Quality Account
2011/12
“
We take great pride in ensuring that our patients are
treated as individuals, in or close to their place of
residence, and that they receive the best treatment
to ensure the best possible health outcomes for them.
Whether you are in the care of one of our services, or
whether you commission Bristol Community Health
to provide a service, you can be assured that quality,
dignity in care, and compassion are our top priorities.
”
Contents
1 Part One
Welcome and Introduction
1.1 Statement from the Board
1.2 What can you expect from Bristol Community Health Social Enterprise?
2 Part Two Our Quality Priorities for 2012-13
2.1 What is a Quality Account?
13
2.2 Our Vision and Goals for Quality Improvement in 2012/13
13
2.3 Patient Safety
Priority One: Pressure Ulcers
Priority Two: Frail Elderly Pathway
17
17
19
2.4 Clinical Effectiveness
Priority Three: Productive Services
Priority Four: Urgent Care Strategy
Priority Five: To implement a Diabetes Pathway and Single
Point of Access for Diabetes Services within Bristol Community Health
21
21
22
23
24
2.5 Patient Experience
Priority Six: Patient experience of the Telehealth services
Priority Seven: Patient Experience at End of Life stage
25
25
27
2.6 Other areas of quality improvement
28
2.7 How are we developing quality improvements capacity and capability
to deliver these priorities?
29
3 Part Three
Review of our Services
3.1 Summary of End of Year Successes for 2011-12
32
3.1.1 Performance on National Quality Priorities 2011-12
33
3.1.2 Performance against national and local CQUINS and contracted activity
3.1.3 Awards received by Bristol Community Health
33
4
8
10
36
3.1.4 Examples and local case studies of specific quality improvement initiatives
relating to patient experience, patient safety and clinical effectiveness
37
3.2 Statements of assurance relating to the quality of services provided in 2011-12
55
3.2.1 Participation in National Clinical Audits, National Confidential Enquiries and
Local Clinical Audits
55
3.2.2 Participation in Clinical Research
56
3.2.3 Research and Development
57
3.2.4 Goals agreed with Commissioners – use of the CQUIN payment framework
58
3.2.5 How our regulator the Care Quality Commission views our services
58
3.2.6 Data Quality
58
3.2.7 Information Governance Toolkit Attainment Levels
59
3.3 Statement from Third Parties
59
3.4 Our response to statements
61
3.5 How to provide feedback
62
5
Part One
Welcome and
Introduction
PART ONE - Welcome & Introduction
1.1 Statement from the Board
Welcome to the first annual Quality Account from Bristol Community Health
Community Interest Company/social enterprise. The 1st October 2011 was a
landmark date for Bristol Community Health as this was the date that we formally
separated from NHS Bristol Primary Care Trust and became an independent
Community Interest Company (CIC).
Our Quality Account is an important document because it provides us with the
opportunity of sharing information about the quality of our services with the public.
In particular it lets everyone know what our priorities for quality improvement are
and provides information on how well we have performed in meeting quality targets.
We hope that it provides interesting and useful information to our commissioners,
partners, staff and most of all, to our patients and the wider community that uses
our services.
This year our Quality Account has been informed by the views and analysis of
information by directors, managers, staff, external stakeholders and people who use
our services and their carers. We have followed the framework for the content for
Quality Accounts toolkit published by the Department of Health to ensure that even
though as a social enterprise we are an ‘independent healthcare provider’, the
public will be able to make a comparison of the information we provide about our
services with other community healthcare providers.
Our priorities for improving patients’ safety, clinical effectiveness and patients’
experience of our services in 2012-13 are set out in Part Two of our Quality Account;
Part Three demonstrates our progress against our quality improvement
initiatives undertaken during 2011-12.
In producing this Quality Account, we have taken into account the following specific
sources of information that have arisen during the year.
•
•
•
•
•
•
Monthly performance reports to the Board
Reports on annual reviews of key functions such as infection prevention and
control, health & safety, risk and incident management, information governance and safeguarding
Quarterly reports on our Quality and Services Strategies
Feedback from staff surveys
Patient and public involvement surveys
Reports from our internal and external auditors
As the main local provider of community based health services for the adult
population of Bristol we are committed to ensuring continuous improvements to the
quality of care we provide. We will continue to work closely with our health and
social care partners, charities and patient representatives to identify quality
improvement priorities for the population we serve.
8
We have set ourselves high ambitions to build on our achievements in future years,
whilst reflecting on the diverse nature of the population we serve when we design
facilities and services – and when we set priorities for improving our quality and
performance standards.
Throughout our Quality Account are examples of the feedback we continuously
receive on the performance of our staff and services, showing the progress we are
making against the standards we have set ourselves.
It gives us great pleasure to introduce our first Quality Account on our work and
achievements this year. To the best of our knowledge the information contained
within this Quality Account sets out a true and accurate representation of our
achievements in 2011-12 and our priorities for continuously improving quality in
2012-13.
Richard Samuel
Chair
Julia Clarke
Chief Executive
9
1.2 What can you expect from Bristol Community Health Social Enterprise?
As an independent social enterprise, Bristol Community Health can respond rapidly to the
needs of commissioners and offer the best value, highest quality community healthcare,
putting patients at the centre of everything we do. This is illustrated in the figure below.
Total
commitment to
helping people live
independently, and
reducing reliance on
acute and other
institutional
care
Innovation and
new services. Every
penny we make will
be reinvested in
improving community
healthcare
Passion for
community health
services...and for
constantly
improving them
Patients at the Centre
Productivity,
efficiency and quality.
Better care for less
money
Flexibility and
responsiveness to
primary care. Our
services will never be
one size fits all
Real change at
the health and social
care boundary driven by excellent
partnerships
Talented and
expert staff who care
about what they do and treat everyone
with
compassion
We rely on our staff’s expertise, skills and their understanding of our patients to succeed.
This is why our staff are the shareholders in Bristol Community Health. Our surpluses will
be reinvested into service development to constantly improve the way we do things. Our
staff and our patients know better than anyone how to do this, and therefore our
organisation is and will remain in their hands.
We have always lived by NHS principles and as a social enterprise we will continue to do
so. Social enterprises are not about profit – they are about combining the best values of the
NHS and the voluntary sector with business acumen and talent to generate surpluses for
re-investment into the community - re-investment that will help people to live life well.
With our long term experience of running NHS community healthcare services across
Bristol and beyond, we are experts in providing urgent care services and supporting and
training people to live with long term conditions. Our specialist nursing and therapies staff
care for patients with a wide range of complex health needs, including those with learning
difficulties and those detained in prison.
10
We also provide a range of unique services including our Tuberculosis Screening and
Contact Tracing service and The Haven, a primary care service supporting asylum seekers
and refugees. From dermatology to district nursing, prison healthcare to physiotherapy,
walk-in centres to wound care, our 1200 strong team helps people to live life well.
We take great pride in ensuring that our patients are treated as individuals, in or close to
their place of residence, and that they receive the best treatment to ensure the best
possible health outcomes for them. Whether you are in the care of one of our services, or
whether you commission Bristol Community Health to provide your service, you can be
assured that quality, dignity in care, and compassion are our top priorities.
For more information visit the Bristol Community Health website.
www.briscomhealth.org.uk
11
Part Two
Our Quality
Priorities for
2012-13
2.1 What is a Quality Account?
This is the first formal Quality Account that Bristol Community Health has published and
follows the format and content laid out in the Department of Health Guidance 2010/11,
where relevant to independent providers of community health services.
The Quality Account provides a structure for us to report on the three key elements of the
quality of care that a person using our services receives as illustrated in the figure below.
Patient Safety
Patient
Experience
Clinical
Effectiveness
Together these elements give a comprehensive picture and that by combining them with
measures of health outcomes for our service users, we will give our management, staff,
patients and the public an informed picture of the quality of our services. As we continue to
analyse this picture we can get a better understanding of our own performance and where
we should target our continued drive for improvement.
2.2 Our Vision and Goals for Quality Improvement in
2012/13 - The coming year
We strive to deliver personalised, responsive, high quality services in a manner that
demonstrates respect, dignity and kindness to the people we serve. In 2011, our Integrated
Business Plan set the scene for more specific focused priorities for each year to support our
approach in delivering Patient Safety, Clinical Effectiveness and Patient Experience.
One year on after this plan was agreed, it is useful to have a reminder or our stated focus
for the coming years.
13
What do we need for
success?
GP Practices and
GP Commissioning Consortia who
believe that we deliver services on
the ground which are high quality,
responsive and good value for
money
What is the most
important factor in
delivering this?
High performing, highly motivated
staff who are empowered to provide
an excellent service focused on the
needs of patients and on GP
Commissioner aspirations
What can deliver the
necessary change in
culture and approach?
A Social Enterprise which turns the
traditional NHS hierarchical model
on its head, with its stakeholders
determining its priorities while the
staff who own it determine the best
way to deliver them
Our organisational
development journey...
Starting to work in this
mode during
transition - our
commitment is that
the staff who will own
the Social Enterprise
shape it from the very
beginning
Over the last 12 months we have developed this Vision into a clear overall strategy for our
services, with clear measures against which to monitor progress. Those directly pertinent to
delivering our quality aspirations come under the service and business objective to
‘Improve the quality of care received by patients and their experience of that care’.
Last year the key measures for this objective included the following.
Enabling more people to receive the care they need closer to their home
•
•
•
•
Successful implementation of the new South Bristol Community Hospital
Measurable reductions in unnecessary emergency admissions to the acute hospital
for local people which are directly attributable to our services
Measurable reductions in acute hospital length of stay which are directly attributable
to our services
Increased service integration with Bristol Health and Social Care
Improve the Quality of Care received by Patients and their Experience of that Care
14
•
An increased use of Patient Reported Outcome Measures (PROMS) across our
services
•
Improvement of patient and carer satisfaction with our services demonstrated through
patient surveys
•
Meeting and exceeding all nationally mandated quality standards for our services;
quality standards set by our local commissioners; and patient safety standards
Use innovation to improve the productivity and value for money of our services
•
All services to have agreed and challenging productivity targets with a timescale for
achievement
•
Year on year increase in proportion of time spent on direct patient care
In determining our quality priorities for the coming year 2012-13 we are continuing to strive
to make tangible differences to the care our patients receive against these key measures.
This is set within the context of delivering care in the community or in patients’ homes
avoiding unnecessary hospital visits and admissions. This is an important element of
improving the quality of patient care.
Programme for CQUIN (Commissioning for Quality and Innovation) targets for 2012-13
The Commissioning for Quality and Innovation (CQUIN) payment framework enables
commissioners to reward excellence by linking a proportion of our income to the
achievement of local quality improvement goals. NHS Bristol, our main commissioner, has
set quality performance measures for our community health services. CQUINS for 201213 reflect national reports and recommendations, patient satisfaction surveys and local
needs and priorities. Our agreed quality and innovation goals are included below and it
should be noted that at this point in time the actual measures for these quality targets are
still to be agreed with our Commissioners.
Nationally mandated objectives
•
•
•
Improved Patient Experience by surveying our patients to establish whether our
services have met their personal needs
Diagnosis and risk assessment of patients with dementia who live in a community
setting
Implementation of the national NHS Safety Thermometer to improve the collection of
data in relation to pressure ulcers, falls, urinary tract infections in those with a catheter
and Venous Thromboembolism (VTE)
High impact regional innovations
•
•
Working with local hospitals to ensure patients with long term conditions such as heart
failure and respiratory conditions are able to be looked after at home through use of
assistive technology e.g. Telehealth
Improved support for carers of people with dementia
Regional system change objectives where we will work in collaboration with our
health and social care partners to bring about
•
5% reduction in the number of emergency admissions
•
51% of people dying at home (including care homes)
15
Bristol Community Health organisational objectives
•
Implementation of the NHS Innovation and Improvement Productive Community
Services Programme in Community Teams. This is the programme to empower local
community teams to provide efficient, responsive services to meet patients’ needs
•
Continued improvement for Patients in the Bristol Learning Difficulties Service
signposted for a GP health check
•
Reduction of the incidence of community pressure ulcers
•
Undertaking surveys with patients with Long Term Conditions such as Chronic
Obstructive Pulmonary Disease (COPD), Heart Failure, Diabetes and Parkinson’s
disease in order to improve patient experience.
In order to shape the areas that Bristol Community Health should focus on for our
quality improvements for 2012-13, we have sought the views of our patients, carers,
staff and stakeholders in a number of ways which have included the following
•
•
•
An analysis of themes from the complaints received, incidents reported and concerns
raised via our Patient Advice & Liaison Service (PALS) during 2011-12
Feedback from representatives of Bristol City Council, NHS Bristol and Bristol LINK
Discussions with our staff at all levels within the organisation in teams and committees
After careful consideration of the main themes that emerged from this feedback and linked
to the national and local objectives, we have agreed the seven key priorities identified in
section 2.3.
16
2.3 Patient Safety
Priority One
Pressure Ulcers
‘Pressure Ulcers – it’s everybody’s business’
Implementation of a strategy to safeguard
patients against the development of pressure
ulcers and ultimately reduce the number of
incidences.
•
The development of four new protocols of care
•
Focus on key areas of skin that are most at risk
•
Working collaboratively with social care agencies,
and across organisational boundaries
Pressure ulceration causes pain, suffering and delays a patient’s rehabilitation and affects
their lives adversely. It is also costly in terms of resources.
Pressure ulcer prevention in the community is extremely challenging with vulnerable and
unwell patients living alone and with often small packages of care making the reality of
moving the patient and monitoring their skin condition very difficult. Working collaboratively
with social care agencies is essential and it has been recognised by both parties that the
implementation of prevention strategies with both staff and patients can be very effective.
The Bristol Community Health vision is to implement a strategy to safeguard patients against
the development of pressure ulcers and ultimately reduce the number of incidences. Our
pressure ulcer prevention project is entitled ‘Pressure Ulcers – it’s everybody’s business’ and
involves the development of four new protocols of care which are linked to the Waterlow
Assessment Tool and associated predicted level of risk. They are based on the ‘SSKIN’
bundle which recognises and guides patients and clinicians to focus on key areas of skin
that are most at risk. For the first time we are able to work collaboratively with social care
agencies, and across organisational boundaries, to ensure the success of this project and
consequently protect patients from unnecessary harm.
The proposal has been very positively received by the care agencies and awareness
training will be delivered to both clinical and care agency staff. We have produced a suite of
supporting materials including educational flashcards to support information given to
patients. This will empower them to look after their own skin and avoid
pressure ulcers.
The team plan to audit the use of the protocols once the project and the educational
initiatives have been embedded with staff. It is envisaged that the incidence reporting of all
pressure ulcers will become a more robust and reliable system as a result of the project. We
are proposing that patient’s level of risk and the implementation of a prevention protocol is
reported on the current tool.
17
This initiative also links to our plans to deliver the National Patient Safety Thermometer. We
will be collecting data through monthly surveys on four outcomes including pressure ulcers,
falls, urinary tract infections in patients with catheters, and VTE (Venous
Thromboembolism). This is one of the ways Bristol Community Health can benchmark
current prevalence of harm in the community we serve. By participating in this survey we
can demonstrate that we are contributing to a national effort to improve care.
18
Priority Two
Frail Elderly Pathways
Developing and enhancing a care
pathway across Bristol, North Somerset
and South Gloucestershire (BNSSG) for
the frail older people population that has
clear outcome measures; encompassing a
virtual ward approach and clarity about
medical “direction” both within the hospital and
community environment.
•
Identify clear benchmarks and agree what
baseline information should be used to measure
changing and improved performance and patient
outcomes
•
Assessing areas of current clinical practice that could or should
be changed to enable reflective frail older people pathways
•
Identify what are the top 5 issues that hinder effective frail older people pathway activities and conversely what needs to change to improve the care management of this vulnerable group of people once identified
•
Agreement in principle of the level of assessment and an approach that ensures this is suitable for the longer term care management, as well as the crisis management, of frail older people.
Julia Clarke, our Chief Executive is the nominated lead for the Healthy Future Board to take
forward the brief for progressing the work across Bristol, North Somerset and South
Gloucestershire (BNSSG) for developing and enhancing a cohesive care pathway across
BNSSG for the frail older people population. The objectives include the following;
•
Agreeing a definition of “Frail Older People” across the health community. This
needs to reflect national definitions, for example:
“Frail older people are defined as patients who are usually over 75 years of age –
and often over 85 years – with multiple diseases (which may include dementia).
They tend to present at hospital with symptoms such as falls, immobility and
confusion. The main characteristic of ‘frailty’ is reduced functional reserve, and
hence frail older people are more susceptible to developing complications in
hospital”
(Focus on: Frail Older People, Institute for Innovation & Improvement)
•
Identifying clear benchmarks and agreeing the baseline information to be used to
measure change and improved performance and patient outcomes
•
Assessing areas of current clinical practice that could or should be changed to enable
reflective frail older people pathways. Examples of this may include reducing the level
of testing by different practitioners / departments that this group of the population are
exposed to; more effective medicines management and subsequent reviews
19
20
•
Identifying across the Health and Social Care community what are the top 5 issues
that hinder effective frail older people pathway activities and conversely what needs to change to improve the care management of this vulnerable group of people
•
Agreement in principle across the Health and Social Care community about the level
of assessment that needs to take place in order to reduce the number of assessments that may currently be taking place
•
Agreement in principle of a “trusted assessor” approach and ensure that this is
suitable for the longer term care management as well as the crisis management of frail older people
•
By Summer 2012 an agreed outline proposal of a Frail Older People Pathway will be
designed. This will be developed across healthcare providers in hospitals and the
community and will have clear outcome measures
2.4 Clinical Effectiveness
Priority Three
Productive Services
Release more clinical time to undertake
patient facing duties to increase our
effectiveness and our understanding of our
patients’ experiences. We will work through the
Productive Community Services Programmes.
The multi-disciplinary teams will follow modules called:
•
•
•
•
•
Well organised working environment
Knowing how we are doing
Patient status at a glance boards
Managing caseload and staffing
Working better with our key care partners
The Programme is underpinned by the patient’s perspective and creates a baseline for understanding patient experience.
As part of the national Transforming Community Services agenda the transformation of
community services within Bristol Community Health has led to the development of eleven
integrated community nursing teams. These teams, together with the three locality Learning
Difficulties teams and the HMP Bristol team, attended a very successful Productive
Community Services launch event led by the NHS Institute for Innovation and Improvement.
The Productive Community Services Programme will run for 18 months to two years and
will cover nine programme modules. The aim of the programme is to release more clinical
time to undertake patient facing duties and to enable evidence based improvements within
community teams. Bristol Community Health will be engaging fully with the Programme to
increase our effectiveness and our understanding of our patients’ experiences. The
Programme will commence with the ‘Well organised working environment’ foundation
module, which will support frontline staff to deliver high quality patient focussed care.
The teams will progress to the other foundation modules, which are ‘Knowing how we are
doing’ and ‘Patient status at a glance boards’. The Programme itself is underpinned by the
patient’s perspective and creates a baseline for understanding patients’ experiences.
As the teams progress through the planning modules within the Programme they will cover
‘Managing caseload and staffing’, ‘Knowing how we are doing’ and ‘Working better with our
key care partners’. These modules will provide a welcome opportunity for us to develop
effective strategies to more effectively manage patient and caseload demands.
The NHS Institute for Innovation and Improvement has highlighted improved patient safety
and satisfaction, improved staff morale, reduced waste elimination, and more effective
processes as successful Programme outcomes. Bristol Community Health expects that the
programme will empower staff to drive through improvements, sustain positive change and
benchmark and evidence further improvements.
21
Priority Four
Urgent Care Strategy
Improve access to non-acute hospital
alternatives by developing an Urgent
Care Centre in South Bristol Community
Hospital. The enhanced facility will extend
choice and improve standards of emergency
and urgent care.
Ensure that patients are assessed and / or triaged
to the same standard as patients attending Accident
and Emergency and are referred to the correct service
delivery point.
Patients are directed to the right service provider thus smoothing
demand and capacity across the urgent care system for the benefit of patient care
and experience.
Bristol Community Health is committed to being a key partner in the urgent care agenda by
supporting the management of more patients in the community and reducing the
dependency placed on acute trust emergency departments.
Our aim is to improve access to non-acute hospital alternatives by extending and enhancing
the current Walk in Centre service provision. Our vision is to extend choice and improve
standards of emergency and urgent care through the development of an Urgent Care
Centre, building on the experiences of minor illness and injury care delivered at the South
Bristol (Knowle West) and City Gate Walk in Centres.
The development of the Urgent Care Centre (UCC) is part of the advancement of
emergency and urgent care. The UCC ensures that patients are assessed and / or triaged
to the same standard as patients attending Accident and Emergency and are referred to the
correct service delivery point. The UCC supports the models of care offered by different
services. This will ensure that patients attend and are directed to the right service provider
thus smoothing demand and capacity across the urgent care system for the benefit of
patient care and experience.
The UCC at South Bristol Community Hospital opened on 30th March 2012 and the new
walk in/urgent care facility at Boots Broadmead opened on 16th April 2012. Brisdoc is
sub-contracted to deliver the city centre walk in service from Boots, Broadmead as a single
service provider on behalf of Bristol Community Health. Both sites are compliant to Care
Quality Commission essential standards of quality and safety.
South Bristol Community Hospital’s Urgent Care Centre offers the following key benefits to patients in Bristol:
•
22
Provides an urgent care service to the South Bristol catchment area for adults and
children who require care for minor illness and injury. Patients may self present or arrive by ambulance.
•
Has a skilled workforce that is able to meet the needs of both adult and paediatric
attendees who have limb, soft tissue or bony injury that require x-rays and potential
onward referral through agreed clinical care pathways.
•
Provides access to appropriate on site diagnostics e.g. plain film x-rays with robust
reporting mechanisms.
•
Provides access to a slit lamp for eye examinations carried out by suitably trained and
experienced practitioners.
•
Has near patient testing i.e. glucose testing equipment, ECG, pregnancy testing in the first instance.
•
Has staff competent in non medical prescribing and in the use of agreed Patient
Group Directives where appropriate.
•
Provides access to physiotherapy to effectively manage soft tissue injuries, initially via
primary care.
•
Has the ability to offer scheduled follow up ‘slots’ for the removal of sutures, certain
dressings, and paediatric bloods at the discretion of the service.
•
Has agreed onward referral and clinical pathways with other specialities / agencies
including sexual health, mental health, social Care, SPA (Single Point of Access), long
term conditions, paediatrics, orthopaedics, ophthalmology, burns and plastics, medicine and surgery.
•
Receives ambulance and community health referrals for minor illness or injury
which fulfil the criteria within the service specification.
23
Priority Five
Diabetes Pathway
Making it easier and more effective for
people to contact our specialist Diabetes
Services, so that we are seeing the right
people at the right time and in the right place.
•
•
•
Establish a single referral process for
diabetes patients to enter and exit our
services
Eliminate inequity of provision across Bristol and
under representation amongst Black and Minority
Ethnic groups, by co-locating and integrating our
Diabetes Education Service with Dietetics and Community
Diabetes Nursing
Make our services more accessible and user friendly by making full use of available technology including text and phone alert appointment reminders, online booking and better web based information
Diabetes is a major area of spend for the NHS nationally. At Bristol Community Health we
plan to make it easier and more effective for people to contact our specialist Diabetes
Services, so that we are seeing the right people at the right time and in the right place.
Our services originally developed independently of each other and therefore we have had
numerous entry and exit points for patients. This is confusing and can cause duplication, or
even delay. There is also currently inequity of provision across Bristol and under
representation amongst Black and Minority Ethnic groups. We are therefore planning to
co-locate and integrate our Diabetes Education Service with Dietetics and Community
Diabetes Nursing teams and will be supporting them with a Single Point of Access and
streamlined referral processes. We plan to make our services more accessible and user
friendly by making full use of available technology including text and phone alert
appointment reminders, online booking and better web based information.
We will measure our effectiveness by the following;
•
•
•
•
•
•
24
Monitoring service access times (18 weeks monitoring) for Dietetics, integrated
community teams and the Diabetes Education service.
The number of Diabetes Education Sessions delivered.
The number of reported ‘Never Events’ for Insulin
Long Term Conditions survey of patient confidence in managing their own conditions.
The integrated community teams will be applying some of the NHS Institute for
Innovation and Improvement principles on productive community services.
Carrying out an annual equalities profile to include five strands such as ethnicity,
gender, age, disability, and sexual orientation.
2.5 Patient Experience
Priority Six
Telehealth Services
Use of feedback from interviews with
patients to influence the way the Telehealth
service is being taken forward to assist and
enhance existing clinical roles through the
provision of remote monitoring of clinical symptoms
and vital signs.
•
•
•
The two conditions selected for this service are
chronic obstructive pulmonary disease (COPD) and
congestive heart failure (CHF).
The Telehealth device provides support to enable home based patients with multiple conditions to self-manage their conditions effectively to avoid unnecessary admissions to Emergency departments.
Patients will be introduced to using the Telehealth service at an earlier stage in their condition; each patient will have a named person who will provide them with on-going support.
Telehealth services assist and enhance existing clinical roles through the provision of
remote monitoring of clinical symptoms and vital signs, such as blood pressure and weight,
for assessment and prevention of exacerbations. Data is transmitted to a clinician’s
computer where it is monitored against parameters set by the patient’s clinician. Results
falling outside the parameters trigger an alert, which lets community nurses know when
there is a problem.
The two conditions selected for this service are chronic obstructive pulmonary disease
(COPD) and congestive heart failure (CHF). The Telehealth device provides support to
enable home based patients with multiple conditions to self-manage their conditions
effectively. This is done in partnership with their clinical lead to optimise disease
management and minimise the risk of hospital admission. Patients are offered the
opportunity to measure and understand oxygen saturation and this significantly reduces
the incidence of panic attacks, which often lead to unnecessary admissions to Emergency
departments.
Bristol Community Health is working in partnership with NHS Bristol and Safe Patient
Systems Ltd to support the introduction of the service. This initiative is part of an integrated
response to the projected increase in the number of older people with one or more long
term conditions. Innovative and effective ways must be found to meet their clinical needs
whilst addressing the additional challenge of delivering sustainable efficiency savings. The
Department of Health has confirmed its backing for the delivery of Telehealth at scale, with
the aim of improving the lives of 3 million people over 5 years. The largest Telehealth pilot
in England (Whole System Demonstrator) has reported initial positive findings, which have
increased interest in this technology.
25
Using semi-structured interviews feedback has been obtained from some early implementer
patients which has provided useful pointers to influence the way the Telehealth service is
being taken forward. Comments included the following:
“I like the fact that it is simple and easy to use.”
“I was so worried about messing up the programme, but the way it was introduced
was done very well. Once you have used it a couple of times that’s it.”
“The great thing about Tele-health is that you really can fit it into your daily routine and
it is easy to do that.”
“I kept it in the spare room. It wasn’t intrusive and became part of my daily routine.”
“I was once late doing the test. Sue phoned up to see if I was alright.”
“Knowing that I can send this information on a daily basis to my nurse is very
comforting and it makes me feel as though I am not far away from help if my condition
worsens.”
However, those who were isolated and more immobile missed the human contact they had
from a regular visit from their nurse. Some users drew attention to the lack of subtlety in the
replies available to them through the system as the device only allows for ‘yes’ and ‘no’
replies.
Based on this feedback we plan to get patients using the Telehealth service at an earlier
stage in their condition. Each patient will have a named person who will provide them with
on-going support and the service will make sure it contacts patients at an early stage of
alert.
Key performance indicators are being established presently and the following three areas
are considered to be important:
1. •
•
•
Reduction in activity
Reduction in A&E attendances
Reduction in unplanned admissions
2. •
Service user experience, Patient satisfaction survey (6 monthly), Patient questionnaires - 100 surveys per long term condition
3. •
•
Set-up and maintenance improvement in the number of Telehealth home hubs and peripherals installed per chosen condition
90% of appropriate staff trained to use and install
Telehealth is integral to our Community Contract and therefore reports will be generated
within timescales agreed with commissioners. The questionnaires will be administered by
Bristol Community Health and the information collated by NHS Bristol. The interviews will
be a collaborative exercise based on an agreed set of questions.
26
Priority Seven
End Of Life Care
Ensure we measure how well we have
supported patients who are expected to
die, and how well our services have
supported them to achieve their wishes.
The things that our patients consider most
important include thinking ahead, discussing and
agreeing what is most important. This is different for
every individual patient, but usually includes making
sure that plans are put in place about where to receive
care (and where to die), making sure that physical and
emotional problems are dealt with appropriately, including of course
all of the practical elements that are a part of this.
When patients are approaching the end of their lives it is really important to ‘get it right’ for
them – there is only one opportunity to do this, and it is so important for each individual and
for those who are left behind.
The things that our patients consider most important include thinking ahead, discussing and
agreeing what is most important. This is different for every individual patient, but usually
includes making sure that plans are put in place about where to receive care (and where to
die), making sure that physical and emotional problems are dealt with appropriately, including
of course all of the practical elements that are a part of this.
In order to measure how well these priority areas are achieved, Bristol Community Health
will record and report on how many people supported by our services are expected to die,
and how well we support them to achieve their wishes.
The things we will measure include the following:
•
•
•
The numbers of people who have made specific plans about their end of life care in
the form of advanced care planning.
The numbers of people who actually achieve these wishes, particularly looking at
helping people to stay at home (and to die at home) whenever this is their wish.
The satisfaction of patients and their carers – we know that compassionate care and
being treated with dignity are highly valued, and we will ask patients and carers about
their experience of care from Bristol Community Health services at the End of Life stage.
27
2.6 Other areas of quality improvement
Our ‘seven priorities for improvement for 2012-13 are not the only areas of quality
enhancement planned for 2012-13. We will also deliver the quality improvements outlined
in our contract and across the CQUINS (identified on page 7). We will also contribute to the
overall delivery of the system-wide Quality Innovation Productivity and Prevention (QIPP)
plan which outlines the opportunity of improving patient care experience through offering care
closer to home and avoiding unnecessary admissions. In particular we will be committing
to introducing a wider range of Patient Related Outcome Measures (PROMS) to our
portfolio of measuring the quality of our outcomes.
We have identified PROMS as a tool which can be used to demonstrate quality and value in
community services. PROMS are self-reported questionnaires validated for a range of
generic or condition specific health-related quality of life (HRQoL) assessments. Bristol
Community Health are collaborating with Avon Primary Care Research Collaborative,
University of West of England and University of Bristol to support research looking into
Quality Indicators for Integrated Community Teams which will also consider using PROMS as
key part of developing this patient outcome focussed work. We are currently developing a set
of recognised tools that will enable us to evidence the impact and outcome of our patients’
treatment as well as their experiences. The data will be collected from patients through
questionnaires and used to improve our service delivery.
Our Quality Account will be monitored through Bristol Community Health’s Quality Assurance
and Governance processes. This will include regular reports to the Board, Quality Assurance
and Governance Committee and the Clinical Governance Working Group. These priorities
will also be an integral part of the Quality Improvement Plan for the coming year.
The image overleaf illustrates The Bristol Community Health Quality Reporting Framework.
28
Membership
Hugh Ross – NED / Chair
Jon Gould - NED
Medical Director
Head of Quality, Assurance & Governance
Director of Services & Strategy
Clinical Cabinet rep
General Manager rep
Risk, Complaints & Security Manager
BCH Board
Meets Monthly
Month Three
Quality Assurance &
Governance Committee
Meets Quarterly
Learning & Development Group
Central Health, Safety,
Welfare & Security Group
Information Governance
Month Two
Membership
Medical Director - Chair
Head of Quality, Assurance & Governance
Director of Services & Strategy or deputy
Clinical Cabinet members
Risk, Complaints & Security Manager
Health and Safety Officer
CA&E Manager
Head of Learning and Development
Prison Healthcare
Service Leads (as required)
Safeguarding Lead
Patient and Public Involvement Lead
Clinical Governance
Working Group
Meets Monthly
Medicines Management
Issues
Clinical Audit and Research
Group
Infection Control Group
Medical Devices Group
Month One
PALS
PPI Group
Safeguarding Groups
Risk Management report
Every Month
Risk Management – informal update
Complaints
Prison Governance
By reviewing quality data at all levels across the key elements of patient safety, clinical
effectiveness and patient experience, our quality reporting framework allows individual
services to take action to improve quality in their areas as part of a rolling programme.
2.7 How are we developing quality improvements capacity and capability
to deliver these priorities?
At Bristol Community Health we believe that if quality is to be at the heart of everything we
do, we must strive to
ensure that we have the capacity, capability and competency to deliver quality services.
We will continue to develop the vision of improvement and innovation in our services to
deliver better outcomes for our service users.
29
Part Three
Review of our
Services
PART THREE - Review of our Services
During 2011-12 we provided 35 community healthcare services commissioned by the NHS
in and around Bristol. Please find below a list of our services:
Community Nursing Services (including multi-skilled teams)
• Community Matrons
• Community Nurses for Older People
• District Nursing
• Continence
• Dermatology
• Falls Prevention
• Palliative Care and Cancer Help for Ethnic Minorities (CHEC)
• Phlebotomy
• Tuberculosis Contact Tracing and Screening Service
• Wound Care and Tissue Viability
Therapy Services
• Domiciliary Physiotherapy
• Musculoskeletal Physiotherapy
• Musculoskeletal Assessment and Treatment Service
• Occupational Therapy
• Podiatry
• Spinal Pain Service
Long Term Condition Services
• Chronic Obstructive Pulmonary Disease (COPD)
• Diabetes Education
• Diabetes Specialist Nursing
• Heart Failure
• Dietetics
• Parkinson’s Specialist Nurse
Intermediate and Urgent Care Services
• Intermediate Care and Reablement
• Single Point of Access (SPA)
• South Bristol Community Hospital Urgent Care Centre
Unique Services
• Disabled Adults Resource Team (DART)
• Diabetic Eye Screening Programmes
• The Haven
• Healthlinks
• Health Assessment and Review Team (HART)
• Infection Prevention and Control
• Learning Difficulties
• Prison Healthcare
• Safeguarding Services
31
We have reviewed all of our quality data in relation to provision of these services. This
information has come from a range of sources including local and national audits, patient
surveys, national targets, locally agreed performance measures and last year’s CQUIN
targets.
During 2011-12, the Board received monthly performance reports and quarterly quality
reports which provided progress against the performance indicators for safety, quality and
performance across all of our services. The information is presented not only as numerical
data and supporting narrative, but also graphs and commentaries to describe changes and
improvements in practice in relation to performance.
During 2012-13 the Board is overseeing the development of a Corporate Performance
Dashboard which will provide an integrated approach to performance management and
business planning by implementing integrated reporting and documentation
management solution for key performance information – including managing evidence for
our Quality Account and compliance with our key regulator for safety and quality, the Care
Quality Commission.
The income generated by the NHS services reviewed in 2011/12 represents 100% of the
total income generated from the provision of NHS services by Bristol Community Health.
3.1 Summary of End of Year Successes for 2011-12
In this section of our Quality Account we report against our quality priorities by reviewing our
contract with Commissioners at the end of this financial year against services highlighted in
the previous section. We provide a summary of the report here, showing progress against
our stated national targets so that performance may be compared with other community
providers. This section is divided into four key themes for reporting our key areas of
success:
32
•
Performance on National Quality Priorities 2011-12
•
Performance against national and local CQUINs and contracted activity
•
Awards received by Bristol Community Health
•
Examples and local case studies of specific quality improvement initiatives relating to
patient safety, clinical effectiveness and patient experience
3.1.1 Performance on National Quality Priorities 2011-12
The table below provides an at a glance look at Bristol Community Health’s performance
against key national indictors. We have used 2010-11 figures as a baseline.
Indicator
Plan
Actual
Performance
Serious Untoward Incidents
0
16
Plan Not Achieved
Never events
0
0
Plan Achieved
Incidence of falls
10
17
Plan Not Achieved
Incidence of pressure ulcers
<100
130
Plan Not Achieved
Medication errors
<200
255
Plan Not Achieved
Adverse incidents
<870
805
Plan Exceeded
MRSA bacteraemias
0
4
Plan Not Achieved
Clostridium difficile Infections
leading/contributing to Death or Colectomy
Complaints investigated and responded to
within 28 days
0
3
Plan Not Achieved
100%
100%
Plan Achieved
Infection control:Pre 48 hour infections with
BCH services involved in patient care:
3.1.2 Performance against national and local CQUINS and contracted activity
We have performed highly against significant targets and a range of these achievements
and improvements are detailed below:
Service Highlights
The Health Assessment and Review Team (HART) has achieved the 2011/12 target for
the percentage of new continuing healthcare cases determined within 28 days. The service
achieved a performance of 98% against a target of 90%.
The Bristol Learning Difficulties service has, in the past two months, turned around a
performance deficit to exceed a CQUIN target set for the percentage of clients signposted
for a Primary Care health check.
33
The Rapid Response service has also posted excellent year end results with the number of
referrals received, achieved prevention of admissions and completed assessments, all
surpassing set targets. This means we prevented over 4,000 patients from being admitted
to hospital as part of the urgent care strategy to improve community alternatives to
admission.
The Bristol and Weston Diabetic Screening Programme and the Bath, Wiltshire and
Somerset Programme have achieved all invitation to screening and grading targets as
specified by the National Programme. This means in Bristol we screened and graded over
80% of the eligible population and in Bath we screened over 90%. The direction of
performance is also showing an improvement from the previous year with screenings in the
Bath programme performing in the top quartile nationally.
All contractual targets for both Bristol and South Gloucestershire commissioners were
exceeded within the Palliative Care Home Support Service and the Bristol enhanced service
supported 92% of its patients to die at home. The numbers of patients supported to die at
home was also more than double the contracted level of activity for the Bristol enhanced
service. End of Life Care therefore represents an excellent growth opportunity for the
organisation to increase service provision to patients and this will be pursued with
commissioners as part of agreed service development areas for 2012/13.
Urgent Care and Intermediate Care Services
The Bristol Urgent Care Centres achieved their target, which was 99% of patients to be
seen and treated within 4 hours.
All targets for the combined REACT (Rapid Emergency Assessment Care Team) service in
the emergency departments at the Bristol Royal Infirmary and Frenchay Hospital were
achieved this year. This is an excellent achievement and combined results show that 35%
of patients seen were discharged within 4 hours, whilst only 17% of patients ended up being
admitted to hospital. The Rapid Response service has also met key performance targets
including the plan for achieved prevention of admissions which was exceeded by 3%.
The Single Point of Access (SPA) end of year performance for the percentage of
appropriate rejected referrals due to lack of capacity in Rapid Response was 3.4%,
therefore well above the 1% target. Upon investigation the majority of these patients either
had an alternative service provided elsewhere in Bristol Community Health or agreement
was reached to manage patient safety overnight and re-refer the next day. These are
therefore not true lack of capacity cases and a new methodology for recording these more
accurately has been piloted in March, with the results expected in May. This area continues
to be closely monitored and has improved significantly since January despite ongoing
pressures in the last two months of the year. The easing of winter pressures and the full
implementation of a recruitment plan in Rapid Response will result in an improvement to
performance during the first quarter of 2012/13.
Performance for other Intermediate Care services including Rehabilitation and Re-ablement
was good in 2011/12 and will be superseded by the new performance framework for the
Intermediate Care and Re-ablement Partnership in 2012/13.
34
Long Term Conditions Services
Bristol Community Health keenly supports innovation and opportunity in patient care. The
Telehealth
programme pilot represents a significant challenge for the organisation in 2012/13 in
ensuring our use of Telehealth results in a marked improvement in the number of patients
with long term conditions self managing their care. In 2011/12 205 units were installed
against a target of 600. A Rapid Review Working Group was convened in April to maximise
the staff within specialist nursing and integrated community nursing teams using the
system, including the development of key competencies and leadership behaviours to
support further deployment. So far, patient identification has focused on COPD and Heart
Failure patients, but plans are now in place to expand this to Diabetes patients in 2012/13,
therefore increasing patient flow in the longer-term.
Bristol Community Health’s activity plans to support the delivery of commissioning
objectives in the Quality, Innovation, Productivity and Prevention (QIPP) programme have
been met for the Chronic Obstructive Pulmonary Disease pathway. As part of this pathway,
Bristol Community Health has led on the review of Home Oxygen provision. Some key
improvements to date include strengthened relationships with the Home Oxygen supplier
Air Liquid, the development of a Primary Care proforma to obtain better information on
patients unknown to the assessment and review service, and the development of an action
plan to address the high level of patient non-concordance in the levels of prescribed and
used oxygen.
All activity and waiting time plans for the Bristol Heart Failure service have been achieved in
2011/12. Funding has been secured for further development and integration of the Heart
Failure service in 2012/13 and Bristol Community Health were successful in winning a British
Heart Foundation bid for developing an in-reach service with North Bristol NHS Trust (NBT).
The Bristol Learning Difficulty Service has achieved end of year activity targets and steady
progress has been made throughout the year to move towards compliance with national
waiting time targets for 18 week referral to treatment times. The South Gloucestershire
Learning Difficulties Service is also continuing to perform to expected contractual targets.
Therapies, Planned Services, and Prisons
The Prison Healthcare Quality and Performance Indicators (PHQPIs) for HMP Bristol,
Eastwood Park and Leyhill are assessed as ‘green’ and performing well. The informal
assessment has been completed at Eastwood Park and Leyhill and will be declared as
‘green’ with the exception of one amber indicator for Learning Difficulties - whilst basic
screening does take place there is currently no further commissioned provision.
The Primary Care Team at HMP Bristol continues to perform highly as their care of inmates
with blood-borne viruses is being recognised both locally and regionally.
The quality of our prison healthcare services was further recognised when, in early March, it
was confirmed that Bristol Community Health had been successful in winning the contract to
provide Medicines Management Services in HMP Eastwood Park and HMP Leyhill with
effect from 1st June 2012.
35
At Eastwood Park Prison Bristol Community Health have 7 Registered Nurses who have
completed Facilitated Learning and Assessment in Practice training. The team were pleased
to welcome their first cohort of 2nd Year Student Nurses from the University of the West of
England (UWE) in December 2011. They worked with learning and development teams at
UWE and Bristol Community Health to ensure the best possible experience for the students.
Therapy and Planned services in all but two services have achieved or exceeded national
standards in referral to treatment time targets. The two exceptions are the Occupational
Therapy service contact level performance and 18 week referral to treatment time in the
Disabled Adult Resource Team (DART). This has been attributed to inaccuracies in target
setting and data quality issues respectively. Plans are in place for resolution of these issues
in 2012/13.
3.1.3 Awards received by Bristol Community Health
Dermatology Service
A Bristol Community Health Dermatology service nurse won an award offered by the British
Dermatology Nursing Group that enabled her to attend the Australian Dermatology Nursing
Conference, held in Brisbane in May 2012.The award was open to experienced dermatology
nurses in the UK and Ireland. This new learning is helping our already successful primary
care dermatology team and award winning dermatology nurses to plan future developments
such as a low risk skin cancer service.
HMP Eastwood Park Healthcare Service
The medical team of Pathways Healthcare Centre in HMP Eastwood Park recently won a
prestigious international competition organised by the World Health Organisation (WHO).
The competition forms part of the WHO’s Health In Prisons Project (HIPP). The role of this
project is to support Member States in improving public health by addressing health and
healthcare in prisons, and to facilitate the links between prison health and public health both
at national and international level.
The winning team included staff from Bristol Community Health and they have been working
hard since 2005 to bring a community model of medical care to the all-female prison,
mirroring the care and environment of a normal NHS practice.
The ambitious and ground-breaking work at HMP Eastwood Park is an excellent example of
our partnership working and was a clear winner in the international competition. The judges
were struck by the breadth and depth of the care that was provided by such a small team
and recognised that the concept could be used more widely to the benefit of prisoners
elsewhere.
Consultant Nurse for Older People
A Bristol Community Health Consultant Nurse for Older for People successfully secured a
place on the National Clinical Fellowship, which is renowned for being highly competitive.
This is a fantastic opportunity for the organisation to engage with other clinical leaders who
have also been identified as showing outstanding potential to contribute significantly to the
future of health services.
36
3.1.4 Examples and local case studies of specific quality improvement
initiatives relating to patient experience, patient safety and clinical
effectiveness
Patient Experience
Ultimately striving for improvements and pursuing awards is all about ensuring the best
possible patient experience. At Bristol Community Health we have found that the patient
experience focus has helped us to bring teams together during a time of organisational
change.
We have seen substantial culture change with staff really showing that they value what
patients are saying about our services.
Who are our Patients?
In September 2011, we carried out an audit of our clinical information system (RIO). We
used this to draw up a profile of patients using our services. The following information was
gathered:
•
•
•
•
•
•
•
•
•
•
92% of our services were monitoring equalities data
Since July 2011 RIO has also been able to collect disability data
The ethnicity of 48% of patients using our community services is known
56% of patients using our community services are female
62% of patients using our community services are older than 45 years
40% of patients using our community services are over 75 years
2.6% of users of community services were identified as being from a black or ethnic
minority background
54% of our total contacts were patients seen in the Walk-in Centres
78% of patients using the Walk-in Centres were under 45 years of age
11% of patients attending the Walk-in Centres were identified as being from a black or
ethnic minority background.
What this means for patient experience
We took a co-ordinated approach to collecting and using patient experience data and used
various methods to collect information from patients and service users. This programme
revealed the importance of a supportive co-ordinator for activities which engage patients. In
addition, our dedicated Questionnaire, Interview and Survey Group has brought clinicians
and the public together to develop and implement the patient experience work.
Our Key Successes Include:
•
Training volunteers at the new South Bristol NHS Community Hospital to meet and
greet the public and direct them to the appropriate service. This was at the request
of Patient and Public Involvement groups and Bristol LINK.
•
Involving patient and public representatives in the procurement of furnishings and
medical equipment at the new Urgent Care Centre.
37
•
The DART (Disability Assessment & Resource Team) service has diversified how it
communicates with its patients. For example, it has introduced a mobile number for
users who prefer to communicate by text. Also telephone reviews are available for
those patients who agreed they would benefit from this.
•
Setting up a Learning Difficulties service user led group - called ‘Listen to us’ which
meets and has speakers from Bristol Community Health, so that service users have an understanding of what services we provide and then ask other service users for their feed back.
•
Increasing self-management of Diabetes amongst the black and ethnic minority
population by providing a Diabetes Education course for South Asian women. This will be taken forward into the wider South Asian community by running the next course as part of the community’s day centre programme.
We use a variety of feedback methods including quantitative data from questionnaire
based surveys (postal and face to face), qualitative data from semi-structured and in-depth
interviews, observational data, focus groups, experience based design and community
outreach with “easy to ignore” groups. We are distributing Freepost postcards to obtain
patient feedback.
We consider it to be extremely important that our expert staff are central to developing new
ideas and we try to involve staff in drawing up action points arising from patient feedback
through team meetings, email networks and so on. The outcomes of surveys and agreed
actions are reported to senior management and progress on actions to improve patient
experience is charted on a database.
Learning from Complaints
We work closely with service users and the public to ensure we deliver the best quality
services that we can. Excellent patient experience is a critical factor. If we get something
wrong it really matters to us. Bristol Community Health views its complaints system as a
very important component in the quest for continually improving patient care.
The system is there to help and assist people when they feel things have not gone as they
should and we will always seek to put it right. Bristol Community Health seeks to learn from
each complaint and treats complaints as an opportunity rather than assigning blame.
Our complaints system seeks to work with individuals to create a plan that details how a
complaint will be handled and the timescale for resolving it. From the outset the process
tries to involve the complainant in the process of resolution, making them a very important
part of the complaint closure.
We seek to resolve all complaints within 28 days, but sometimes more than one
organisation is involved in the investigation. Sometimes resolution within the agreed
timescale is not possible due to external complexities and when this occurs the complainant
is consulted on extending the deadline within agreed time scales.
38
20 complaints were received during 2011-2012 and whilst nearly all were complex in nature
they can be grouped into the following categories:
•
•
•
•
Delays in appointments
Service provision
Attitude of staff
Communication
All of the above complaints were responded to in the agreed time frames and positive
learning has arisen from the complaints system.
Learning from complaints made during the year included:
•
•
•
•
•
Improved appointment booking methods
Much improved lines of communication with patients and relatives
Greater understanding of the organisation’s policies by staff
Better support mechanisms for staff during difficult times
Better customer service skills
Complaints are reported monthly and the Chief Executive is personally involved with the
resolution of each and every complaint.
Celebrating our Compliments
Striving for quality does mean that Bristol Community Health receives far more compliments
than we do complaints. Staff are truly motivated when they are thanked for their efforts.
Below is a selection of anonymised compliments received by Bristol Community Health.
“To the Rapid Response team that bought such joy and kindness to our
home - I am just writing to say a big thank you for all the loving care you
gave over many weeks. The support you gave us both was excellent and
I am very grateful.”
“Dear L-------,
Just a short note to say how much I enjoyed the course and how useful it
was. It was run brilliantly and was so interesting. I feel re-invigorated
about my diabetes, putting it as a far higher priority not just needing to
know but now knowing what to do. Many bits of knowledge were new, all
were relevant, and being able to discuss in a group with people facing
the same issues was brilliant. It exceeded my expectations and has totally
helped me.”
“Dear Sir,
I would like to take this opportunity to express my thanks to ----------- and
her assistant for their professionalism, understanding and nursing care.
Since being referred to the Wound and Tissue specialists I have gone
from a disaster to an ever improving situation. My ulcer is healing and the
pain levels are decreasing daily. The staff exude confidence and after
nine weeks of getting nowhere I felt at last I was involved with somebody
who knew what they were doing.”
39
Patient Safety - Learning from Incident Reporting
A key element of high quality service provision is delivering services professionally and very
safely. Patient safety is a prime objective for Bristol Community Health and to this end the
organisation encourages staff to report incidents to the Risk department.
Reported incidents are logged on the Ulysses system and management reports are
generated from the data. These reports are shared with staff and senior management to
enable trend analysis and improvements.
The incident reports are in a “no blame” environment to maximise reports received. In
2011/12 we recorded 805 incidents and the graph below outlines the types of incident that
were recorded.
The above graph shows that drug error/incident’ was the most frequently reported category.
In summary, the highest reporters were prison establishments. All of these incidents
are discussed at the Incident Review Group which exists in HMP Bristol and a joint one in
HMP Eastwood Park/Leyhill. These groups meet regularly to review all incidents, share
learning, and improve patient outcomes.
The HMP Bristol Incident Group report into the Integrated Clinical Governance Group led by
NHS Bristol. The HMP Eastwood Park/Leyhill group report to the Provider Governance
Forum led by NHS South Gloucestershire. Bristol Community Health’s Prison Healthcare
Manager reports to the Quality and Assurance Working Group on the prisons where any
issues would be escalated if the prison Clinical Governance Group were unable to resolve
any incidents. This level of reporting at the prisons correlates to a strategy supported by the
Risk Group to ensure that all incidents are reported irrespective of degree of risk. This
provides the organisation with the opportunity to examine all incidents and not just those
considered significant.
40
Injury/ill health to patient was the second highest reported category. This category remains
a high reporter owing to Bristol Community Health logging and monitoring all grade two
pressure sores. Pressure sores categorised as grade two or below accounts for a significant
number of incidents. A regular summary of pressure sore incidents are provided to the
Tissue Viability Specialists who are currently working on prevention projects. Currently new
pressure ulcer prevention protocols are being embedded with staff with a view that initially
70% of at risk patients will have a prevention protocol commenced during Quarter 1 in 2012
rising to 90% in Quarter 3 in 2012. These targets form the basis of a CQUIN, which Bristol
Community Health has fully embraced to proactively manage pressure ulcers.
Degree of Harm of Incidents
Every incident is profiled to ascertain the degree of harm, classed in terms of the effect on
patients, staff or services. The organisation records, investigates and learns from a range
of incidents including those which have impacted on the delivery of services, issues with
buildings and infrastructure and information technology.
In 2011/12 Bristol Community Health reported the following degree of harm for the incidents
reported.
The above graph shows that the reported incidents for the year was as predicted, where the
majority fell into the centre section of the scale relating to severity 7-12 followed by 0-6 and
finally the most serious 13-25.
41
Examples of these would be:
•
•
•
Drug errors/incidents that did not cause harm
Injury/ill health to patient specifically Pressure ulcers
Delay in providing treatment that could have resulted in harm
Each incident is recorded and logged on our incident data base and is monitored for
suitable actions. Management reports are generated from the database to ensure that
senior management are kept aware of incident patterns and trends that could be adverse for
patients and staff alike.
The Risk Group scrutinise all reported incidents to establish trends and implement any
actions deemed necessary to highlight and ensure identified risk categories remain
controlled as required. An example of this is the continuing implementation of the changing
of syringe drivers to a standard type. Examination of the incident database at the time
showed that the organisation had experienced a number of incidents relating to incorrectly
set syringe drivers and this was followed by a central alert instructing each organisation to
change certain types of driver. This was discussed by the group and raised to senior
management who agreed to a programme of replacing all syringe drivers to a type
recommended. This programme involved not only clinical staff but finance and purchasing
too and a series of training courses is being organised to ensure staff are conversant with
the operation of the new equipment.
Learning from Serious Investigations Requiring Investigation (SIRIs)
In 2011/12 Bristol Community Health launched 16 SIRIs - 13 were pressure
ulcers; 1 was an accident to a patient; 1 was vandalism to a building and 1 was loss of
confidential information from which the following learning points have been implemented.
•
•
•
•
•
Recognise potential problems early in the provision of the care pathway and act quickly to avoid the problem
Continually assess dynamic risks and act early on the results
Involve as many carers and relatives in the care delivery as possible
Communicate openly and effectively at all times
Promote a responsive learning culture
Bristol Community Health recognises the value of the data collated from reported incidents
and receives reports at the Clinical Governance Working Group. These reports are
scrutinised for trends and outstanding features and short life working Groups and work
streams can and are created to embed points of learning and improvement programmes.
When required issues are raised to the Senior Management Team and the Board and are
monitored through risk registers.
Promoting Infection Prevention and Control
Our Infection Prevention and Control Team consists of two experienced Community
Infection Prevention and Control Practitioners who support a network of link practitioners.
42
The infection prevention and control work programme is steered by an Infection
Prevention and Control Group. Membership of this group includes clinical leaders and an
active lay member.
The team strives to keep community infection prevention and control high on the agenda
locally and nationally, being involved in regional and local groups and the national Infection
Prevention Society. Both practitioners have been involved in national / regional developments
including the development of guidance documents and they are involved in work streams right
across the organisation.
Activities to ensure quality and compliance in Infection Prevention
Ensuring compliance with The Health and Social Care Act 2008 Code of Practice on the
Prevention and Control of Infections and Related Guidance (The Hygiene Code) (DH, Last
revised 2010) is a key driver for Bristol Community Health, as part of the assurance required
for registration with the Care Quality Commission (2008).
The team is committed to ensuring that infection prevention and control is a priority for all
our staff, and that this commitment is embedded in service planning and in everyday
practice.
The team works pro-actively to identify problem areas and to develop strategies that will
improve practice and performance. These include the use of active communication, audit
activity, involvement in surveillance and analysis of the causes of infections where they do
occur.
The practitioners visit sites and check infection prevention standards are being maintained in
the buildings from where Bristol Community staff provide clinical services to ensure that care
is being provided in a clean, safe, appropriate environment. The importance of good hand
hygiene in the prevention of transmission of infection is reinforced through training, education,
environmental prompts and through supporting clinical staff to undertake regular hand hygiene
audit.
Risk assessment and the use of safety-engineered devices are strategies being
encouraged by the team to reduce sharps incidents. The Infection Prevention and
Control Team and the Health and Safety Teams held a “Be Sharps Safe” week
to raise staff awareness about sharps incidents and means of preventing them.
43
Root Cause Analysis (RCA) Activity
Since the start of MRSA bacteraemia surveillance in April 2001, nationally there has been a
62% decrease in cases of MRSA bacteraemia reported to the Health Protection Agency
(HPA), and a 50% reduction in the number of cases of Clostridium difficile reported in
patients aged two years and over from April 2007 (HPA 2009). We are working with our
partners to meet the quality requirements of our contract with our Commissioners to meet
the local infection prevention and control targets, by undertaking thorough investigation of
incidence when required and monitoring trends within the community.
From July this year the team have not only participated in full root cause analysis
investigations on pre-48hr Clostridium difficile Infections (CDI) leading to death/colectomy
and MRSA bacteraemias, but also investigated trends in Methicillin sensitive
Staphylococcus aureus (MSSA) and Escherichia coli bacteraemias where our services have
been in contact with the patient in their packages of care.
Three RCAs were undertaken for clostridium difficile infection leading to death or colectomy.
Four MRSA bacteraemia RCA investigations were undertaken. None of these resulted from
any particular systemic practice causation and did not require action plans for remediation.
Most MRSA and E.Coli cases forwarded to the team had not had any contact with Bristol
Community Health staff or services, and no trends were identified.
Promoting Safeguarding Services
Safeguarding Adults
Bristol Community Health is committed to ensuring that all adult clients are protected and
safeguarded from abuse in line with the National Framework of Standards of good practice
and outcomes in adult protection work (ADASS 2005). We work predominantly with adults
and older people with complex health care needs although the safeguarding adults
investigatory process is the responsibility of the local authority. We have a duty to safeguard
vulnerable clients; to act on any concerns, and to ensure the situation is appropriately
assessed and investigated.
Policy and Practice
Multi-agency partnership working has seen us sign up to using the Bristol No Secrets Policy
(2010). We produced a Supplementary Guidance to the Bristol No Secrets (2010) for Bristol
Community Health staff. This guidance includes information on principles underlying the
work with vulnerable adults, referral forms, what to do when abuse is suspected or
disclosed, how to record information and information on training. This document is reviewed
annually by the Safeguarding Adults and Mental Capacity Group.
Publicity and Information
As part of multi-agency partnership working all agencies have agreed to include a
Safeguarding Adults web page on their organisational website. Bristol Community Health
has a web page which can be found here.
http://www..briscomhealth.org.uk/oue-services/items/52-safeguarding-adults?sid=52
44
This web page includes information on what to do if staff and the general public suspect
abuse. As social services are the leading authority for safeguarding adults our Safeguarding
Adults webpage hosts the direct link to the Bristol City Council Health and Social Care
Safeguarding Adults web page
http://www.bristol.gov.uk/ccm/content/Health-Social-Care/Help-for-adults/safeguardingadults.en
Safeguarding Adults Training
Bristol Community Health is committed to ensuring that all adult clients are protected and
safeguarded from abuse. To achieve this, our safeguarding adults training is mandatory for
all staff. We are a member of the safeguarding multi-agency group and contribute to the
reviewing and the evaluating of the all safeguarding adults training programmes. Our in
house level 2 safeguarding adults training provides up to date information on national and
local safeguarding adults policy. The training sessions provide the opportunity for staff to
reflect on and discuss complex cases, provide peer support, share best practice and lessons
learnt.
Safeguarding adults Training Level
Staff trained
in 3yrs to
31/03/2012
Level 1
61.6%
Level 2
20.2%
45
In line with National guidance we have introduced two levels of Safeguarding training.
There is a programme in place to train all staff to the appropriate level. The completion rate
shown is based on a headcount of all clinical staff (excluding bank staff)
Safeguarding Children
Bristol Community Health, in line with the National Service Framework for children, young
people and maternity services, are committed to ensuring that all children within the service
are protected and safeguarded from harm or potential risk of harm.
The Named Nurse for Safeguarding Children commenced in post in April 2012 to
further ensure Bristol Community Health is able to develop within the Safeguarding Children
role and maintain standards set by the framework.
Bristol Community Health is predominantly an adult led service but we have a duty to ensure
that vulnerable children accessing Bristol Community Health are identified and reported so
that appropriate action may be taken to address their needs. It is therefore important that all
staff undertake appropriate level safeguarding training in order to meet this requirement.
Accurate reporting and documenting of any concerns will enable the most appropriate
assessment and investigation to take place and this is led by the Local Authority.
Policy and Practice
Two policy documents have been recently revised and ratified.
1. Was Not Brought (Dec 2011).
2. Safeguarding (Child Protection) Policy for Children (Dec 2011).
These are for Bristol Community Health staff reference and guidance. Within the
safeguarding policy is access to referral forms, the referral process and contact numbers of
specialists for further guidance and support.
Publicity and Information
Bristol Community Health has a web page.
http://www.briscomhealth.org.uk/our-services/item/47-safeguarding-children?sid
The web page has information on what to do for both staff and the general public if abuse is
suspected.
As Social Work Assessment Teams hold the lead responsibility for safeguarding children,
the web page for Bristol City Council may also be helpful.
http://www.bristol.gov.uk/page/child-protection-and-abuse
46
Safeguarding Children Training
Bristol Community Health is highly committed to training all staff at the appropriate level to
ensure all children are protected and safeguarded from abuse. It is mandatory for all staff to
receive Induction safeguarding training within six weeks of commencing in post.
Level 2 Safeguarding training provides up to date current practice and an opportunity for
staff to reflect and discuss issues with their peers. At the present time there is a
determination to train all staff outstanding in Level 2 training and as a service have arranged
to achieve all those outstanding within the next few months.
2012 Staff Group
Headcount (2011
Group Headcount)
% trained
Level 1 (all Staff)
949 (949)
61.6%
Level 2
761 (436)
20.2%
Safeguarding Children
Training Level
Level 3
80
All staff are required to attend Level 1
A review of the latest national guidance and levels of training assigned/required carried out
December 2011 greatly increased the numbers of staff deemed to require level 2 & 3 training.
Numbers of staff identified as requiring level 2 increased by over 75%
Numbers of staff identified as requiring level 3 increased by over 300%
There is a programme in place to ensure all staff are compliant at the required level as
soon as is practicable.
47
Medicines Management
Non-medical prescribing (NMP)
We are currently reviewing our records to ensure we understand who our Non Medical
Prescriber’s (NMP) are, where they work and if there are areas where we need to improve
training. We are also trying to understand where we are prescribing and what medications
we are using most to help us plan for the future. The Clinical Cabinet will monitor prescribing
practice and use the data to inform future planning of prescribing in the organisation.
The Clinical Cabinet have liaised with the Learning and Development team to arrange
twice yearly training updates and networking forums to assist NMPs in their professional
development. The Head of Medicines Management (HoMM) is revising the Bristol PCT
Non-Medical Prescribing Policy to produce a Bristol Community Health specific policy and a
competency structure (following national guidance) for the organisation.
Policies and Guidance
We are developing a Bristol Community Health overarching medicines policy to include
Controlled Drugs which will reference any existing policies and guidance. We have reviewed
Patient Group Directions for the organisation to incorporate the legal changes necessary as
a result of the split from the Primary Care Trust.
We have reviewed and developed a range of medicines policies at HMP Bristol to include
Out of Hours, Medicines Possession, Minor Ailment and a range of Patient Group Directions
to support delivery of timely and effective treatment. Standard Operating Procedures for
management of Controlled Drugs at HMP Bristol and HMP Leyhill have been reviewed and
improved to comply with legislation and good practice requirements.
Miscellaneous Medicines Management Activity
The HoMM has been involved in a wide range of other internal advisory and external
networking and governance -related activity to support Bristol Community Health operations
and business teams, and to link with the wider health community medicines management
leads. This includes attendance at: NHS Bristol Controlled Drug monitoring meeting; Area
Controlled Drug Accountable Officer meeting; BNSSG Drugs and Therapeutics Committee;
South Gloucestershire Prisons Drugs and Therapeutics Committee; Regional NMP Leads
meeting; Regional Providers Medicines Management meeting.
The HoMM has presented a session on Evidence-based Medicine for the preceptorship
programme.
A medicines management page for the website has been developed and is being uploaded.
Clinical Effectiveness
NICE Guidance, examining clinical pathways and outcomes, and developing new services
In addition to improvements in clinical effectiveness arising out of our clinical audit
framework, service evaluations and patient and public involvement initiatives, all clinical
policies are in the process of being reviewed, and all of the national guidance released
during 2011/12, by the National Institute for Health and Excellence (NICE), which is relevant
to Bristol Community Health CIC services, is reviewed by our Clinical Cabinet.
48
Our General Managers and their respective teams are actively working with primary care
colleagues in the continuous development of the ‘cluster teams’ that are aligned around the
GP Practices within our three localities (Inner City and East Bristol, North and West Bristol,
and South Bristol). At the same time, they are also building clinical and service-led
relationships with GP Practices, which is an important part of Bristol Community Healths’
continued GP Relationship Management Plans.
We have also worked with our partners in Bristol in redesigning how clinical services
are provided, so that patients experience care which is more effective, evidence-based, and
has less duplication, and is more easily accessed and closer to home. Examples include:
•
•
•
The development of three new Allied Healthcare Professionals Pathways, the
Complex Elderly and Fallers Pathway, the Neuro Pathway, and the Diabetes
Pathway
Integrating the Musculoskeletal Assessment and Treatment Service, Musculoskeletal
Physiotherapy, and Podiatry under one service structure and incorporating a central
clinic booking facility
The pilot of a Hospital Hub team to facilitate the discharge of patients within 48 hours of them being deemed medically fit for discharge. The team will carry out a single assessment of the patient, and will liaise with the rehabilitation centres, rehabilitation teams, Rapid Response and Re-enablement teams.
Telehealth
Bristol Community Health has continued to implement this assistive technology initiative
in conjunction with NHS Bristol and Safe patient systems, having deployed just over 200
units. Staff engagement is steadily increasing to support this and will be critical to longer
term success. A rapid review group has been set up to drive this forward clinically and
to establish crucial baseline data to support longer term deployment of up to 600 units.
Telehealth assistive technologies support patients in the community with long term conditions
such as heart failure or COPD to self manage their condition. The devices monitor patients’
preset parameters associated with their condition and alert a clinician when these have
breached. This prompts contact by the team and may result in a visit or telephone support.
By empowering patients this reduces dependency and promotes independence and releases
clinicians to focus on those patients who require more intensive input if their long term
condition has exacerbated. Patients are now being offered the choice to self-select to be
part of this initiative rather than a clinician predetermining which patients are eligible. The
intention is to extend this to other conditions such as Diabetes.
Heart Failure
This service is supporting the management of patients in the community by stabilising patient
medication, encouraging self management and preventing emergency and readmissions into
secondary care. More time for face to face patient care has been released and the clinical
model is developing with the aim of harmonising community heart failure services across
Bristol.
An award from the British Heart Foundation has recently been secured which
will support the further development of the community model and increase
partnership working with the local acute trusts. Access to the clinics for referrers
has been made easier with the launch of the clinics onto Choose and Book.
49
Chronic Obstructive Pulmonary Disease (COPD)
The COPD Community Pathway was launched across the city in May 2011. This was a new
approach to managing and delivering existing COPD services in a coordinated way to
improve coverage and capacity. This pathway is delivered in partnership with primary care
and the acute trusts. The key elements to the pathway include admission avoidance,
pulmonary rehabilitation and “HOT” clinics with a community oxygen service alongside. The
pathway has a single point of access and extended coverage over evenings and weekends.
A database has also been developed which enables clinicians across the pathway to access
and share information regarding patients on oxygen. Good progress has been made to
date.
The original COPD Partnership Delivery Board has been reconfigured to include Heart
Failure and Telehealth and is now the Long Term Conditions Delivery Board. This will
oversee the service development and delivery of the COPD and Heart Failure services.
These work streams form part of the QIPP agenda and will militate against the continued
and unsustainable number of emergency admissions and ensure better long-term condition
management in the community.
Referral Management Centre
Work continues to develop this and it closely aligns with the national initiatives 111 and
Choose and Book. By refining the access and management of referrals to the organisation
benefits will be delivered for both internal and external stakeholders and support the timely
and appropriate access to the right services for patients.
Integrated Nursing Teams
As part of the Bristol Community Health Transformation Programme each locality has an
identified number of Integrated Teams to be co-aligned with 3 or 4 practices to form a cluster
team. Within the Inner City and East locality it became evident that it was necessary to
progress with this integration swiftly. The integrated team has brought together community
nurses from Eastville, Montpelier and Charlotte Keel and all these staff will eventually be colocated at Charlotte Keel Health Centre. The approach taken to move this work forward was
one of full
involvement of the team members in the design of processes.
The process for referral consists of:
•
Referral to a singe point of access
•
Dedicated case manager to triage referral to appropriate team member
50
Case Managers are usually the senior community nurses in the team and the system was set
up and tested for its effectiveness during the first two weeks by the two community matrons
who have roles as clinical leaders of the team. To support the implementation of this
new way of working an initial review has been undertaken by the team looking at how the
service is working. The key points are as follows.
•
•
•
Use of one referral phone has been well received by GP referrers who find it straight
forward to ring one number during the Monday-Friday 8am-8pm period.
Community Matrons need to be focused on working with highly complex patients,
thereby using their high level complexity skill sets appropriately.
It is important to maintain strong links with GP practices (usually through a named
nurse) to ensure that good communication is maintained and patient care is not compromised.
The work on integrating community teams will continue and team 1 and team 3 within the
locality will take the lessons learned from team 2 to support their integration.
South Bristol
Walk-in Centre
City Gate
Walk-in Centre
South Bristol
Community Hospital
Diabetic Retinopathy Service
The Bristol and Weston Diabetic Retinopathy Screening Service (DRSS) hosted a training
day in Bristol at the end of November 2011 (see photo overleaf). This training day was
initially advertised to community optometrists across Bristol, North Somerset and South
Gloucestershire and was then opened up nationally. Delegates attended from as
far afield as Lancashire and Cornwall.
There was a wide range of speakers. Professor Colin Dayan from the University of Cardiff
gave the opening talk and he spoke about the nature of diabetes and about the changing
profile of current diabetic populations. The Bristol and Weston DRSS programme manager,
clinical lead and associate clinical lead spoke in detail about the programme’s operational
procedures, emphasising in particular the stringent national quality assurance procedures
which programme staff follow to ensure that every stage of the patient pathway, from the
patient’s initial referral and invitation to the assessment of their images after screening, is
performed to high standards.
The four Medical Retinal Consultants from Bristol Eye Hospital spoke at length about the
treatment patients will typically receive if referred in by the screening programme.
51
The recurring message throughout the day was that a regular full eye examination with a
community optometrist and an annual screen with the retinopathy screening programme are
both essential parts of a diabetic’s eye care. It was agreed that we could work together to
encourage patients to attend both appointments.
BCH Diabetic Retinopathy
Training Event
One of our patients
undergoing
screening
One of our patients
undergoing
screening
Urgent Care Programme
Bristol Community Health’s Urgent Care Programme has successfully been progressing
work since January, with the following areas of particular note.
Medical Model to Support Rapid Response
Having secured further funding to expand this work across Bristol following the successful
implementation and execution of a pilot using the ‘Plan Do Study Act’ model for
improvement, we are looking at the potential for a consultant Geriatrician from North Bristol
NHS Trust supporting the Rapid Response service.
Key findings from the pilot highlighted:
•
The usefulness of the Comprehensive Geriatric Assessment supporting teams
managing complex frail elderly patients in the community
•
The crucial roll that a Geriatrician in the community can play in the interface between
primary and secondary care to provide seamless care pathways
•
The importance of education around dementia and common geriatric syndrome for
community services
Importantly it was felt there was significant value of having this role in the community in
providing the best care for the frail elderly population. A steering group will be established to
take this forward over the next few months.
Great Western Ambulance Service - GWAS
The pilot between Bristol Community Health and GWAS to review patients as they were
bought into the Emergency Department at Frenchay to see if alternative care pathways
could be identified was successfully completed during February with the final report currently
under collation. Initial findings indicate that there are a number of people who could
successfully be managed by a paramedic and advanced nurse practitioner, prior to
admission through the Emergency Department within the hospital. This avoids unnecessary
hospital attendance or admission enabling people to return home and be managed in their
own environment.
52
Care Planning Approach
A workshop has been held with our senior community nurses to look at developing the use of
an integrated care plan that can be used across all community services, the benefits of which
should lead to more consistent communications across services.
The care plan will be used at first through our newly forming integrated nursing
teams. This work is the first phase of a wider Bristol Urgent Care workstream to look at
developing a care planning approach that can be shared across all community interfaces
including primary and health and social care.
Marketing
Following feedback from patients and stakeholders it has been indicated that
there is a need for clear and coherent information for patients and the public to communicate
what our urgent services are and what they offer. As part of our urgent care programme
Bristol Community Health have developed a comprehensive marketing plan that will focus
two strands of work on stakeholders and patients. Through this work we will be assessing
and reviewing referral sources as well as piloting a template engine called ‘Prinkk’. This
will involve commissioning the creation of a bespoke website to house branded, pre
designed templates which can then be accessed remotely by staff to use for creating patient
information in standard formats.
In addition to the above areas the work programme will be progressing projects over the
coming months in line with local and national priorities. These include the development of
systems to support 111 primarily through implementing the new ‘Directory of Services’.
Work will also continue with other partners such as GWAS and the acute hospitals
on ensuring pathways continue to provide seamless care for patients.
Bristol and South Gloucestershire Learning Difficulties
Bristol Service
People with learning difficulties have significantly poorer health than their non-disabled
peers. The Disability Rights Commission recommended the introduction of annual health
checks to address the health inequalities faced by people with Learning Difficulties.
The commissioners set Bristol Community Health a target of 90% to improve the uptake of
health checks for people with Learning Difficulties to reduce health inequality. The Learning
Difficulties service over achieved the target set with an outcome compliance of 94%
Waiting times for Learning Difficulties services are decreasing with over 66% of referrals
being seen within 8 weeks.
We are working towards developing care planning templates on our clinical information
system to facilitate effective person centred care planning.
A monthly service user feedback forum has been set up for both service users and carers.
The aim of this will be to engage service users and carers in feeding back about their
experiences and for the service to implement any appropriate changes in line with their
recommendations.
53
.
Loss and Change groups are underway within the Psychology service to support service
users with longer term health needs.
The Avon and Wiltshire Positive Behaviour Interventions booklet has been produced in
conjunction with various agencies across the local area.
South Gloucestershire Service
Bristol Community Health is providing interim management of the South Gloucestershire
Learning Difficulties service for an eighteen month period . Multi-disciplinary teams have
been developed and they are based at Kingswood and Thornbury
The service wide “service user satisfactory survey” received a good response - 80% of the
responses were “good” or “very good”. The Hydrotherapy service received a 90% response
rate of which all responses were “good or very good”.
Work is continuing on the quality of pathways and referral processes with Community Care
and Housing following the division of the service. Information provided to service users is
continually reviewed and adapted into accessible letters, leaflets, booklets with photographs
to explain programmes, and recommendations for service users.
Annual Health Checks for service users continue to be high on the agenda and feedback
forms from GPs with outcomes of the appointments and access to cancer screening is
monitored by the team. In addition service user feedback forms are used to identify
experiences and thoughts on the health checks service users receive.
Intermediate Care and Re-ablement Service
Our partnership work continues to strengthen with the implementation of Phase 1 of the
revised Commissioner Intentions and performance remains good. We have recruited a joint
Strategic Manager who works on behalf of the Partnership Board and who will be leading
the Phase 2 developments, some of which include dementia care pathways, reviewing
assistive technology opportunities and the evaluation of the hospital hub service due to
commence in September 2012.
The Partnership, with Commissioners, successfully facilitated a visit to the South Bristol
Intermediate Care Centre on 5th January 2012 by Paul Burstow, Minister for Care Services
(see photo below). Feedback was positive and he supported the approaches that we had
taken over recent years and that this service served the entire population across the city.
Paul Burstow, Minister for Care Services, on the left
with Karen Cole, Clinical Services Manager meeting
with patients and staff at South Bristol Intermediate
Care Centre
54
3.2 Statements of Assurance Relating to the Quality of Services Provided in
2011-12
Bristol Community Health is required to report on statements prescribed for inclusion in all
NHS Quality Accounts as detailed in the following sections.
3.2.1 Participation in National Clinical Audits, National Confidential Enquiries
and Local Clinical Audits
National Clinical Audits and National Confidential Enquiries
During 2011/12 five national clinical audits and no confidential enquiries covered NHS
services that Bristol Community Health provides.
During that period, Bristol Community Health participated in three national clinical
audits and no confidential enquiries, which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Bristol Community Health
were eligible to participate in during 2011/12 are as follows.
National Clinical Audits for inclusion in
Quality Accounts
Diabetes (National Adult Diabetes Audit)
Other National Clinical Audits
Partook?
Yes
Partook?
National Audit of Falls and Bone Health
Yes
National Audit of Multiple Sclerosis
Yes
National Audit of Continence Care
No
English National Screening Programme for Diabetic Retinopathy
No
National Confidential Enquiries
Partook?
None
Bristol Community Health took part in three of the five national clinical audits it was
eligible to take part in. In all three audits, Bristol Community Health was only eligible to
participate in the organisational section of the audits (National Adult Diabetes Audit,
National Audit of Falls and Bone Health, and National Audit of Multiple Sclerosis), and was
not therefore required to submit any cases.
The 2010/11 National Diabetes Audit is yet to be published. It will be reviewed by the
Clinical Cabinet in due course.
The National Falls and Bone Health Audit made several recommendations for our
commissioners, which are under consideration.
55
.
The report on the National Audit of Multiple Sclerosis was reviewed by Bristol Community
Health in 2011/12, and we intend to take the following actions to improve the quality of
healthcare provided.
•
•
•
•
Conduct pain assessments with all patients suffering from MS, in line with NICE
Guidance CG96 (Neuropathic Pain).
Conduct structured assessments of mood, cognition and daily activities, using the
review checklist template within NICE Guidance CG8.
Consider the need for equipment and assess accordingly.
Clinical Audits (including Local Audits)
During 2011/12 Bristol Community Health produced a Clinical Audit Framework.Priorities
within the audit framework are closely linked with priorities identified within our
Quality Accounts, service priorities, and the implementation of NICE Guidelines. Progress
is monitored by the Clinical Governance Working Group and reported in the Quarterly
Quality Report.
Breakdown of Clinical Audits 2011/12
Type of Audit
Total to Report
Stage
National Clinical Audits
3
Audits of NICE Guidelines
5
Interface Audits (with another Trust)
2
Local Audits
65
Total
75
Bristol Community Health has undertaken 75 clinical audits during 2011/12, which will
all be reviewed by the Clinical Cabinet. We intend to take all the recommended actions from
the audits, to improve the healthcare of quality provided. The outcomes from the Clinical
Audit Framework will be reported in the Quality Accounts 2012/13.
“The audit process has enabled the DART service to further clarify
the strengths of its offering, as well as pinpoint areas for improvement.”
John Ashworth
3.2.2 Participation in Clinical Research
The number of patients receiving NHS Services provided by Bristol Community Health
in 2011/12, that were recruited during that period to participate in research approved by a
research ethics committee, was 380.
56
Bristol Community Health was involved in conducting five clinical research studies
during 2011/12, which were approved by a research ethics committee, covering the following
areas: Speech and Language Therapy, Community Nursing, Continence Nursing,
Wound Care, and Physiotherapy.
As part of our commitment to increasing levels of participation in clinical research, and to
making our contribution to wider health improvement, Bristol Community Health is
developing closer working links with the Avon Primary Care Research Collaborative, and is
continuing its involvement with both the University of Bristol and the University of the West
of England.
3.2.3 Research and Development
The Avon Primary Care Research Collaborative provides a research governance service to
Bristol Community Health. However, since becoming a Social Enterprise, all new
research projects are also reviewed by Bristol Community Health’s Clinical Cabinet, prior to
being given approval by the Avon Primary Care Research Collaborative.
The following are the research projects approved by Bristol Community Health between
October 2011 and March 2012.
Research Title and Lead
Group / Service
Wound healing
Sue Murphy
Wound Care,
Community Nurses
Clinical
Perceptions around Corporate Review
Carly Rosser
Service redesign, all
affected staff
Non-Clinical
An Augmentative and Alternative Communication
(AAC) Evidence Base
Simon Judge
Development of a Questionnaire to Assess
Incontinence in Patients
Paul Abrams
Children of the Children of the 90s (part of the Avon
Longitudinal Study of Parents and Children)
Deborah Lawlor
Investigation into the NHS Reforms on
Management of Physiotherapy Services
Fiona Jenkins
Congenital disorders
neurological, Speech
& Language Therapy
Continence Service,
Community Nursing
Clinical
Community Nursing
Clinical
Physiotherapists
Clinical or
Non-Clinical
Clinical
Non-Clinical
57
.
3.2.4 Goals Agreed With Commissioners – CQUIN
Payment Framework
The Commissioning for Quality and Innovation (CQUIN) payment framework is an arrangement
between providers and their commissioners aimed at creating an incentive for quality and
improvement activity.
In 2011/12 1.5% of the Bristol Community Health contract value was linked directly towards
the achievement of these CQUIN targets. Over 85% of this money was secured due to some
excellent achievements including the following:
•
•
•
•
•
•
•
An increase in the percentage of new assessments for continuing healthcare
determined within 28 days from 67% in March 2011 to 90% in March 2012.
Over 50% of patients on an end of life care pathway have an advanced care plan in
place, up from 43% in 2011/12.
New innovations including the establishment of new care pathways with our key
partners, including the Intermediate Care Partnership with Bristol City Council.
An improvement in the experience of patients with long term conditions with over 43% strongly agreeing that they had discussed what was most important for them in
managing their own condition and as a result were confident they could now manage
their own health.
A 60% increase in the number of referrals from the ambulance service to our Rapid
Response service in 2011-12.
A 12% increase in the number of patients discharged from hospital within 48 hours
and supported with community services as an alternative to hospital admission.
Over 90% of clients with a learning disability living in Bristol being signposted for a GP health check.
3.2.5 How our regulator the Care Quality Commission views our services
Bristol Community Health is required to register with the Care Quality Commission for the
regulated services we provide and our current status is ‘full registration status without
conditions.
The Care Quality Commission has not taken enforcement action against Bristol Community
Health during 2011/12. Bristol Community Health has not participated in any special reviews
or investigations by the CQC during the reporting period.
3.2.6 Data Quality
A high level of data quality underpins the effective use of information in decision making to
improve the quality of Bristol Community Health services. In 2011/12 a data completeness
and data validation exercise showed the following.
•
95% of patient records had an NHS number recorded
•
74% of patient progress notes had been validated
•
99% of audited patient records had the correct name recorded
•
100% of audited patient records had the correct date of birth recorded
58
•
•
99% of patient records had a GP practice recorded and 97% of these records had the
correct details
The audit covered 16 services with 364 sample records from a population size of
17,949 on the caseload.
Data quality is also systematically reviewed as part of ongoing monthly reporting
arrangements to commissioners and the Bristol Community Health Board. This included the
following:
•
•
•
•
A programme of Performance and Finance Reviews with Service Leads and / or
Budget Holders to review areas where underperformance is linked to data quality
Monthly sense checking of activity information and key performance indicators against
data quality key lines of enquiry
Monthly IT User Group and Avon I&IMT Consortium meetings to review data quality
issues either from an inputting ‘front-end’ or reporting ‘back-end’ perspective
Ongoing peer review of coding scripts and data collection processes as part of the
overall Bristol Community Health reporting framework
In 2012/13 Bristol Community Health will be putting in place processes to ensure compliance
with the Community Information Data Set (CIDS) submission to the Department of Health.
The 2011-12 Data Completeness and Data Validation exercise will also be expanded to
cover more services. This will further support our continuing ambition to improve data quality.
Bristol Community Health was not subject to the Payment by Results clinical coding audit
during 2011/12 by the Audit Commission.
3.2.7 Information Governance Toolkit attainment levels
A baseline assessment has been conducted that indicates an overall baseline score for
2011-12 of 71%.
3.3 Statement From Third parties
Statement from NHS Bristol, North Somerset and South Gloucestershire Primary Care Trust
NHS Bristol, North Somerset and South Gloucestershire have reviewed the Bristol Communit
Health Social Enterprise first Quality Account document for 2011–2012.
We have reviewed the data presented and provided feedback on some areas.
NHS Bristol, North Somerset and South Gloucestershire will continue to work with Bristol
Community Heath Social Enterprise to raise the profile for quality improvement focusing on
patient safety, data accuracy and information governance . The ongoing engagement of
clinicians close working with other providers will remain crucial in monitoring standards and
improving services for local people.
The account identifies services that are in place and will be developed in 2012-13.
59
Part 1
There is a statement signed by CEO and
senior clinical staff stating report content is
accurate
Part 2
For 2012-13: Bristol Community Health
have indicated various areas they aim to
improve on, further clarity on specific measurement of some goals and how they will
be measured
Clearly set out the mandatory measures and
how these will be managed
Statement on quality from Chief Executive,
senior employee, stating document is accurate
Priorities for improvement
8 Mandatory Quality Measures
Review of Services
Participation in Clinical Audits
In this Quality Account many of the services
provided by Bristol Community Health are
not benchmarked against comparative data,
making it difficult for patients to compare
performance against other providers or to
see trends over time
Compliant, although any change to
processes following audits are not listed
National Audit
Compliant
Participation in Clinical Research
Compliant
CQUINs ( Commissioning for Quality
Improvement scheme)
Care Quality Commission
CQUINS for 2012-13 are noted but measurements and outcomes are not stated for
all. Achievement against some of the 201112 CQUINs is provided
Compliant and no conditions
Data Quality
Compliant
Deborah Evans, Chief Executive,
NHS Bristol, North Somerset and South Gloucestershire Primary Care Trust Cluster
14 June 2012
60
Bristol City Council Health Overview and Scrutiny Committee
Due to the end of the municipal year and the timing of this Quality Account, it was not
possible for the Health and Adult Social Care Scrutiny Commission to discuss the Quality
Account at a scheduled meeting. The Quality Account has been circulated by email
however, and members have commented favourably. In the year to come, the Committee
will be considering how best to deal with Quality Accounts from NHS Trusts and other
providers of NHS healthcare, given that the number of these coming to the Committee is
likely to increase in future years.
Bristol Local Involvement Networks
The LINK Management Group welcomes the production by Bristol Community Health of its
Quality Accounts 2011/12. We are pleased to be part of a continuing dialogue about the
work of Bristol Community Health. We note with interest the priorities for 2012/13 identified
in the document that will provide the basis for service development and feel they are ones
we can support. We understand that a revised and up-dated set of Quality Accounts for
2012-14 will be produced later in the year and will be glad of the opportunity to be involved
in helping to shape these.
3.4 Our Response to Third Party Statements
We are grateful to those third parties who have responded to our Quality Account and will
consider their responses carefully.
Specifically we will continue to work in partnership with the full range of providers in the
health and social care sector and will reflect these partnerships in the development of our
future Quality Accounts.
This has been the first Account that we have developed as a new and independent social
enterprise and its contents relate to only six months in that state. We recognise that on a
number of fronts there is insufficient data on the metrics that are relevant to the whole range
of our services to make meaningful comparisons between Bristol Community Health and
other similar providers. In the coming year we are working hard on aligning performance
indicators that are meaningful to patients, the public, staff, partners and commissioners.
We anticipate that as a result of this effort we shall be able to provide higher quality, more
relevant data for comparison in future years. Our stated priority areas will be those that
we focus on and this will help meet the requirements of commissioners as set out in their
response.
Additionally, we are working on developing a range of Patient Reported Outcome Measures
that are relevant for all stakeholders and would expect to be able to report on this important
aspect of our work in our next Quality Account which will be the first that reflects a full year of
independence from an NHS parent body.
Our mission is to be the provider of choice of high quality sustainable community services in
and around Bristol. Demonstrating quality and value is fundamental to achieving this mission
and giving an account of this is therefore a top organisational priority.
61
If you would like to comment on our 2011/12 Quality Account please get in touch with our
Marketing and Communications Team.
Email: bristolcommunityhealthcomms@briscomhealth.nhs.uk