BIRMINGHAM ST MARY’S HOSPICE
QUALITY ACCOUNT
2012-13
Our vision is for a future where
the best experience of living
is available to everyone leading
up to and at the end of life
We continually strive to achieve this through
the specialist and practical range of services we
offer to individuals, families and carers; through
education and partnerships; and through working
with professionals and communities to share our
expertise and learn from others
Birmingham St Mary’s Hospice
176 Raddlebarn Road
Selly Park, Birmingham B29 7DA
Registered Charity Number 503456
Page 1 of 37
INDEX
Part 1 - Statements
1.1 Statement from Tina Swani, Chief Executive
1.2 Endorsement from Judi Millward, Chairman of Trustees
4
5
Part 2 – Priorities for Improvements and Statements of Assurance
2.1 Priorities for Improvements 2012-13
(what we achieved last year)
Priority 1 - Patient safety
Root cause analysis for pressure ulcers
and serious falls
Priority 2 - Clinical effectiveness
Implement use of NHS clinical portal to
access patient information
Priority 3 - Patient experience
Development of the patient garden area
2.2 Other Hospice achievements 2012-13
2.3 Priorities for Improvements 2013-14
(what we will do this year)
Priority 1 - Patient safety
Staff Nurse development programme
Priority 2 - Clinical effectiveness
Combined Specialist MDT
Priority 3 - Patient experience
Family Centre
2.4 Statement of assurance from the Board
Review of services
Participation in clinical audit
Research
Guideline development and review
Use of the CQUIN payment framework 2012-13
Statement from the Care Quality Commission
Data quality
Information Governance toolkit
Clinical coding error rate
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Part 3 – Review of quality of performance
3.1 Clinical data
Inpatient Unit
Community Palliative Care Team
Day Hospice
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22
3.2 Quality markers
Patient slips, trips and falls
Pressure ulcers
Infection prevention and control
Complaints
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27
3.3 Clinical audit
28
3.4 Feedback from patients and families on services
Patients’ Forum
CQUIN
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32
3.5 Benchmarking activity
36
3.6 Statements on Birmingham St Mary’s Hospice
Quality Account for 2011/12
37
Cross City CCG
Senior Commissioning Manager
Sandwell & West Birmingham
3.7 Feedback and comments
37
ABBREVIATIONS
CPC
CQUIN
IPU
MHRA
NICE
OOH
RCA
SCCM
Clinical Practice Committee (part of the Hospice’s governance framework)
Commissioning for Quality and Innovation (payment)
Inpatient Unit
Medicines and Healthcare Products Regulatory Agency
National Institute for Clinical Excellence
Out of hours
Root cause analysis
Senior Clinicians Communications Meeting
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Part 1 - Statements
1.1
Statement from Tina Swani, Chief Executive
At Birmingham St Mary’s Hospice patients and families are at the centre of all we do.
The approach taken for the Quality Account for 2012-13 has been to focus on three
specific priorities across patient safety, clinical effectiveness and patient experience.
These relate to identified aspects of care that may not otherwise have received public
attention and yet have made a difference to quality of care and outcomes for those
patients and families. We have also followed the recommended format to demonstrate
compliance with Department of Health requirements.
Our service quality, standards and approach to care are not limited to simply what is
required but to the needs and aspirations of our service users, driven by our own high
standards and specialist expertise in end of life care and supported by our commitment to
maintaining a well run, sustainable organisation.
A wider picture of successes and improvements along with our approach to governance
and quality can be found in the following public documents due for publishing this year:
•
•
St Mary’s Hospice Ltd Annual Report 2012-13
Birmingham St Mary’s Hospice – The Next Four Years – Reaching More People
Reaching more people
Strong
foundations
Working in partnership to achieve high
standards in more settings
The priorities for the next four years are shown in below. They reflect our successes and
wider plans for improvement:
1.
2.
3.
4.
Make it easier for people to know how to get help
More care at home
Increase confidence and independence of patients and carers
Expand our expertise across a wider range of conditions and
services
5. Work with communities to foster the contribution of local society
6. Grow our education so more people are able to deliver & influence
care
7. Pioneer and explore innovative ways to meet changing needs
8. Our impact: prove the difference we make
9. Our people: attract the best workforce and supporters
10. Our funding: continue to build financial strength
11. Our organisation: well run and organised
12. Our reputation: well known, well regarded and influential
We hope that by sharing the more specific improvements and practice in this Quality
Account, there is practical value to all readers of this document.
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1.2
Endorsement from Judi Millward, Chairman of Trustees
This Quality Account is produced to inform current and prospective service users, their
families and carers, Hospice staff, our supporters, commissioners and the public, of our
commitment to ensure quality across all our services.
Trustees have an active role in our Governance Framework. Each Trustee has, as part of
his or her portfolio, a Governance Committee or Board Sub-Committee. This way,
Trustees are actively engaged in understanding their responsibilities as individuals and
conducting them collectively as a Board.
I confirm that I endorse this Quality Account on behalf of the Board of Trustees.
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Part 2 - Priorities for improvement and statements of assurance from
the Board (in regulations)
2.1 Priorities for improvement 2012-13 – what we achieved last year
Patient Safety
Priority One: Undertake Root Cause Analysis (RCA) for pressure ulcers and
serious falls and the organisation will share learning from this
Standard: Root Cause Analysis will be carried out on
• All Grade 3 and 4 pressure ulcers
• Any serious fall or where a patient has fallen on more than 3 occasions
How was this identified as a priority?
Pilot of RCA in these two groups was carried out and demonstrated that effective learning and
improvements in safety takes place.
How was Priority One achieved?
•
•
•
Teaching regarding RCA’s delivered on Band 5 study day in 2012
RCA’s for pressure ulcers completed by all grades of nursing staff with support. Outcomes fed
back to all staff
RCA’s for falls organised with a multidisciplinary investigation group. Results are discussed at
the falls meeting and action plans disseminated to all staff.
How was progress monitored and reported?
Pressure ulcer RCA’s were monitored through the pressure ulcer audit process and reported to the
Clinical Practice Committee and Environment and Risk Committee as part of incident reporting.
RCA’s for falls were monitored through the falls audit process and reported to the Health and
Safety Group, Clinical Practice Committee and Environment and Risk Committee as part of
incident reporting.
Evidence of staff attending study days has been collected.
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Clinical Effectiveness
Priority Two: Implement use of NHS clinical portal to access patient information
Standard: Hospice clinical staff will be able to access patient letters, scans, x
rays and pathology reports from Queen Elizabeth Hospital system
How was this identified as a priority?
Use of clinical and administrative resources to follow up results and information has become more
significant. Information such as discharge and outpatient summaries from hospital need to be
available in a timely manner to be able to provide effective care and this is currently not the case
How was Priority Two achieved?
o
o
o
o
Hospice and hospital teams have agreed an Information Governance Agreement and IT
Support Model.
Hospice IT team have added "desktop link" to home page of all proposed users.
Pending confirmation that hospice information governance training is adequate for UHB
regulations, roll out and training for Hospice staff is planned for May/June 2013.
Thereafter there will be scope to add other clinical information systems to this package eg
PACS, PICS
How was progress monitored and reported?
Progress is being monitored and reported through the Information Governance Committee
and Senior Clinicians Communication Meetings. Numbers of staff trained to use portal and
numbers regularly accessing patient records can be audited. Qualitative feedback from staff
members regarding use and usefulness will be part of the ongoing support and monitoring.
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Patient Experience
Priority Three: Development of the Inpatient Garden area, by improving access to
all areas & reducing the risk of slips and falls due to uneven paths.
Standard: The Inpatient Garden project will be completed within timescale and
access to all areas improved.
How was the priority identified?
The hospice garden is used by patients and their visitors all year round and provides relaxation
and a space to reflect. The state of the paths and patios has deteriorated and they require work to
restore to a safe and enjoyable environment. Following risk assessment we have had to restrict
the use of wheelchairs and patients in beds to the patio areas as the paths are unsafe for moving
and handing reasons but this is not a situation we wish to continue.
Consultation with patients and carers took place to elicit their views on the work.
How was Priority Three achieved?
The contractor installed new landscaping designed to enable more patients to safely access and
enjoy the pleasant outdoor surroundings. This included block-paving and level edges to all paths
making it easier for people with wheelchairs and restricted mobility to traverse the area. With
these improvements, beds can now be easily transported from the Inpatient bays and single rooms
giving patients with no mobility the opportunity to spend time outside. Safety fencing with glass
screening ensures the garden view from a patient’s bed is not restricted. The screening and
electrically operated awnings give protection from the elements with availability of a power supply if
needed.
The centrepiece of this space is an armillary sphere1 which will be illuminated at night. The sphere
has been inscribed with words chosen by our Patients’ Forum and a poem selected by a patient’s
husband who made a significant donation towards the cost of the project. Some of the existing
mature shrubs have been re-planted and some new shrubs have been donated by the contractor.
How was progress monitored and reported?
Progress was monitored against an action plan which was reported to Senior Management Team
and the Environment and Risk Committee.
1
The original armillary sphere was designed by a great astronomer almost 2,000 years ago.
Consisting of a spherical framework of rings, these spheres are now mostly used as sundials.
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Pathways in the garden before the improvements
After:
Page 9 of 37
Access to the garden for patients from inpatient bays and single rooms
before the new patio, screening and electric blinds:
After:
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2.2 Other Hospice achievements
•
•
Food Hygiene
Following inspection by a Birmingham City Council authorised Environmental Health Officer
in May 2012, the Catering Team achieved 5 stars (excellent) for food hygiene. This is an
indication of the level of compliance with food safety legislation.
Infection Prevention and Control Award
The Infection Prevention and Control Nurse, Ruth Roberts, successfully completed the
Infection Prevention Society IPC Nurse Development Programme. Ruth’s essay “A
reflection on Developing an Infection Prevention and Control Service in a Hospice
Environment” was awarded the Marian Reed prize of £200 which is awarded annually for
innovation in Infection Prevention and Control. The essay was a summary of the work of
the whole Infection Control team over the past 18 months. The judging panel stated they
were particularly impressed with the number of changes made in a relatively short space of
time. All members of the team are to be congratulated for this formal acknowledgment of
their on going hard work.
•
Space to breathe pilot
In January 2013 we piloted a ‘Space to Breathe Clinic’. This was a 5-week programme for
patients and carers affected by COPD. Patients were referred by the Respiratory Team at
Queen Elizabeth Hospital Birmingham. The aim of the clinic was to help patients feel more
in control of their breathing and be more independent in daily living, through providing
education and information, demonstrating how to manage their daily activities, addressing
anxiety through the use of CBT and showing them relaxation and breathing techniques.
The second programme of 8 patients with carers commenced in May 2013. It is led by a
multidisciplinary team of physiotherapy, occupational therapy, psychology, nursing and
respiratory specialists.
•
Published work
Two members of our clinical team had articles published:
o European Journal of Palliative Care
‘Introduction of electronic patient records in a hospice inpatient unit’
Nicola Butterfield, Lead Nurse, Inpatient Unit
o
•
National End of Life Care Programme - The College of Social Work
Good practice example: ‘Using social work skills to build links into the community
and access informal support’
Diana Murungu, Specialist Palliative Care and Equalities Social Worker
Hospice at Home
Following a series of multi-agency workshops in 2011/12 the Hospice received funding to
establish and pilot a Hospice at Home (H@H) service which commenced on 7 January 2013.
The new H@H delivery model cares for patients with a limited life expectancy in their own
home via a team of Registered Nurses and Health Care Assistants. The team work
collaboratively with Birmingham Community Health Care Trust (BCHC) and local GP
practices. Referrals are made via the Community Trust Single Point of Access (SPA).The
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H@H team provide a 7 day a week service with night sits as necessary.
The service provides care to patients at the end of life who either:
o have intensive needs and who may previously have been admitted to hospital and/or
o are in hospital, imminently dying and requesting a speedy hospital discharge
The project will be evaluated during 2013 to establish whether Hospice at Home will become
a core hospice service
•
Department of Health Grant
At the end of March 2013 we received notification that we had been awarded £214,362 by
the Department of Health to support the delivery of the following projects:
o Family Centre plus relatives overnight room
o Mortuary and viewing room update
The total cost of our application had been £315,268 and we are now working on closing this
funding gap.
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2.3 Priorities for improvement 2013-14 – what we will achieve next year
Patient safety
Priority One: To provide increased in house training for the Registered nursing
staff on the Inpatient Unit
Standard:
• All registered nurses recruited to the IPU within the last twelve months to
undertake a new ‘development programme’
• To upskill the nursing staff in teaching skills
• Registered nurses to have up-to-date training records
How was this identified as a priority?
An increase in the ward establishment has enabled us to recruit two new nurses. This, in addition
to the nurses recruited this year has meant that we have a cohort of junior staff. In order to
maintain the specialist knowledge of the nursing team the need for a development programme was
identified in order to provide safe clinical practice.
The increased demands on the ward for teaching has highlighted a gap in the staff confidence and
competence in their teaching ability
How will the priority be achieved?
•
•
•
•
Implementation of a new band 5 Staff Nurse development programme
Pilot of a band 6 ‘Education Resource Facilitator’
Ward staff away days for team building and empowerment
Education/training to enable staff to improve teaching skills
How will progress be monitored and reported?
• Evaluation of the development programme
• Training records
• Attendance records
• Records of staff able to teach on different sessions
• Implementation of Education Resource Facilitator role
A report will be produced outlining progress in March 2014
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Clinical Effectiveness
Priority Two: Evaluate effectiveness of a Combined Specialist Palliative Care
Multidisciplinary Meeting (SPCMDT) between the Hospice and an Acute Hospital
Standard: Complete a six monthly pilot and undertake evaluation of a weekly
Combined Specialist Palliative Care Multidisciplinary Meeting
How was this identified as a priority?
The Manual for Cancer Services: Specialist Palliative Care (SPC) Measures was published in April
2012 by the National Cancer Peer Review- National Cancer Action Team. The revised Specialist
Palliative Care Measures are based on the requirements for SPC in Improving Supportive and
Palliative Care for Adults with Cancer (2004).
There is a requirement for all inpatient hospital and hospice SPC services to be covered by a
named SPCMDT which is put forward for review against the SPCMDT measures. In order to
achieve compliance the hospice must demonstrate that they meet the standard under peer review.
How will Priority Two be achieved?
A review of the effectiveness of the meetings will take place after six months looking at:
• Numbers of meetings held
• Attendance at each meeting of each discipline
• Numbers of patients reviewed
• Time keeping
• Documentation of outcomes and actions agreed
• Overall assessment of effectiveness of model in review of patients
How will progress be monitored and reported?
Progress will be monitored through a Review meeting comprising the Multidisciplinary Team, the
Acute Unit Cancer Manager and Hospice Head of Nursing Services.
A written report of the evaluation will be compiled and submitted to Senior Clinicians
Communication Meeting and Clinical Practice Governance Committee.
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Patient Experience
Priority Three: Family Centre
Standard: New extension to house a ‘Family Centre’ will be completed within
agreed timeframe and comply with patient/carer expectations
How was this identified as a priority?
Facilities in the existing ‘patient flat’ are outdated and in need of complete refurbishment. In
addition the location of this facility offers limited privacy to patients and their family/carers as it
overlooks an area designated for receiving deliveries and collections. Users of the ‘patient flat’ can
be disturbed by the noise from the adjacent service area. In addition there is no access to outside
space.
The new ‘Family Centre’ will include space for relatives to stay overnight. There is no such facility
at the moment other than using a camp bed or recliner and there are no shower facilities available
to visitors.
How will Priority Three achieved?
We will:
o Develop a project plan with detailed timescales and ensuring AEDET and ASPECT are
incorporated into the project
o Develop a communication plan
o Assess risk and impact on patients and relatives who use the Hospice facilities during the
project
o Undertake a tender process to appoint project management of the work
o Appoint contractors who will be instructed to undertake the work within the specified
timeframe
Ongoing consultation will take place with Patients Forum. Nursing staff, physiotherapists,
Occupational Therapists and the Infection Prevention and Control Team have also been consulted
regarding the layout and specification of the project and this will be ongoing.
The ‘Family Centre’ will be purpose built to a specification that provides a comfortable and safe
environment for patients and their family/carers. The facilities will allow users to be independent
but with the support of staff close by. It will include wheelchair access and an assisted bathroom
and will ensure privacy for families in a homely environment. An important part of the Centre will
be easy access to the Hospice garden to enjoy the benefits of an outside space.
How will progress be monitored and reported?
Progress will be monitored as follows:
o Regular site meetings with the contractor
o Reports to
o Executive Officer Team
o Environment Risk Committee
o Premises Sub- Committee
o Board of Trustees
There will be regular bulletins to our Patients Forum, staff and volunteers
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2.4
STATEMENT OF ASSURANCE FROM THE BOARD
The following are statements that all providers must include in their Quality Account. Many of
these statements are not directly applicable to specialist palliative care providers, and therefore
explanations of what these statements mean are also given.
Review of services
During 2012-13 Birmingham St Mary’s Hospice supported commissioning priorities in Birmingham
and Sandwell with regard to the provision of local specialist palliative care by providing the
following services which were also part-funded through charitable funding:
•
•
•
•
•
•
•
•
Inpatient Unit
Community Palliative Care Team
Day Hospice
Hospice at Home pilot project
Occupational therapy
Physiotherapy
Complementary therapies
Family & Carer support services, including bereavement support and spiritual care
Participation in Clinical Audit
•
During this period Birmingham St Mary’s Hospice did not participate in any national clinical
audits or confidential enquiries as it was not eligible to do so.
•
The reports of 0 national clinical audits were reviewed by the provider in 2012-13. This is
because there were no national clinical audits relevant to the work of Birmingham St Mary’s
Hospice.
What this means:
As a provider of specialist palliative care Birmingham St Mary’s Hospice is not eligible to
participate in any of the national clinical audits or national confidential enquiries. This is
because none of the 2012-13 audits or enquiries related to specialist palliative care.
The Hospice will also not be eligible to take part in any national audit or confidential
enquiry in 2013-14 for the same reason.
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Research
The Hospice participated in the following research study during 2012:
Metaphor in End of Life Care
Researcher: Prof Elena Semino, Lancaster University
Start date: July 2012 End date: November 2012
Aim: To investigate the use of metaphor in the construction of the experience of end of life care
by studying the metaphors used by members of different stakeholder groups (patients, unpaid
family carers and healthcare professionals). Also to investigate the implications of the use of
metaphor and explore what aspects of metaphor use are relatively stable and what aspects vary
depending on the mode of communication and the roles and identifies of speakers/writers.
Guideline Development
The Hospice contributed to the development of the following Pan Birmingham Cancer Network
Guidelines:
• January 2012
o Use of Ketamine In Palliative Care Version 2:1
o Management of Drugs in Symptom Control (West Midlands)
o Use of Naloxone in Palliative Care
o Use of Methadone for adults with pain in Palliative Care Version 1:1
o Accessing Urgent drugs for Palliative and End of Life patients from Acute Trusts
Version 2.1
o Management of Diabetes Mellitus in Palliative Care Version 1:1
• October 2012
o Subcutaneous Hydration in Palliative Care
o Guideline for Adults, Children and Young People’s Bereavement Support Across
Disciplines
o Guideline for Referral, Admission and Discharge of Patients to Specialist Palliative Care
Services
• December 2012
o Malignant Spinal Cord Compression
The following NICE guidance applicable to hospice clinical practice was reviewed
•
•
•
•
April 2012
o Infection Control
o PleurX Peritoneal catheter drain
o Implantable cardioverter defibrillator guidance
October 2012
o Venous Thromboembolism
o Chronic Obstructive Pulmonary disease
o Opioids
November 2012
o Organ donation
December 2012
o Acute upper gastro intestinal bleeding
Use of the CQUIN payment framework 2012-13
A proportion of Birmingham St Mary’s Hospice income in 2012-13 was conditional on achieving
quality improvement and innovation goals agreed between the Hospice and Birmingham and
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Solihull Cluster, through the Commissioning for Quality and Innovation payment framework.
Details of the initiative for 2012-13 are given below.
Description of CQUIN indicator
•
•
•
To ensure that providers have real-time systems in place to monitor patient/carer experience
To demonstrate improvements in patient/carer experience
Demonstrate clear commitment from the Board to improve patient/carer experience
Aim
To assure patient/carer satisfaction and to measure the outcome of patient care whilst continuously
monitoring the quality of the services provided through the use of questionnaires.
More detail on the methodology and outcomes from these questionnaires is given on page 32.
Statement from the Care Quality Commission
Birmingham St Mary’s Hospice is registered with the Care Quality Commission to carry out the
following regulated activities:
Diagnostic and screening procedures
Transport services, triage and medical advice provided remotely
Treatment of disease, disorder or injury
Personal care
Nursing care
The following conditions of registration apply to all regulated activities listed above:
• The Registered Provider must ensure that the regulated activities are managed by an individual
who is registered as a manager in respect of the activity, as carried on at or from the location
St Mary’s Hospice Limited
• These regulated activities may only be carried out at or from the following location: 176
Raddlebarn Road, Selly Park, Birmingham B29 7DA
The following additional conditions apply:
• This hospital is registered to provide treatment and care under the following service user
categories only: Hospice for adults H(A).
Reason for condition: To ensure that only treatment and services within the scope of the
providers’ knowledge, skills and experience are offered.
• A maximum of 25 patients may be accommodated overnight.
Reason for condition: To ensure that only treatment and services within the scope of the
providers’ knowledge, skills and experience are offered.
• A maximum of 20 persons only may receive services provided on a day-case basis.
Reason for condition: To ensure that only treatment and services within the scope of the
providers’ knowledge, skills and experience are offered.
• Notification in writing must be provided to the Care Quality Commission at least one month
prior to providing any treatment or service not detailed in your Statement of Purpose
Reason for condition: To ensure that only treatment and services that are safe to be
undertaken in the premises and within the scope of the providers’ statement of purpose are
offered.
The Care Quality Commission has not taken any enforcement action against Birmingham St
Mary’s Hospice during 2012-13.
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Birmingham St Mary’s Hospice has not participated in any special reviews or investigations by the
Care Quality Commission during 2012-13.
We were last inspected by the Care Quality Commission in February 2013. We were inspected on
the following standards as part of a routine inspection and the inspector found that we met all 5
standards:
• Consent to care and treatment
• Care and welfare of people who use services
• Safeguarding people who use services from abuse
• Staffing
• Records
An extract from the Commission’s report is given below:
Why we carried out this inspection
This was a routine inspection to check that essential standards of quality and safety
were being met. We sometimes describe this as a scheduled inspection. This was an
unannounced inspection.
How we carried out this inspection
We looked at the personal care or treatment records of people who use the service,
carried out a visit on 27 February 2013, observed how people were being cared for and
checked how people were cared for at each stage of their treatment and care. We talked with
people who use the service, talked with carers and / or family members and talked with staff.
What people told us and what we found
People's needs were assessed and care and treatment was planned and delivered in line with their
care plans. People told us they were clear about the aims of care and treatment and they were
very positive about their experience of the service. Before people received any care or treatment
they were asked for their consent and we saw regular accounts of verbal consent from day by day
discussions between people and staff in people's records.
One person said, "It's very good here, very well run. If I wanted to I couldn't find anything to
complain about."
There was written policy and procedures for recognising and responding to abuse of
vulnerable people. People said they felt safe at the service and staff said there was an
'open culture' in which staff could raise any concerns and managers would act on them.
There were sufficient numbers of staff on duty to meet people's needs and people told us that
there was always someone available when they needed them. People said that staff were
competent and took time to listen to them. We found that the service was well
supported with medical, care and ancillary staff and also volunteer workers.
People were protected from the risks of unsafe or inappropriate care and treatment
because accurate and appropriate records were maintained. We found that people's
medical and care records were up to date and kept securely. Records necessary for the
safe running of the service and the building were also up to date.
Data Quality
Birmingham St Mary’s Hospice did not submit records during 2012-13 to the Secondary Users
Service.
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This is because:
Birmingham St Mary’s Hospice is not eligible to participate in this scheme. We have a Clinical
Information Officer who collects and collates data extracted from the electronic patient records
system and a data integrity sub-group reviews the data quarterly.
Information Governance Toolkit attainment levels
Birmingham St Mary’s Hospice Information Governance Assessment Report overall score for
2012-13 was 66% against a target score of 68%. We achieved Level 3 compliance in 2 areas and
Level 2 in a further 28 in our first year of independent assessment. However, overall we were
graded red (not satisfactory) because we achieved only Level 1 for 2 areas. We are working to an
action plan to achieve and sustain at least level 2 compliance in all areas for 2013/14.
Clinical coding error rate
Birmingham St Mary’s Hospice was not subject to the payment by results clinical coding audit
during 2012/13 by the Audit Commission. This is because Birmingham St Mary’s Hospice receives
payment under a mix of block contracts and payment on a cost per case basis when delivered, not
through tariff and therefore clinical coding is not relevant.
Page 20 of 37
Part 3 - Review of quality of performance
3.1 Clinical Data
Birmingham St Mary’s Hospice uses ‘SystmONE’, an electronic patient records system which all
patients are entered onto. We have, therefore, chosen to present data extracted from that system
for the year 1 April 2012-31 March 2013 for the following services:
Inpatient Unit (IPU)
o There were 412 admissions to our IPU – this includes those patients hat may have been
admitted more than once
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Number of Admissions
Inpatient Unit Admissions 2012 / 13
Month
Community Palliative Care Team (CPCT)
o 755 new referrals were received for this service
o 9,101 patient contacts were made during the year
o There were between 250-300 patients per month on the Team’s caseload during the year
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Number of New Referrals
Community Palliative Care Team New Referrals 2012 / 13
Month
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1200
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600
400
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Number of Contacts
Community Palliative Care Team Patient Contacts 2012 / 13
Month
Day Hospice
o Attendance in our Day Hospice was 2,065
o Patients were unable to attend Day Hospice for a variety of reasons on 1007 occasions
(see the breakdown on the next page)
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be
r
Ja
nu
ar
y
Fe
br
ua
ry
be
r
t
Se
pt
em
Au
gu
s
Ju
ly
Ju
ne
M
ay
0
Ap
ril
Number of Patients
Day Hospice Attendance 2012 / 13
Month
Page 22 of 37
ar
ch
M
O
ct
ob
er
No
ve
m
be
r
De
ce
m
be
r
Ja
nu
ar
y
Fe
br
ua
ry
be
r
t
Se
pt
em
Au
gu
s
Ju
ly
Ju
ne
M
ay
160
140
120
100
80
60
40
20
0
Ap
ril
Number of Patients
Day Hospice Non-Attendance 2012 / 13
Month
Reasons for non-attendance – Day Hospice
Reason
Outpatient appointment
In hospital
In Hospice Inpatient Unit
Unwell
On holiday/away
Other (Visitors – family/district
Total for
2012/13
91
138
131
359
45
132
nurse/friends/workmen/delivery)
Reason unknown
Cancelled by service
Death
TOTAL
3
107
1
1007
Page 23 of 37
3.2 Quality Markers
• Patients slips, trips and falls
• Pressure ulcers
• Infection prevention and control
• Complaints
Patients slips, trips and falls
Patient slips, trips and falls are monitored. Serious incidents are reported under Statutory
notifications to the Care Quality Commission.
A Root Cause Analysis is undertaken when:
• Fall results in hospital assessment or admission
• Patient suffers loss of consciousness
• The patent has abnormal neurological observations
• The patient has had repeated falls – more than 3 on current admission
• Death occurs as result of fall or within 24 hours of fall
April –
June
July – Sept
Oct –
Dec
Jan –
Mar
TOTAL
Number of No Injury
Slips, Trips
and Falls
22
22
Minor
Injury
Serious
Injury
Reported
to CQC
RCA
Undertaken
0
0
0
1
20
14
6
0
0
0
17
14
3
0
0
0
21
80
20
70
1
10
0
0
0
0
1
2
There has been an overall reduction in the number of slips, trips and falls from 91 last year.
There have been no serious injuries sustained and no reports to Care Quality Commission during
the year compared to 1 last year.
Page 24 of 37
Pressure ulcers (Inpatient Unit)
The total numbers of pressure ulcers that patients are admitted with or develop whilst on the
Inpatient Unit are monitored. Root cause analysis was undertaken for all grade 3 and above
pressure ulcers and statutory notifications were also made to the Care Quality Commission.
Grade 2
Grade 3
Grade 4
No. reported
to CQC
No. of RCA
under-taken
19
(68%)
9
(32%)
12
2
0
0
1
2
108
18
(17%)
12
(67%)
6
(32%)
4
1
0
0
0
2
99
15
(15%)
11
(73%)
4
(27%)
6
3
0
1
1
3
107
12
(11%)
8
(67%)
4
(33%)
6
3
0
0
0
3
424
73
(17%)
50
(68%)
23
(32%)
28
9
0
1
1
10
OctDec
JanMar
Total
Grade 1
Home
28
(25%)
Hospital
Admitted with
pressure
ulcer
110
No of admissions to
IPU
April June
Developed on IPU
July –
Sept
Admitted from
The overall numbers of patients admitted to the IPU with pressure ulcers has reduced this year,
with a smaller percentage coming from home and a larger percentage from hospital.
There has been an increase in the number of grade one pressure ulcers that have developed on
the IPU and a reduction in the number of grade two ulcers.
One patient developed a grade 4 pressure ulcer which was reported to the CQC and an RCA was
undertaken.
Ten RCA’s were undertaken this year compared to eight last year
Page 25 of 37
Infection Prevention and Control Annual Programme
The annual Infection Prevention and Control (IPC) programme seeks to ensure that standards of
Infection Prevention and Control practice are high and that Birmingham St Mary’s Hospice is
compliant with the Health and Social Care Act (2008). Examples IPC of activities from the annual
programme to improve and maintain quality this year have included:
•
Delivery of mandatory Infection Prevention and Control training to clinical staff
•
Review and implementation of EU Directive 2010/32/EU on the prevention of sharps
injuries in the health care sector
•
Policy reviews to ensure policies and procedures follow the latest research
recommendations and legislation
•
Audits on key areas of IPC
•
Surveillance of infections
Outbreaks
There were no outbreaks of infection during April 2012 to March 2013.
Surveillance of MRSA and Clostridium difficile
Total Incidents of patients known to have MRSA/ C diff on the In Patient Unit in April 2012-March
2013
Micro organism
Total number of in
patients April 2012March 2013 known to
be colonised
MRSA
5
Clostridium Difficile
2
It is worth noting that:
•
Birmingham St Mary’s Hospice does not routinely screen patients for MRSA on admission. All
5 of the patients known to be colonised with MRSA were recognised as being so either in the
community or in an acute trust prior to admission.
•
All patients with c diff/MRSA were barrier nursed and commenced on the appropriate care
plans as per policy in a timely manner.
Page 26 of 37
Complaints – April 2012 to March 2013
Complaints Summary 1 April 2012 to 31 March 2013
Total No. Complaints
Nursing:
• In Patient Unit
• Day Hospice
• Community Palliative Care
Team
Medical
Family and Carer Support Team
Non Clinical:
Other
7
3
0
2
2*
1
* 1 complaint refers to both Community Palliative Care Team and Family and Carer Support Team
Developing a Learning Culture
The numbers of complaints are very small in relation to the numbers of patients, families and
carers that are looked after by the Hospice. However, it is important that as part of the Hospice’s
desire to develop a culture of learning and openness any learning is shared across the
organisation and not just within Teams. In future we will ensure that:
•
•
Any learning outcomes from the complaint received are discussed by the relevant Team
and documented as part of the complaint response
Complaints form part of the annual audit programme, including a review of learning
outcomes
Compliments and “Thank You’s”
The Hospice receives numerous compliments and “thank you” cards and letters. These are
generally forwarded to individual departments. However, they are also rich sources of information
about the services delivered and next year will put a system in place to collate these after they
have been displayed by individual departments.
Page 27 of 37
3.3 Clinical audit
Clinical audit is a way in which the organisation can learn and improve the delivery of its services,
the outcomes for patients and the experience they have. The Audit group has undertaken a
programme of audits. The following tables show the audits completed in 2012.
Where issues are identified during an audit an action plan is developed to address these and learn
from them. Progress on the action plans is monitored through the Hospice’s clinical governance
committee, the Clinical Practice Committee, to ensure that they are completed. We undertake a
further audit where we assess the outcomes of the actions taken to ensure that standards continue
to be measured and improved.
General
Date
Title of Audit
Learning outcomes achieved
1
January
Standard fully achieved
2
January
Study Day Evaluation –
Medical Students
Integrated notes documentation
3
4
March
January
CPCT – Waiting times
Hoist Sling/Slide sheet
documentation
5
February
Blood transfusion
Pathway
6
7
March
March
8
March
9
March
10
May
11
12
13
May
June
June
Study day attendance
Education programme
evaluation forms
Appropriate use of
Dipstick and MSU tests
Management of
Diabetes
Labelling of mobility
equipment on IPU
Handover
Delayed discharge
Commode cleanliness
14
June
15
June
16
June
17
18
July
July
Diagnosis/Management
of UTI –Inpt Unit
Hoist Sling/Slide sheet
documentation
Infection Control – 5
subtopics
CPCT – Waiting times
Slips, Trips and Falls
CQC
Outcome
12
7/14 standards achieved
Further education required on 7
standards
Standard fully met
Standard fully achieved on 2
points, 1 point non compliant
(slide sheets)
6/9 standards met
3 standards require further
medical education
2/4 standards were compliant
100% compliance
21
2/5 standards met
Clinical staff education
6/7 standards met
16
3/4 standards met
11
4/6 standards met
3/6 standards met
100% compliance for JanMarch
Improvement to be maintained
2/5 standards met
16
16
8
Standard 100% compliant
1
Subtopic 1- 79% compliant
Subtopic 2 – 77.6% compliant
Subtopic 3 – 61.5% compliant
Subtopic 4- 87.5% compliant
Subtopic 5 – 100% compliant
Standard 100% compliant
3/6 standards met
8
16
4
16
12
12
4
4
16
16
Page 28 of 37
19
August
Waiting times –Inpt Unit
1 Standard fully met
1 Standard 97% compliant
16
20
21
22
23
September
October
October
October
100% compliance
100% compliance
99% compliance
95% compliance
16
16
16
16
24
December
Bed rail assessment
Bereavement -CPCT
Waiting times -DH
Response times to
contacting pts in DH
CPCT Documentation –
next contact
90% compliance
21
Medicines Management Audit Programme 2012
Date
Title of Audit
Learning outcomes achieved
1
February
CD Administration timing
CQC
Outcome
9
81% compliance
2
February
3
4
May
July
5
August
6
7
September
September
8
September
9
10
11
September
October
December
12
December
Stock controlled drug
check
Drug Omissions
Corticosteroid Use on
Inpatient unit
Oxygen prescription,
administration and
monitoring
Medication Storage
Discharge TTO turn
around times
Drug chart
documentation
Drug fridge temperature
Patient Group Directions
Controlled drug storage
and use
Accountable Officer
9
2 standards met
2 standards not met
2 standards not met
8 out of 9 standards not met
9
2 out of 6 standards met
9
2/2 standards met
1/2 standards met
9
9
3/6 standards 100% compliant
9
4/6 standards met
3/5 standards met
5/6 standards met
9
9
9
3 out of 4 standards met
9
9
Page 29 of 37
Audit presentations in 2012
Date
March
Title (s) of presentations
• Indications for oxycodone use
• Venous thromboembolism prophylaxis
• Electronic verbal orders
• Drug chart documentation
July
• Integrated Notes Documentation
• Drug omissions
• CPCT – Waiting times
• CD Administration timing
September
• OOH Calls – Inpatient Unit
• Waiting Times – Inpatient Unit
• Corticosteroid Use on Inpatient Unit
• Oxygen prescription, monitoring and
administration
December(postponed • Accountable Officer Role
to January)
• Infection Prevention and Control
• IPU Documentation
Surveys/reviews in 2012
Date
Title
Report to
January
Patient satisfaction with
medicine administration
•
•
March
April
June to
December
(monthly)
Patient Experience –
Inpatient Unit
Out of Hours Call – Inpatient
Unit survey
•
CQUIN
• Inpatient
• Discharged patients from
inpatient unit
• Day Hospice
• CPCT
•
•
•
•
Clinical Practice
Committee (CPC)
Medicines
Management
Committee (MMC)
CPC
CPC
Senior Clinicians
Communication
Meeting (SCCM)
Commissioner
CPC
CQC
Outcome
1
1
1
1
Page 30 of 37
3.4 Feedback from patients and families on services
• Patients’ Forum
• CQUIN
Patients’ Forum
In addition to conducting regular patient surveys across our services, we also have a patient
participation group – Patients’ Forum. This Forum meets monthly on alternative days of the week.
The membership is mainly drawn from patients attending the Day Hospice, although meetings are
open to in-patients and community patients as well. The meetings are supported by the Head of
Nursing Services and a non-clinical Senior Manager (rotating role).
The dates the Patients’ Forum met, main topics discussed and patient numbers in attendance are
shown below:
Meeting date
2012
16 April
23 May
21 June
20 July
26 September
18 October
16 November
2013
27 February
Patient
Attendance
4
5
8
10
3
4
7
4
Main topics discussed:
• Inpatient Unit Family Area – Hospice plans to develop an area to replace the current flat on the
Inpatient Unit.
• Hospice Volunteers and National Volunteers Week – celebrating role of the Volunteers at the
Hospice
• Hospice Branding – Branding and Reputation Committee recently created to refresh the
Hospice’s brand and try and alter the stigma that is associated with Hospice care.
• Volunteer Role Inpatient Unit – new role
• Future Clare Planning – Discussion on improving documentation of patient decisions.
• Patient Satisfaction Surveys – surveys to be handed out to Patients on fourth visit to Day
Hospice
• Education Sessions – introduction of education sessions
• Exercise – advice sought
• Health Lottery – information requested
• Medical Students – patients asked for views if this would be something they would be willing to
participate with
• Hospice Menu – more selection/variety requested
• Entertainment – discussion
• Three Local Charities Lottery – information distributed
• Garden Project – funding obtained for garden redesign.
• Patient’s Expectation of Notes – information given
Page 31 of 37
•
•
•
•
•
•
•
•
•
•
•
•
Humour – information given on ‘story telling workshops’. Patients welcomed attending
workshops.
Fundraising Events – notice to be displayed of forthcoming events
Discharging Patients – explanation to patients
Christmas Fayre – Day Hospice Stall
Private Insurance Services – views requested
Complete Palliative Care – explanation of services available to patients
Department of Health Bid – application submitted for Family Centre
CQUINN – feedback from patients
Narrative Therapist – views requested
Resuscitation – views requested
Patients wished to record how much they enjoy their day hospice visits and appreciation for
care they receive
Smoking Shelter – discussion
CQUIN
As noted above, a proportion of our income in 2012-13 was conditional on achieving quality
improvement and innovation goals agreed between the Hospice and Birmingham and Solihull
Cluster, through the Commissioning for Quality and Innovation payment framework. The CQUIN
ran from June 2012 to March 2013 and the method we used for collecting information from our
patients is given below:
Inpatient Services
• A questionnaire was given to the patient or carer on the fourth day following admission
Discharged Patients from Inpatient Unit
• A questionnaires was given to the patient/carer on the day of discharge
Day Hospice
• A questionnaire was initially given to all patients attending Day Hospice and thereafter on a
patient’s fourth visit
Community Services
• A questionnaire was given to the patient/carer after the third community visit with a prepaid,
addressed envelope for its return to the hospice
Page 32 of 37
Questionnaires returned analysed by month
45
40
35
30
25
20
15
10
5
0
Inpt
Discharge
Day Hospice
y
Au
g
Se ust
pt
em
be
Oc r
to
No ber
ve
m
be
De
r
ce
m
be
r
Ja
nu
a
Fe r y
br
ua
ry
M
ar
ch
Ju
l
Ju
n
e
CPCT
INPATIENT UNIT
Question
Strongly agree Agree
Neither agree nor Strongly
disagree
disagree
The first three days of my
stay have been satisfactory
107
20
1
2
I understand the reasons for
my admission and what the
hospice is trying to achieve
for me
I have found the staff
approachable
I have been given the
opportunity to discuss my
care and treatment
I have been able to express
any concerns or issues that
I’ve had
The inpatient unit staff are
doing everything I would
expect them to do
If I had a complaint about the
care I was receiving I would
know what to do
The service I have received
could be improved in some
way
97
30
3
1
110
2
1
1
98
28
4
1
99
27
1
2
104
23
0
3
77
32
7
7
26
9
8
71
Page 33 of 37
PATIENTS DISCHARGED FROM THE INPATIENT UNIT
Question
Strongly agree Agree
Neither agree nor Strongly
disagree
disagree
I was satisfied with the care
and treatments I received
68
4
1
0
I always felt that I knew what
was going on
59
8
2
1
The service I received could
be improved in some way
15
6
8
35
COMMUNITY PALLIATIVE CARE TEAM
Question
Strongly agree Agree
Neither agree nor Strongly
disagree
disagree
I have found the staff
approachable
84
9
0
0
I have been given the
opportunity to discuss my
care and treatments
80
14
0
0
I have been able to express
any issues or concerns I had
81
13
0
0
The Community Team is
doing everything I would
expect them to do
81
13
0
0
DAY HOSPICE
Question
Strongly agree Agree
Neither agree nor Strongly
disagree
disagree
My recent visits have been
satisfactory
57
12
0
0
I understand the reasons for
attending Day Hospice
53
15
0
1
I understand what the hospice
is trying to achieve for me
53
14
2
0
The service I received could
be improved in some way
3
4
12
47
Page 34 of 37
SOME OF THE POSITIVE COMMENTS WE RECEIVED:
•
‘My CNS has been absolutely vital in me keeping my sanity at this awfully heartbreaking time.
Her support, care and love is second to none and I couldn’t have got through this without her.
Don’t let them leave please. If anything support them because honestly I couldn’t get through
this without them’
•
‘Service excellent, I could not fault the care and understanding. Very compassionate and
hardworking staff and also volunteers’
•
‘Can’t improve on perfection’
•
‘I was a bit anxious to come to Day Hospice but the kindness and professionalism of everyone
has helped me enormously. I don’t know how things could possibly be improved’
LEARNING AND ACTIONS
Throughout this exercise we gathered important information from our patients and as a result we
were able to make improvements in some areas.
Page 35 of 37
3.5 BENCHMARKING ACTIVITY
With regard to the safety dimension of quality, the West Midlands region is collating data on a
monthly basis in the following areas:
•
•
•
•
•
Percentage occupancy
Pressure ulcers
Slips, trips and falls
Infection control
Deaths and discharges
The West Midlands Hospice Nurse Managers Group (WMHNMG) scrutinise the data n a quarterly
basis. Following reflective discussion, the WMNM are in agreement that there is consistency
between the hospices in the West Midlands region.
Through this process of continuous quality monitoring, the WMHNMG would quickly identify any
significant differences between hospices and act to identify the underlying cause(s).
Page 36 of 37
STATEMENTS ON BIRMINGHAM ST MARY’S HOSPICE QUALITY
ACCOUNT FOR 2012/13
Cross City CCG
We have been unable to obtain a statement from Cross City CCG as a Commissioner for
End of Life Care has yet to be appointed. Their statement will be inserted in due course.
Senior Commissioning Manager for End of Life Care (Sandwell & West
Birmingham CCG)
As previous years, the hospice is to be congratulated yet again on its achievements. It is clear that
the Hospice listens well to feedback from the people / families who have used the service. The
recognition and the continuing focus on workforce is excellent as is the refurbishment work that
has taken place to improve the physical environment - supporting the known social benefits of the
environment on physical and mental wellbeing. It is also clear that the Hospice has an excellent
model for Day Hospice and that the Leaders within the organisation respond and react to the
needs of the local health population they provide services for.
The priorities identified for the next 4 years are in line with the direction of travel of the CCG. The
Hospice has continued to work with other organisations and Commissioners as part of a wider
network to ensure we can provide the best quality services possible.
On that basis, I have no hesitation in supporting this quality account as it reflects local priorities
and their response for delivering those priorities.
FEEDBACK AND COMMENTS
If you would like to provide feedback on the report or make suggestions for content for future
reports, please contact:
Helene Trebinska
Governance Manager
Birmingham St Mary’s Hospice
Tel: 0121 472 1191
Email: helene.trebinska@bsmh.org.uk
Page 37 of 37