BIRMINGHAM ST MARY’S HOSPICE
QUALITY ACCOUNT
2011-12
Our vision is for a future where the
best possible care is available to
everyone at the end of life
We will achieve this by providing specialist palliative care,
education and support to families and carers,
sharing our expertise and working with others to meet the
diverse needs of our community
Birmingham St Mary’s Hospice
176 Raddlebarn Road
Selly Park, Birmingham B29 7DA
Registered Charity Number 503456
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INDEX
Part 1 - Statements
1.1
1.2
Statement from Tina Swani, Chief Executive
Endorsement from Judi Millward, Chairman of Trustees
Part 2 – Priorities for Improvements and Statements of
Assurance
2.1
Priorities for Improvements 2011-12
(what we achieved last year)
Priority 1 - Patient safety
Increase access to bed rail assessment training
Priority 2 - Clinical effectiveness
Full review of the Day Hospice Therapeutic Clinic
Priority 3 - Patient experience
Refurbishment of Day Hospice environment
2.2
Priorities for Improvements 2012-13
(what we will do this year)
Priority 1 - Patient safety
Root cause analysis for pressure ulcers
and serious falls
Priority 2 - Clinical effectiveness
Implement use of NHS clinical portal to
access patient information
Priority 3 - Patient experience
Development of the Inpatient Unit garden area
2.3
Statement of assurance from the Board
Review of services
Participation in clinical audit
Research
Use of the CQUIN payment framework 2011-12
Use of the CQUIN payment framework 2012-13
Statement from the Care Quality Commission
Data quality
Information Governance toolkit
Clinical coding error rate
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Part 3 – Review of quality of performance
3.1
Clinical data
Inpatient Unit
Day Hospice
Community Palliative Care Team
3.2
Quality markers
Patient slips, trips and falls
Pressure ulcers
Infection control
Complaints
3.3
Clinical audit
3.4
Feedback from patients and families on services
3.5
Statements on Birmingham St Mary’s Hospice
Quality Account for 2011/12
QIPP Account Director for End of Life,
Birmingham and Solihull PCT Cluster
Programme Manager End of Life Care and Dementia,
Sandwell NHS
3.6
Feedback and comments
ABBREVIATIONS
CPC
CQUIN
IPU
MHRA
NICE
OOH
RCA
SCCM
Clinical Practice Committee (part of the Hospice’s governance framework)
Commissioning for Quality and Innovation (payment)
Inpatient Unit
Medicines and Healthcare Products Regulatory Agency
National Institute for Clinical Excellence
Out of hours
Root cause analysis
Senior Clinicians Communications Meeting
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Part 1 - Statements
1.1
Statement from Tina Swani, Chief Executive
At Birmingham St Mary’s Hospice patients and families are at the centre of all we do.
The approach taken for the Quality Account for 2011-12 has been to focus on three
specific priorities across patient safety, clinical effectiveness and patient experience.
These relate to identified aspects of care that may not otherwise have received public
attention and yet have made a difference to quality of care and outcomes for those
patients and families. We have also followed the recommended format to demonstrate
compliance with Department of Health requirements.
Our service quality, standards and approach to care are not limited to simply what is
required but to the needs and aspirations of our service users, driven by our own high
standards and specialist expertise in end of life care and supported by our commitment to
maintaining a well run, sustainable organisation.
A wider picture of successes and improvements along with our approach to governance
and quality can be found in the following public documents due for publishing this year:
•
•
St Mary’s Hospice Ltd Annual Report 2011-12
Birmingham St Mary’s Hospice – The Next Four Years – Reaching More People
Reaching more people
Strong
foundations
Working in partnership to achieve high
standards in more settings
The priorities for the next four years are shown in below. They reflect our successes and
wider plans for improvement:
1.
2.
3.
4.
Make it easier for people to know how to get help
More care at home
Increase confidence and independence of patients and carers
Expand our expertise across a wider range of conditions and
services
5. Work with communities to foster the contribution of local society
6. Grow our education so more people are able to deliver & influence
care
7. Pioneer and explore innovative ways to meet changing needs
8. Our impact: prove the difference we make
9. Our people: attract the best workforce and supporters
10. Our funding: continue to build financial strength
11. Our organisation: well run and organised
12. Our reputation: well known, well regarded and influential
We hope that by sharing the more specific improvements and practice in this Quality
Account, there is practical value to all readers of this document.
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1.2
Endorsement from Judi Millward, Chairman of Trustees
Trustees have an active role in our Governance Framework. Each Trustee has, as part of
his or her portfolio, a Governance Committee or Board Sub-Committee. This way,
Trustees are actively engaged in understanding their responsibilities as individuals and
conducting them collectively as a Board.
I confirm that I endorse this Quality Account on behalf of the Board of Trustees.
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Part 2 - Priorities for improvement and statements of assurance
from the Board (in regulations)
2.1 Priorities for improvement 2011-12 – what we achieved last year
Patient safety
Priority One: Increase access to Bed Rail Assessment Training
Standard:
• All relevant clinical staff will be trained in risk assessment of the use of bed rails
• Risk assessments will be documented in patient notes
How was the priority identified?
In February 2011 the hospice commissioned an independent Health and Safety Report
which identified that all staff should undertake training in bed rail use in accordance with
MRHA document Safe Use of Bed Rails 2006(06). The inpatient unit had, in place, a risk
assessment tool which was used regularly but staff training was not routinely done.
In order to comply with MRHA guidance of safety for patients this was identified by senior
managers as a priority for the organisation
How was Priority One achieved?
A training plan for all relevant clinical staff was developed as part of the mandatory training
day during 2011-12. All clinical staff who attended received bed rail assessment training.
Audit of compliance with the standard was undertaken in January 2012 and is due to be
repeated in September 2012.
How was progress monitored and reported?
Attendance at mandatory training is monitored and reported through hospice governance
committees.
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Clinical Effectiveness
Priority Two: Provide a full Review of the Day Hospice Therapeutic Clinic to
ensure continued effectiveness of service.
Standard: Undertake a review of services provided in the Therapeutic Clinic and make
changes to service provision
How was the priority identified?
The Therapeutics Clinic had been operational for a number of years on Tuesdays which
was specifically for patients requiring therapies and was not for patients who attended for a
regular scheduled visit. Numbers of patients had reduced over the past three years as
clinical treatments had changed – specifically patients requiring intravenous
bisphosphonate drugs are more commonly now prescribed oral medication which they can
take at home.
The review scoped:
• Need for the service
• Treatments required
• Service delivery
• Cost effectiveness
• Patient views
• Resource implications – staff, volunteers, facilities
How was Priority Two achieved?
A full appraisal of the service was undertaken and resulted in a change in service in
January 2012.
Summary of changes
• Increased access and flexibility - Patients can now attend for therapies on one of four
days in Day Hospice, according to personal choice.
• Re-marketing of service to referrers was undertaken, allowing referrers and
commissioners to understand the wider service provision
• Improved patient involvement – with commitment to continually receive feedback from
service users on impact of changes
• Establishment review and changes to staffing levels, allowing more appropriate staffing
levels to meet the diverse needs of users.
How was progress monitored and reported?
Progress was monitored and reported through Senior Management Team, Hospice
Leadership Team and Board of Trustees
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Patient Experience
Priority Three: Refurbishment of Day Hospice environment
Standard: Refurbishment of Day Hospice will be completed within agreed timeframe
and comply with patient expectations
How was the priority identified?
The priority was identified through consultation with patients who were attending the Day
Hospice, key staff who work in the area and volunteers who support Day Hospice. All
these groups expressed concerns about various aspects and limitations of the building as
it was. The priority was also evident due to a general deterioration of the fabric of the
building in spite of regular maintenance and was required to ensure compliance with
health and safety legislation and to update some facilities e.g. toilets and access to
building.
How was Priority Three achieved?
Careful logistical planning was carried out to minimise impact on patients who were
attending Day Hospice. Patients were relocated to an area within the Inpatient Unit for the
duration of the refurbishment works.
The works were carried out to:
• Improve access and the look of the main entrance
• Provide more privacy for patients by incorporating access to treatment and
counselling areas without the need to walk through the main patient area
• Create a garden terrace area
• Improve the craft and art area
• Provide more flexible spaces for people to be in groups or have private space
• Improve lighting throughout the area
• Improve toilet facilities
How was progress monitored and reported?
Progress was monitored and reported through Premises Sub- Committee, Senior
Management Team and Board of Trustees
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BEFORE - Day Hospice dining area before the refurbishment
AFTER - Day Hospice lounge area (taken from the same angle as the picture
above) - lighter, brighter with easy outside access to a terrace with seating
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BEFORE – the corridor to Day Hospice
AFTER – automatic doors and better lighting
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BEFORE –the main entrance to Day Hospice (dark and unwelcoming)
AFTER – automatic doors with ramp access
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2.2 Priorities for improvement 2012-13 – what we will do this year
Patient Safety
Priority One: Undertake Root Cause Analysis (RCA) for pressure ulcers and
serious falls and the organisation will share learning from this
Standard: Root Cause Analysis will be carried out on
• All Grade 3 and 4 pressure ulcers
• Any serious fall or where a patient has fallen on more than 3 occasions
How was this identified as a priority?
Pilot of RCA in these two groups has been carried out and has demonstrated that effective
learning and improvements in safety take place.
How will Priority One be achieved?
•
•
•
Education to ensure that staff identify incidents that require RCA
Senior Clinical staff to set up RCA in a timely manner involving relevant clinical staff
Feedback of action plans disseminated to staff
How will progress be monitored and reported?
Progress will be monitored through a Quarterly report of all RCA’s undertaken and
reported to two governance committees: the Clinical Practice Committee and the
Environment and Risk Committee.
Clinical Effectiveness
Priority Two: Implement use of NHS clinical portal to access patient information
Standard: Hospice clinical staff will be able to access patient letters, scans, x
rays and pathology reports from Queen Elizabeth Hospital system
How was this identified as a priority?
Use of clinical and administrative resources to follow up results and information has
become more significant. Information such as discharge and outpatient summaries from
hospital need to be available in a timely manner to be able to provide effective care and
this is currently not the case
How will Priority Two be achieved?
Hospice staff will work with the hospital team to ensure all information governance
arrangements are in place to introduce the new system.
Clinical staff will be trained on the use of the clinical portal
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How will progress be monitored and reported?
Progress will be monitored and reported through the Information Governance Committee
and Senior Clinicians Communication Meetings.
Numbers of staff trained to use portal and numbers regularly accessing patient records will
be audited.
Patient Experience
Priority Three: Development of the Inpatient Garden area, by improving access to
all areas & reducing the risk of slips and falls due to uneven paths.
Standard: The Inpatient Garden project will be completed within timescale and
access to all areas improved.
How was this identified as a priority?
The hospice garden is used by patients and their visitors all year round and provides
relaxation and a space to reflect. The state of the paths and patios has deteriorated and
require work to restore to a safe and enjoyable environment. Following risk assessment
we have had to restrict the use of wheelchairs and patients in beds to the patio areas as
the paths are unsafe for moving and handing reasons but this is not a situation we wish to
continue.
Consultation with patients and carers has taken place to elicit their views on the work.
How will Priority Three be achieved?
Contractors will be instructed to undertake the work and logistics around maintaining the
inpatient clinical service will be planned. Consultation will continue with patients and key
staff groups at all stages of the work.
How will progress be monitored and reported?
Progress will be monitored against an action plan which will be reported at Senior
Management Team meetings and the Environment and Risk Committee.
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2.3
STATEMENT OF ASSURANCE FROM THE BOARD
The following are statements that all providers must include in their Quality Account. Many
of these statements are not directly applicable to specialist palliative care providers, and
therefore explanations of what these statements mean are also given.
Review of services
During 2011-12 Birmingham St Mary’s Hospice supported Birmingham and Sandwell
PCT’s commissioning priorities with regard to the provision of local specialist palliative
care by providing the following services which were also part-funded through charitable
funding:
•
•
•
•
•
•
Inpatient Unit
Community Palliative Care Team
Day Hospice
Occupational therapy
Physiotherapy
Family & Carer support services, including bereavement support
Participation in Clinical Audit
•
During that period Birmingham St Mary’s Hospice participated in no national clinical
audits and no confidential enquiries of the national clinical audits and national
confidential enquiries as it was not eligible to participate in any.
• The reports of 0 national clinical audits were reviewed by the provider in 2011-12. This
is because there were no national clinical audits relevant to the work of Birmingham St
Mary’s Hospice.
What this means:
As a provider of specialist palliative care Birmingham St Mary’s Hospice is
not eligible to participate in any of the national clinical audits or national
confidential enquiries. This is because none of the 2011-12 audits or
enquiries related to specialist palliative care.
The Hospice will also not be eligible to take part in any national audit or
confidential enquiry in 2012-13 for the same reason.
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Research
The Hospice participated in the following research studies during 2011:
Bereavement and Immunity in Older Adults
Researcher: Dr Anna Phillips, University of Birmingham
Start date: January 2008 End date: December 2011
Aim: To examine whether bereaved individuals suffer from poorer immune function
than non-bereaved individuals around the time of bereavement.
A qualitative study exploring the perceived barriers of healthcare professionals to
the delivery of effective palliative care to patients with chronic obstructive
pulmonary disease
Researcher: Sandy Cherry
Start date: July 2010 End date: March 2012
Aim: To explore what are healthcare professionals perceived barriers in relation to the
delivery of effective palliative are to patients with chronic obstructive pulmonary
disease.
Does the End of Life Education Consortium work as a community of practice
Researcher: Vivienne Forrester
Start date: April 2010 End date: January 2012
Aim: To explore the theory that the End of Life Care Consortium work together as a
community of practice. To investigate whether the participants and the education
departments have learnt from each other through collaborative working.
Data Collection and Information Giving Activities
Research commissioned by: Dimbleby Cancer Care and Marie Curie Cancer
Care
Date: December 2011
Aim: To assess the value of directly involving volunteers in palliative care and
their families.
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The benefits of complementary therapy on pain relief within hospices
throughout the UK
Researcher: Hannah Cooke, Stratford College
Date: December 2011
Aim: To gain knowledge n the techniques used by complementary therapists
across the country.
Guideline Development
The Hospice contributed to the development of the following Pan Birmingham Cancer
Network Guidelines:
• June 2011
o Prescribing algorithm for restlessness in the dying patient
o Prescribing algorithm for nausea and vomiting in the dying patient
o Prescribing algorithm for excessive secretions in the dying patient
• August 2011
o Guidance for the prescription, administration and monitoring of oxygen therapy
in the hospice setting
o Guidance on management of pain in the dying patient using subcutaneous
diamorphine for injection
o Guidance on management of pain in the dying patient using subcutaneous
morphine for injection
o Guidelines for primary prophylaxis for venous thromboembolism in palliative
patients with malignancy where treatment is primarily palliative
NICE guidance applicable to hospice clinical practice
• April 2011
o Lung cancer
o Ovarian cancer
• May 2011
o Common mental health disorders
• November 2011
o Colorectal cancer
• December 2011
o Anaphylaxis
o Organ donation
Use of the CQUIN payment framework 2011-12
A proportion of Birmingham St Mary’s Hospice income in 2011-12 was conditional on
achieving quality improvement and innovation goals agreed between the Hospice and the
South Birmingham Primary Care Trust, through the Commissioning for Quality and
Innovation payment framework. Details of the pilot initiative for 2011-12 are given below.
Description of CQUIN indicator
We provided clinical staff in nursing homes with the opportunity to identify their end of life
care learning needs using a reflective learning approach and so facilitating ‘live’ learning
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over a period of 8 months. This learning was led by a clinical nurse specialist (CNS) in
palliative care from Birmingham St Mary’s Hospice who facilitated discussion and
reflection around clinical management taken from past or present clinical cases.
The sessions were delivered in 5 nursing homes identified by the Primary Care Trust who
are contracted to provide end of life care. Each nursing home was assigned a palliative
care CNS from the Hospice to facilitate 6 (1 hour long) sessions at approximately 6 weekly
intervals between July 2011 and February 2012.
Aim
The aim of the CQUIN, which was to provide clinical staff in nursing homes with the
opportunity to discuss clinical cases and issues relating to end of life care, was
completed and an evaluation report submitted to the PCT. Domains covered in the
sessions were:
•
•
•
•
•
•
•
Communicating with patients
Recognition and management of the dying phase
Symptom management strategies
Bereavement issues
Dealing with ethical dilemmas
Staff training needs and signposting to resources
End of life care planning tools
Use of the CQUIN payment framework 2012-13
CQUIN has been agreed with Birmingham & Solihull Cluster for 2012-13 ‘Patient/Carer
Experience’.
Description of CQUIN Indicators
•
•
•
To ensure that providers have real-time systems in place to monitor patient/carer
experience
To demonstrate improvements in patient/carer experience
Demonstrate clear commitment from Board to improve patient/carer experience
Statement from the Care Quality Commission
Birmingham St Mary’s Hospice is required to register with the Care Quality Commission
and is currently registered to carry out the following regulated activities:
Diagnostic and screening procedures
Transport services, triage and medical advice provided remotely
Treatment of disease, disorder or injury
The following conditions of registration apply to all regulated activities listed above:
• The Registered Provider must ensure that the regulated activities are managed by an
individual who is registered as a manager in respect of the activity, as carried on at or
from the location St Mary’s Hospice Limited
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These regulated activities may only be carried on at the following location: 176
Raddlebarn Road, Selly Park, Birmingham B29 7DA
•
The following additional conditions apply:
• This hospital is registered to provide treatment and care under the following service
user categories only: Hospice for adults H(A).
Reason for condition: To ensure that only treatment and services within the scope of
the providers’ knowledge, skills and experience are offered.
• A maximum of 25 patients may be accommodated overnight.
Reason for condition: To ensure that only treatment and services within the scope of
the providers’ knowledge, skills and experience are offered.
• A maximum of 20 persons only may receive services provided on a day-case basis.
Reason for condition: To ensure that only treatment and services within the scope of
the providers’ knowledge, skills and experience are offered.
• Notification in writing must be provided to the Care Quality Commission at least one
month prior to providing any treatment or service not detailed in your Statement of
Purpose
Reason for condition: To ensure that only treatment and services that are safe to be
undertaken in the premises and within the scope of the providers’ statement of purpose
are offered.
The Care Quality Commission has not taken any enforcement action against Birmingham
St Mary’s Hospice during 2011-12.
Birmingham St Mary’s Hospice has not participated in any special reviews or
investigations by the Care Quality Commission during 2011-12.
We were last inspected by the Care Quality Commission in May 2008 – the inspection was
unannounced - the Commission’s main findings were:
•
•
•
The hospice supplied a number of documents which were supported by interviews
with staff that showed a high level of compliance with the National Minimum
Standards. Where minor deficiencies were noted the hospice has plans already in
hand to address these.
Patients spoken to at the hospice were positive about their experiences and felt
involved in planning their care. Nursing staff interviewed were enthusiastic about
their work and displayed a commitment to put the patient at the centre of care.
No requirements have been made following this visit.
Data Quality
Birmingham St Mary’s Hospice did not submit records during 2011-12 to the Secondary
Users Service.
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This is because:
Birmingham St Mary’s Hospice is not eligible to participate in this scheme. We have a
Clinical Information Officer who collects and collates data extracted from the electronic
patient records system and a data integrity sub-group reviews the data quarterly.
Information Governance Toolkit attainment levels
We have policies, procedures and training in place and are currently working with our NHS
Cluster Information Team partners towards compliance in line with the IGSOC toolkit. We
will manage this process through the Hospice Information Governance Committee.
Clinical coding error rate
Birmingham St Mary’s Hospice was not subject to the payment by results clinical coding
audit during 2011/12 by the Audit Commission. This is because Birmingham St Mary’s
Hospice receives payment under a mix of block contracts and payment on a cost per case
basis when delivered, not through tariff and therefore clinical coding is not relevant.
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Part 3 - Review of quality of performance
Birmingham St Mary’s Hospice uses ‘SystmONE’, an electronic patient records system
which all patients are entered onto. We have therefore chosen to present data extracted
from that system for the year 1 April 2011- 31 March 2012 for the following services:
•
Inpatient Unit (IPU)
o There were 433 admissions to our IPU – this includes those patients that
may have been admitted more than once.
o The clinical team arranged for 19 patients (4.3% of all admissions) to be
transferred from the IPU to an acute unit during the year for investigation or
treatment. 15 of these patients returned to the Hospice for ongoing care, 3
patients were discharged home from hospital and 1 patient died in hospital.
•
Day Hospice
o Attendance in our Day Hospice was 2,199
o Patients were unable to attend Day Hospice for a variety of reasons on 789
occasions
•
Community Palliative Care Team
o 776 new referrals were received for this service
o 10,067 patient contacts were made during the year
o There were between 250-300 patients per month on the Team’s caseload
during the year.
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Quality Markers we have chosen to measure
Patients slips, trips and falls
Patient slips, trips and falls are monitored. Serious incidents are reported under Statutory
notifications to the Care Quality Commission.
The following new policy was implemented during the period under review:
• Policy and procedure for fall assessment prevention and management
A Root Cause Analysis is undertaken when:
• Fall results in hospital assessment or admission
• Patient suffers loss of consciousness
• The patent has abnormal neurological observations
• The patient has had repeated falls – more than 3 on current admission
• Death occurs as result of fall or within 24 hours of fall
April June
July - Sept
OctDec
JanMar
TOTAL
Number of
Slips, Trips
and falls
22
No Injury
Minor
injury
Serious
Injury
Reported to
CQC
RCA
Undertaken
15
6
1
1
2
11
31
10
25
1
6
0
0
0
0
0
3
27
19
8
0
0
0
91
69
21
1
1
5
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Pressure ulcers (Inpatient Unit)
The total numbers of pressure ulcers that patients are admitted with or develop whilst on
the Inpatient Unit are monitored. Root cause analysis was undertaken for all grade 3 and
above pressure ulcers and statutory notifications were also made to the Care Quality
Commission.
Home
Grade 1
Grade 2
Grade 3
No. reported
to CQC
No. of RCA
under-taken
19
(18%)
15
(79%)
4
(21%)
1
0
0
0
2
113
22
(19%)
18
(81%)
4
(19%)
4
5
0
2
2
97
28
(29%)
21
(67%)
7
(33%)
7
5
1
1
4
115
24
(21%)
18
(75%)
6
(25%)
2
1
0
0
0
433
93
(21%)
72
(77%)
21
(23%)
14
11
1
3
8
OctDec
JanMar
Total
Hospital
Admitted with
pressure
ulcer
108
No of admissions to
IPU
April June
Developed on IPU
July –
Sept
Admitted from
Complaints – April 2011 to March 2012
Total No. Complaints received
Number of Complaints Upheld in Full
Number of Complaints Upheld in Part
Number of Complaints Not Upheld
5*
1
3
1
* 1 complaint re-opened from 2009.
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Clinical audit
Clinical audit is a way in which the organisation can learn and improve the delivery of its
services, the outcomes for patients and the experience they have. The Audit group has
undertaken a programme of audits. The following tables show the audits completed in
2011.
Where issues are identified during an audit an action plan is developed to put the
problems right. Progress on the action plans is monitored through the Hospice’s clinical
governance committee, the Clinical Practice Committee, to ensure that they are
completed. We undertake a further audit to see if the actions we have taken have
resolved the issues identified.
General
Date
Title of Audit
1.
January
CPR documentation
2.
3.
February
March
Smartcard compliance
Response to blood sample
requests
4.
March
Delayed discharge
5.
May
6.
July
Labelling of Mobility Equipment on
IPU
Use of bowel charts
7.
8.
July
August
9.
September
Management of delirium guideline
Incidence of pressure ulcer
development/progression
Complaints management
10.
11.
12.
September
September
September
Use of Interpreters
Study Day Attendance
Study Day Evaluation form
13.
September
14.
October
Preferred place of care at time of
death
Falls management documentation
15.
November
Waiting times for admission
16.
December
Diabetes monitoring
Learning outcomes
achieved
Further work required – S1
inclusion
High compliance
Month 1- 100% compliance
in 3 standards, 55%
compliance in 1 standard
Month 2 –100% compliance
all 4 standards
100% compliance for 1
standard. 33% compliance
nd
for 2 standard
Further staff education
needed
100% compliance with
Standard 1. No protocol
available for Standard 2
Guideline to be reviewed
100% compliance in two of
three standards
100% compliance in 2 of 4
standards. Learning
outcomes/actions plans to
be recorded and
implemented
50% compliance
100% compliance
Two out of four study days
failed to meet standard
1 standard met
1 standard not fully met
Staff education on
assessment and care
planning
• Network standard met
for 2 day admission
• 97% for 7 day
admission
1 /6 standards met
CQC
Outcome
1
21
16
16
11
16
4
4
17
1
12
12
16
16
16
4
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Medicines Management Audit Programme 2011
Date
Title of Audit
1.
2.
3.
February
April
July
Sedative drugs in last days of life
Electronic verbal orders
Steroid guideline/monitoring
4.
August
5.
September
Oxygen prescribing and
administration
Drug chart documentation
6.
September
Medication storage
7.
8.
9.
September
October
November
Drug fridge temperature recording
Medicines storage
Prescription Turnaround times
10.
11.
December
December
Controlled drug management
Electronic verbal orders
12.
December
13.
December
Documentation of indication for
oxycodone use
Patient Group Direction
Learning outcomes
achieved
Staff education required
Further education required
3 out of 6 standards met.
S1 template developed
Much improved from
previous audit (Aug 2010)
100% compliance in 3 out of
9 standards
CQC
Outcome
4
9
9
9
9
9
1 out of 3 standards met
1/5 standards met
1 standard met
1 standard not met
4 out of 5 standards met
5/7 standards met. Staff
education 2 standards
9
9
9
9
9
9
2/4 standards met. Staff
education required
9
Surveys/reviews
Date
Title
Reported to
2011
January
February
August
September
Patient satisfaction survey – Day Hospice
Family Reported Outcomes- Inpatient unit
MDM Review
Patient satisfaction survey- Community (Dr visits)
1
1
16
1
Patient Satisfaction survey – Inpatient Unit
Patient Medication survey – Inpatient Unit
Admission Process – Inpatient Unit
Patient Experience – Inpatient Unit
SCCM/CPC
SCCM/CPC
SCCM
Ongoing in
2012
SCCM/CPC
SCCM/CPC
SCCM/CPC
SCCM/CPC
Patient Experience – Inpatient Unit
SCCM/CPC
1
September
September
October
December
2012
March
CQC
Outcome
1
1
1
1
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Feedback from patients and families on services
Patients’ Forum
In addition to conducting regular patient surveys across our services, we also have a
patient participation group – Patients’ Forum. This Forum meets monthly on alternative
days of the week. The membership is mainly drawn from patients attending the Day
Hospice, although meetings are open to in-patients and community patients as well. The
meetings are supported by the Head of Nursing Services, a non-clinical Senior Manager
(rotating role) and one member of the Board of Trustees with the specific remit to
represent user views to the Hospice’s Board.
The dates the Patients’ Forum met, issues consulted on and patient numbers in
attendance are shown below:
Meeting date
2011
20 April
26 May
17 June
18 July
31 August
15 Sept
21 October
14 Nov
2012
16 February
16 March
Patient
attendance
8
10
5
4
4
7
5
6
6
12
Main topics covered in the above meetings of Patient Forum
• Refurbished Day Hospice – views requested
• Donations – discussion regarding envelopes versus collection boxes
• Blood transfusions – views on change to schedule
• Hospice food – views on IPU patients being offered a cooked breakfast each day
• Discharge of patients from Day Hospice
• IPU garden – plans shared and proposal for using donation from a patient’s
husband
• Patient Information Booklet – views requested
• Hospice menu – views requested
• Day Hospice Administrator – new role
• Bereavement booklet – views requested
• Views on newly refurbished Day Hospice
• Serving meals on the IPU – ways of identifying those patients needing assistance
with feeding
• Education – information from Medical Director on the Summary Care Record
• IT support for patients
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End of life terminology
Therapeutic Activities feedback and ideas
DVD on patient/doctor scenario for views
Armillary sphere – artwork for the garden
Hospice 3-Year Plan – patient feedback
Day Hospice staff changes
‘Small is beautiful’ new way of giving feedback and sharing ideas
Patients requested that more cardboard collection boxes be made available in
the Day Hospice for them to take home.
Garden - further discussion about the garden refurbishment and particularly the
Armillary sphere inscription
Hospice 3-Year Plan - further discussion and patient feedback
Afternoon snack - discussed whether to have one – patients decided this was not
necessary.
Complementary therapy treatments - clarification about what is available to
patients
‘Bald Statements exhibition’ – patients views sought on whether to host an
exhibition by a local artist depicting her personal journey through cancer
diagnosis and treatment.
Hospice developments – explained to patients:
o Oxygen system on Inpatient Unit
o Garden project (already discussed)
o Bathroom/sluice refurbishment on Inpatient Unit
o Proposal to build a new flat/family area on Inpatient Unit
Care Agency – explained to patients the possibility of the Hospice setting up a
Care Agency to provide a variety of care in the Community
Bereavement booklet – patients and carers asked to review the new booklet
Patients asked for their thanks to be passed to Day Hospice staff and volunteers
for all they do
New mini bus – patients viewed it and named it ‘Carrie’
National Volunteers Week – patients asked to help with the National Volunteers
Week display as part of their arts and crafts group
Hospice branding – discussed the need for a brand and asked for patient
feedback
The Patient Survey
We conducted 7 patient surveys during September 2010 and March 2011 in our Inpatient
Unit and Day Hospice. Surveys of up to 20 questions were sent to a sample of patients
receiving care from the Hospice at the time. The surveys were used to gather data to
measure patient satisfaction, the admission process and patient medication.
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Inpatient Unit – patient experience (14/20 - 70% response rate)
Did we treat you as an individual and fully respect your privacy and dignity?
• 78% of patients selected ‘all of the time’
• 14% of patients selected ‘most of the time’
100
80
60
Patients response %
40
20
0
All of the time Most of the time
Other
How effective were we in controlling pain and other symptoms?
• 64% of patients selected ‘excellent’
• 36% of patients selected ‘good’
100
80
60
Patients response %
40
20
0
Excellent
Good
Other
Additional comments:
• Thank you for all you support and care
• Couldn’t be any better
• Couldn’t fault the care given in any way
• Felt that nurses were rushing around trying to get things done and not spending
enough time with patients because everything was too far away medication wise
Action: Keeping controlled drugs in PODS - commenced May 2011
• Would prefer to self-medicate Action: remind staff of the policy and the
options for patients if appropriate
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Inpatient Unit – admission process (16/20 - 80% response rate)
Overall did you think that you were given enough information to make the admission
process as smooth and as easy as possible?
• 88% of patients selected ‘yes’
• 12% of patients selected ‘not sure’
100
80
60
Pt response %
40
20
0
Yes
Not Sure
Thinking about the admission assessment conducted by the doctor and the nurse, how
happy were you with the process
• 81% of patients selected ‘very’
• 19% of patients selected ‘it was ok’
100
80
60
Pt response %
40
20
0
Very
It was OK
Additional comments:
• Too long waiting for a bed / think I should have got a bed a lot sooner, felt let down
Action: revisit audit collection tool to identify reason for waiting time
• Too long waiting for a doctor / feel like waited too long for doctor to admit patient
Action: Changed the process of admitting patients
• Staff were brilliant and very welcoming
• Very happy with everything
• Happy with the whole admission process
• Would have liked to have the choice of a side room or ward bed Action:
Admissions process adjusted, patients now given full information re location
of bed pre admission
• Prefer admission not to be at mealtimes Action: nursing and medical staff will
strive to avoid mealtimes
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Inpatient Unit – patient medication survey (9/14 – 64% response rate
Did you feel fully involved with your medications whilst at the Hospice?
• 33% of patients selected ‘all of the time’
• 56% of patients selected ‘most of the time’
60
50
40
30
Pt response %
20
10
0
All of the time
Most of the time
Were your drugs administered at a suitable time during the day?
• 67% of patients selected ‘all of the time’
• 33% of patients selected ‘most of the time’
70
60
50
40
Pt response %
30
20
10
0
All of the time
Most of the time
Additional comments were requested on how things could be improved:
• Would like better nausea control
• Service was wonderful
• Not at all you do an excellent job
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Day Hospice – patient experience (29/40 – 72% response rate)
Did we treat you as an individual and fully respect your privacy and dignity?
• 93% of patients selected ‘all of the time’
100
80
60
Pt response %
40
20
0
All of the time
In overall terms how do you rate the support that we gave you?
• 70% of patients selected ‘excellent’
80
60
Pt response %
40
20
0
Excellent
Additional comments were requested to explain/comment further on responses:
• I am always made to feel welcome and everyone is so friendly and helpful I think
the staff and volunteers do a wonderful job
• As a day centre patient I would like to see the return of the envelopes for donations
back on the table as other patients I have spoken to feel the same
• A wide range of activities or entertainment would be appreciated and more group
participation. Action: New therapeutic activities coordinator in post –
developments planned. Ensure post holder is aware of issue. Discuss at
Patients’ Forum for ideas and suggestions. Raise staff awareness
• Everything that you do or provide for us at the Hospice cannot be faulted. It is
brilliant support for everyone that has the opportunity to come to St Mary’s. Cannot
think of anything that you can add to make it any better.
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STATEMENTS ON BIRMINGHAM ST MARY’S HOSPICE QUALITY
ACCOUNT FOR 2011/12
QIPP Account Director for End of Life
Birmingham and Solihull PCT Cluster
Birmingham St Mary’s Hospice has continued to work as a major partner in delivery of
Specialist Palliative care to people in the city. St Mary’s clearly focus on the clinical quality
priorities raised through feedback of people who have used the service and of the
population needs based on local data and information which supports the overall Quality
priorities of Birmingham and Solihull PCT Cluster.
Birmingham St Mary’s Hospice is working jointly with colleagues within GP practices and
Community services and the local acute trusts to improve delivery of the pathway and
patients journey and achieve a collaborative and partnership where quality and safety of
care can be enhanced.
The amount of research and review of services demonstrates their commitment and their
mind set to pursue quality improvements as part of every day working life.
On that basis, I support this quality account as it reflects local priorities and those of
service users and has a direct impact on the quality of service people and their families
receive.
Programme Manager End of Life Care and Dementia
Sandwell NHS
The Hospice is to be congratulated on its achievements in 2011/12, and the plans for
2012/13 represent a good mix of priorities. The implementation of an NHS clinical portal to
access patient information offers opportunities for using the learning from this to expand to
other hospitals and benefit more patients.
The priorities identified for the next 4 years, in terms of reaching more people, are
completely in line with Sandwell and West Birmingham CCG's aims for end of life care,
and Birmingham St Mary's are providing leadership in a key work area for the CCG to
achieve this.
FEEDBACK AND COMMENTS
If you would like to provide feedback on the report or make suggestions for content for
future reports, please contact:
Helene Trebinska
PA to Chief Executive
Birmingham St Mary’s Hospice
Tel: 0121 472 1191
Email: helene.trebinska@bsmh.org.uk
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