 2004). In addition, eleven UK hospices have confirmed that their
figures are 4.5-5.1 falls per occupied bed per year (personal; communication). These
figures have been assessed as acceptable for the patient group cared for in hospices.
Five patients experienced a fracture or other serious injury as a result of falling in the
past three years (0.03% of patients cared for).
All of these patients had significant
underlying health problems.
Over the past three years, thirty-nine patients were known to have MRSA or some
other infection when admitted to the in-patient unit. The nursing care and infection
control measures in place ensured that no patient contracted MRSA or any other
infection during a stay on out in-patient unit.
Over the past three years, twenty four of 1842 patients (1.5% of the patients cared for)
developed pressure sores whilst an in-patient. In all cases the patients were
particularly frail. In all cases, appropriate treatment was given to prevent further
deterioration of skin integrity.
Patients were transferred to hospital where specific treatment of a non palliative
nature was needed in the acute sector or the patient had experienced a fracture. Over
the past three years, twenty-four patients (1.3% of the patients cared for) were
transferred to the acute sector.
13
Our participation in clinical audits
To make sure that we are providing a consistently high quality service, we take part in our own
clinical audits, using national audit tools developed specifically for hospices. This allows us to
monitor the quality of care being provided in a systematic way and creates a framework where
we can review this information and make improvements where needed.
Each year, the Board approves the audit schedule for the coming year. Priorities are selected in
accordance with what we have to do and any areas where a formal audit would inform the risk
management processes within the hospice.
Through the Clinical Governance report, the Board of Trustees is kept fully informed about the
audit results and any identified shortfalls. Through this process, the Board has received an
assurance of the quality of the services provided.
The following audits were completed during the audit year 2009-10. The hospice conducted the
audits using national hospice-specific audit tools, which had been peer reviewed and quality
assessed.
Self-assessment by the
The hospice was fully complaint with the post-
Accountable Officer
Shipman requirement.
Management of controlled
A few minor shortfalls were identified. The Board is
drugs
assured that the hospice is now fully compliant.
Management of general
A few minor shortfalls were identified. The Board is
medicines
assured that the hospice is now fully compliant.
Self-administration of
The hospice has modified the procedure to enable
medicines
respite patients to continue to self-medicate during an
in-patient admission. This area will be re-audited in
2010-2011.
Medical gases
The hospice has strengthened the procedures relating
to the prescribing and administration of oxygen. This
area will be re-audited in 2010-2011.
Infection control:
The hospice has streamlined the documentation
decontamination
systems associated with the decontamination
processes. This area will be re-audited in 2010-2011.
14
What our patients say about the organisation
During the period 1st July 2008 to 31st January 2010, 421 patients completed a 3-day postadmission questionnaire. All patients reported that they were very happy with the care
provided.
The hospice routinely sends out a questionnaire to our patients, and to the recently bereaved,
to ask them about their experience of the service provided and to determine if there were any
areas for improvement. By looking at trends, we have identified areas for improvement:
o Approximately 20% of our patients have reported that they do not always
understand fully what is said to them. To improve the communication skills of
our clinical staff, the hospice is providing clinical staff with communication skills
training.
o Providing addition support to meet an identified need The hospice has
identified an unmet need in the local population to provide support for families
facing End of Life situations but where the referral criteria for Hospice at Home
support are not being met. A volunteer respite sitting service has been put in place
to help families and reduce the potential of them reaching a crisis point.
Our Patients’ Forum meets each month. At these meeting, the patients are given the
opportunity to voice any concerns and make recommendations. The patients enjoy the
opportunity to be involved in discussions and have input into important issues, which are
reported directly to the Chief Executive. It is through the voice of the Patients’ Forum that
future initiatives, such as the development of a new spiritual area, are being actively pursued.
During the unannounced visit by a member of the Board of Trustees on 13th January 2009,
the patients interviewed made the following comments:
•
“Sometimes in the morning I feel down but after a day at the hospice I am left
feeling very uplifted.”
•
“Coming to the hospice gives me confidence.”
•
“The food is outstanding and flexible when needs require something
different.”
•
“Staff will always give time and go that “extra mile” to give support and help.
Nothing is too much trouble.”
•
“Staff listen and are patient driven.”
15
What our staff say about the organisation
The Douglas Macmillan Hospice values the opinions of the staff regarding the quality of the
service provided.
The Hospice undertakes a staff survey every 2 years to ascertain
engagement levels, celebrate success and to highlight areas for improvement.
In October 2008 the Hospice took part in the Nursing Times/ Health Service Journal
Healthcare 100, an award identifying the Top 100 healthcare providers to work for in the UK.
The Douglas Macmillan Hospice is included in the Top 100 for the second year running, a
great achievement for the Hospice of which we are all proud. We achieved 34th place overall
in the UK. Ninety-two percent of our staff reported that they are actively engaged in their
role. Levels of engagement are very important to the Hospice as a high level of staff
engagement results in high standards of patient care, customer satisfaction, organisation
effectiveness, readiness to innovate and change and a reduction in turnover.
The hospice has a very low turnover of staff.
2008-2009
2007-2008
2006-2007
Staff leaving (other than retirement)
15
5
9
New staff
21
15
22
16
What our regulators say about the organisation
The Douglas Macmillan hospice has to submit a self-assessment to the Care Quality
Commission (CQC), formerly the Healthcare Commission, on an annual basis. The self
assessment submitted in November 2008, covering the inspection period 1st April 2008 to 31st
March 2009, provided our regulator with sufficient evidence to grade the Douglas Macmillan
Hospice as low risk. This meant that the hospice would not receive an announced inspection.
However, our regulator undertook a prescribed inspection or “spot check.” on 5th February
2009. Such inspections are unannounced and are designed to enable the inspector to see
what happens during a routine day. During this visit, the inspector paid particular attention to
the following areas:
Safety
Is the hospice providing treatment and care safely?
Clinical and cost effectiveness
Is the best possible treatment being provided?
Governance
Is the hospice run well?
Patient focus
Does the hospice put the patient first?
Care environment and amenities
Is the hospice well designed and maintained?
The hospice was found to be fully compliant in all areas. There were no recommendations to
improve the service.
In November 2009, the hospice submitted the self-assessment for the inspection period
covering 1st April 2009 to 31st March 2010. The evidence provided was sufficient to reassure
our regulators that the hospice remains fully complaint.
The Board of Trustees’ commitment to quality
The Board of Trustees is fully committed to the quality agenda. The hospice has a well
established governance structure, with members of the Board having an active role in
ensuring that the hospice provides a high quality service in accordance with its statement of
purpose. Every six months, a member of the Board undertakes an unannounced visit and
produces a quality report for the Board. During this visit, the Trustee speaks to patients and
staff on the In-Patient Unit and in the Day Hospice. In this way, the Board has first hand
knowledge of what the patients and staff think about the quality of the service provided. The
Board is confident that the treatment and care provided by the Hospice is of high quality and
is cost effective.
17
References
Cartlidge, D & Read, S. 2010, “Exploring the needs of hospice staff supporting
people with an intellectual disability: a UK perspective.” International journal of
palliative nursing, vol. 16, no. 2, pp. 93-98.
Flanagan, P. 2009. Current standards for infection control: audit assures compliance.
British journal of nursing, vol. 18, no. 16, pp. 970-975.
Goodridge, D. & Marr, H. 2002, "Factors associated with falls in an inpatient
palliative care unit: an exploratory study", International journal of palliative
nursing, vol. 8, no. 11, pp. 548-556.
Pearse, H., Nicholson, L. & Bennett, M. 2004, "Falls in hospices: a cancer network
observational study of fall rates and risk factors", Palliative medicine, vol. 18, no.
5, pp. 478-481.
18
Annex
What the PCTs say about the organisation
Guidance on Quality Accounts from the Department of Health for 2010 states that
commissioning Primary Care Trusts are required to:
•
Corroborate whether a provider’s account is accurate only for those service
which form part of a contract arrangement (i.e. NHS services).
•
Endorse the information within the quality account which pertains to NHS
services provided.
•
For this, the first year of the Quality Accounts, all providers or sub contractors
of NHS services are required to produce a Quality Account but not in relation
to the provision of primary care or community health services.
The Douglas Macmillan Hospice have produced a comprehensive Quality Account
for 2009-10 which incorporates community and acute aspects of care and touches
both on services that Stoke on Trent PCT directly commission, which can be
classified as “NHS provision”, as well as their own services and business functions as
agreed by the Douglas Macmillan board of Trustees. This statement from NHS Stoke
on Trent, in line with Department of Health guidance, only endorses the NHS funded
in-patient function provided by the Douglas Macmillan Hospice.
NHS Stoke on Trent, as the main commissioning PCT for the Douglas Macmillan
Hospice, has reviewed the Douglas Macmillan Hospices Quality Account for
2009/10. The PCT is happy to confirm the accuracy of the information provided
within the Quality Account for services covered by the current service level
agreement including hospice at home and inpatient hospice facilities. NHS Stoke on
Trent is satisfied that the Douglas Macmillan’s Quality Account provides an accurate
reflection of the quality of NHS services purchased from the hospice for patients
across Northern Staffordshire.
The Douglas Macmillan Hospice’s Quality Account offers a comprehensive view of
what the hospice as an organisation is doing well; where improvements in service
quality are required; priorities for improvement for the coming year; and how service
users, staff and others with an interest in the hospice were consulted in determining
priorities for improvement.
Funding
The hospice was successful in its application to the Department of Health to support the
building of the new intermediate care unit. Building work is scheduled to commence in July
2010 and to be completed by March 31st 2011.
19