Earl Mountbatten Hospice Quality Account 2013 An independent charity providing healthcare for the Isle of Wight Community, we support and care for people living with and dying from a life limiting illness “We aim to provide the very best patient-centred care, and ensure that our patients remain at the heart of everything we do” Earl Mountbatten Hospice Nursing Strategy 2012 - 2015 Contents Part 1 1.1 Part 2 2.1 2.1.1 2.1.2 2.1.3 2.2 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 2.2.6 2.2.7 2.2.8 Part 3 3.1 3.1.1 3.1.2 3.1.3 3.2 3.3 3.4 Chief Executive’s Statement on Quality Priorities for improvement for 2013/14 Priority 1: Patient Safety - documentation Priority 2: Clinical Effectiveness – non-malignant diagnosis referrals Priority 3: Patient Experience - the new Earl Mountbatten Hospice John Cheverton Centre Day Services Statements of Assurance from the Board Review of Services Participation in Clinical Audits Trustee Unannounced Provider Visits Participation in Clinical Research Goals Agreed with Commissioner What Others Say about the Provider Data Quality Quality Indicators Review of Quality Performance for 2012/13 Priority 1: Patient Safety Priority 2: Clinical Effectiveness Priority 3: Patient Experience Statements provided by Commissioning CCG, Healthwatch and the Overview and Scrutiny Committee Statement of Directors’ Responsibilities How to Provide Feedback on this Quality Account Page 3 4 4 4 4 5 5 5/6 6-9 10 10 10 11 11 - 13 13 13 13 13/14 14/15 15 - 17 18 19 20 2 PART 1 1.1 Chief Executive’s Statement on Quality I am delighted to introduce this, the first Quality Account produced by Earl Mountbatten Hospice, which is a testimony to the expertise and endeavour of its staff and volunteers. Above all else at Earl Mountbatten Hospice we strive to meet the needs and preferences of our patients, their family and friends. We do this by offering services and support that exceed all expectations, enabling our Island community to feel safe in the knowledge that they will be well cared for when they need us most. This Quality Account allows us to demonstrate formally the high professional standards that are achieved by all our multidisciplinary teams, those working in the local hospital and the surrounding community as well as within the Hospice. This formality of process in relation to clinical and corporate governance is evidence of the commitment we have to providing high quality patient care. Our first Quality Account sets out the priorities for improving quality during 2013/14, including a focus on strengthening record-keeping, understanding patient experience in our new day services in the EMH John Cheverton Centre and ensuring we are providing specialist palliative care to patients with conditions other than cancer. We have also reviewed some of our successes during 2012/13, including the introduction of a strengthened telephone advice service, improving access to specialist palliative care services seven days a week and the introduction of a real time patient survey within our inpatient unit. 2012 was not without its challenges and in the Autumn a routine unannounced inspection visit from the Care Quality Commission identified a need to improve record keeping at Earl Mountbatten Hospice, whilst acknowledging that patients were very positive about their care when they spoke with the inspection team. Immediate action was taken to address their concerns. The philosophy at the heart of our organisation is one of abundance: our multidisciplinary team members have more time for hands-on patient care, our therapists have more time to give holistic treatments, our support staff work hard to facilitate time to attend to the important details and our volunteers have the time to go the extra mile! I am proud to be associated with Earl Mountbatten Hospice, to be able to recognise publicly and formally the hard work, commitment and achievements over the past year, to look forward to the developments for the coming year, improvements and upgrades to other areas of the site and the integration of our community nursing services. Together, all of these will help towards supporting a seamless overarching service to reach anyone on the Isle of Wight requiring specialist palliative care services. Despite the current economic climate, the Hospice has continued to be able to provide a high quality, cost effective, specialist service to patients and their families. The Board of Trustees and I would like to thank all our Staff and Volunteers for their achievements in providing this quality of service. The last word must go to the whole Island community, without whose constant efforts and generosity we simply would not survive. A supporter once said “The commitment of staff and volunteers in providing a five star service at Earl Mountbatten Hospice is outstanding, it shines like a beacon and should be used to set the standard for all healthcare professionals”. As Chief Executive of Earl Mountbatten Hospice, I am responsible for the preparation of this report and its contents. To the best of my knowledge the information contained therein is an accurate and fair representation of the quality of the healthcare services provided by Earl Mountbatten Hospice. Tina Harris, Chief Executive Earl Mountbatten Hospice 3 PART 2 2.1 Priorities for Improvement Priorities for improvement for 2013/14 Earl Mountbatten Hospice, in consultation with key stakeholders, has identified three key priorities for quality improvement during 2013/14. These priorities have been selected as they build on work already underway within Earl Mountbatten Hospice and are areas that can be measured to demonstrate how improvements have been achieved and reported in the next Quality Account. Performance against all of these priorities will be reported to and monitored by the Patient Services Committee on a quarterly basis. The priorities for quality improvement we have identified for 2013/14 are set out below. 2.1.1 Patient safety - Documentation During 2012 it became apparent that nursing documentation was not meeting the needs of patients and staff, and following an inspection by the Care Quality Commission (CQC) it was apparent that a complete review was needed. The CQC had highlighted that they could see patients were receiving high quality care but this was not adequately documented. In light of this a new set of documentation has been developed for implementation from 1st April 2013 to support individualised patient care. The documentation is intended to be used by all the teams working at or from Earl Mountbatten Hospice. The aim of this priority area is to ensure patients receive a thorough assessment and appropriate individualised care planning that is documented correctly and meets local and national guidelines. Measures: • • Monthly audits to test appropriate completion of documentation Monthly audits monitoring that care plans reflect individualised care. 2.1.2 Clinical effectiveness – non-malignant diagnosis referrals Earl Mountbatten Hospice does not just provide palliative care services to people with cancer. During 2013/14 we are further developing our enhanced service to increase the number of patients able to benefit from the hospice services and care. This will mean people who have a non-cancer diagnosis but need specialist palliative care should be able to access our services. A robust referral and admission criteria is being developed and a training programme will need to be developed to ensure any gaps in the knowledge of staff caring for this wider patient group can be met. Measures: • • • Compare number of referrals for patients with a non-malignant diagnosis during 2013/14 with referrals for the same patient group during 2012/13 with analysis by month Monitor the referrals received representing specific diagnosis to allow investigation of reasons for non-referrals from those specialties not referring Develop a training needs analysis and an appropriately targeted training programme for management of patients with non-malignant diagnosis to ensure patient needs can be appropriately met. 4 2.1.3 Patient experience - the new Earl Mountbatten Hospice John Cheverton Centre Day Services On the 12th October 2012 the new EMH John Cheverton Centre was formally opened. The Centre provides day services for specialist palliative care patients. The service aims to provide flexible and holistic palliative care tailored to the individual’s needs within modern and inspiring facilities, giving a seamless comprehensive service, enhancing patient care and improving patient experience. As this is a new service, our Trustees feel it is vital to ensure that it meets the needs of service users. This will form the basis of the patient experience priority, focusing on the experience of services used, including availability and timeliness of services for an individual patient. Measures: • • An ongoing patient survey, with questions designed to reflect the care received, with quarterly reports A monthly audit to understand the availability and timeliness of services for the individual patient and whether this is meeting the needs of service users. 2.2 Statements of Assurance from the Board 2.2.1 Review of services During 2012/13 Earl Mountbatten Hospice provided specialist palliative care services within the following areas: • • • • • • • Inpatient Unit Palliative care services at the EMH John Cheverton Centre Community Outpatients Patient’s own home District General Hospital Nursing/Residential Homes. These departments were supported by the following services: • • • • • • • • • • Community Nurse Specialists Hospital Palliative Care Team Hospice @ Home Mountbatten Nursing Services Physiotherapy Occupational Therapy Complementary Therapies Psychological Services Chaplaincy Education. The provision of care across all settings is underpinned by the ethos and provision of high quality education and training. Earl Mountbatten Hospice staff are supported in their mandatory training requirements and are actively encouraged to advance their continuing professional development. 5 During 20012/13 the Earl Mountbatten Hospice provided four NHS services; these are as follows: 1. 2. 3. 4. Specialist Palliative Care Hospital Palliative Care Community Palliative Care Lymphoedema Service. Earl Mountbatten Hospice has reviewed all the data available to them on the quality of care in these four NHS services. Of the total income received by Earl Mountbatten Hospice 35% was funded by the NHS. 2.2.2 Participation in Clinical Audits National Clinical Audits During the period 2012/13 there have been no national clinical audits and no confidential enquiries relating to the services that Earl Mountbatten Hospice provides, so the Hospice did not participate in any national clinical audits and national confidential enquiries. Regional Audits In line with regional guidance from the Central South Coast Cancer Network (CSCCN) Earl Mountbatten Hospice undertook an audit of Out of Hours telephone calls to the service. Aims/objectives • • • • • Highlight any need for change to the template of the existing form Inform how many calls are received, Assess the time of calls received out of hours Establish the category of person requesting advice Establish the type of advice requested. Findings Seventy-seven forms were identified as the representative number of forms for inclusion in the audit of ‘Record of out of hours contact to specialist palliative care services’, thus N = 77 FIELD TO BE COMPLETED ON EVERY FORM NAME DATE TIME OF CALL REASON FOR CALL CALL RECEIVER DETAILS CALLER ADVICE GIVEN DURATION OF CALL CONTACT AREA (HOSPICE, H@H) ACTION TAKEN EXPECTED % 100% 100% 90% 100% 100% 100% 100% 80% 80% 100% N= 77 77 77 77 77 75 77 77 77 77 76 ACTUAL% 100% 100% 100% 100% 97% 100% 100% 100% 100% 99% 6 Observations The form had been changed to reflect the findings from the previous audit. Good practice points • • • The form was well completed in all but two cases The information was well recorded overall The percentage overall was very high. Areas for improvement It is not possible to know how many calls went unrecorded over the three-month period. Recommendations • • To ensure staff are informed of completing more accurate data, and much improved results To endorse the need for the advice sheets to be used at any time of the day. Local Clinical Audits Earl Mountbatten Hospice undertook several audits during 2012-13 creating, developing and utilising the Help the Hospices’ audit tools. These included Management of Controlled Drugs, General Medicines and Nutrition. The tools were relevant to the particular requirements of hospices, allowing our performance to be benchmarked against that of other hospices. The reports of 17 local clinical audits were reviewed by the provider in 2012/13 and Earl Mountbatten Hospice intends to take the following actions to improve the quality of healthcare provided. Audit Title Recommendations Infection control - Equipment The audit demonstrated 100% compliance with all infection control policies and procedures Infection control – Peripheral Venous Access Device policy Infection control - Ward Kitchen Infection control - Personal Protective Equipment (PPE) Infection control - Commodes Infection control - Sharps Hand hygiene was assessed and received a 100% compliance rating; however it is recommended for best practice that the doctors are issued with doctors coats as a measure of PPE The audit also highlighted that there is the need to introduce a programme of education with regard to the new clinical waste system recently introduced Infection control – Clostridium difficile policy audit Infection Control - Hand hygiene Out of Hours Telephone Calls Audit The introduction of the out of hours telephone calls recording algorithm has improved the documentation of reported concern and advice given. Since March 2013 staff complete forms over a 24 hour period regarding advice requests and advice given in order to ensure that all out of hours palliative care advice is recorded in an accurate and timely manner 7 Liverpool Care Pathway Audit Mortality Review Medication Errors Prescribing Audit Controlled Drugs Pressure Area Care Venous thromboembolism (VTE) assessment Record Keeping / Care Plan Documentation Non-malignant diagnosis referrals Accountable Officer Recommendation from the Hospice Medical Team that the Liverpool Care Pathway should be replaced with an ‘End of Life Care Plan’ in order to ensure excellent clinical care at the end of a patient’s life This is a National Requirement and the review looks at the reported cause of death for all patients in addition to the care the patient received 60% of all reported medication errors are due to prescribing errors – this has been addressed through the implementation of a new medication administration chart The audit looked at the current prescribing practices within the inpatient unit; the recommendations from the audit were to re audit when the revised medication charts are fully embedded, and medication round times are reviewed To establish good practice regarding the prescribing, administration, record-keeping and safe storage of controlled drugs within the in-patient ward at EMH. It is recommended that individual Patient Own Drugs lockers are installed within each of the patient’s rooms The audit identified that 100% of patients are risk assessed upon admission to the inpatient unit; however it was identified that there were a few discrepancies in the grading of pressure areas and Waterlow scoring. To address this additional tissue viability training has been provided to all nursing staff so that they are fully conversant with current best practice 100% of patients are assessed for VTE risk upon admission to the EMH inpatient unit; VTE risk assessment has been incorporated within the new inpatient paperwork as well as a reminder prompted on the front of the revised inpatient administration chart Ensure staff populate newly introduced documentation for EMH for all new admissions within the agreed timeframe. Regular monitoring and feedback meetings will be held to promote ongoing compliance Promotion and networking with the clinical nurse specialists from the NHS IW Trust and GPs will continue in order to offer more services to more people for more of the time To comply with National Guidelines and to assure the EMH Trust Board that the Hospice meets regulatory requirements in respect of the safe custody and management of Controlled Drugs For patients to be responded to in an appropriate and timely manner at the first point of contact with EMH Referral response rate The audit identified that there was a need to enhance information and understanding of referrers to EMH services. All Island GP practices were visited by a senior hospice nurse and contacted by one of the consultants in palliative medicine 8 The audit identified that there were areas of good practice regarding food and nutrition, including the documentation of personal preferences, as well as the efficient mealtime service offered via the volunteers Food and nutrition Preferred place of care Do Not Attempt Cardio Pulmonary Resuscitation - documented discussions Controlled Drugs Reconciliation with the Controlled Drug register Discharge Summary Audit The recommendations from the audit include a requirement to support and improve patient choice and timing of meals to promote individualised care. Each patient will be assessed on admission to identify any specific dietary requirements and to highlight any patient who may require help with additional nutritional needs The audit found that the preferred place of care was not always well documented, or was difficult to locate within the patients notes. Preferred place of care is now included as part of the initial assessment on the revised clinical documentation in order to address this outcome At the time of the audit it was found that 50% of patients did not have a documented discussion regarding their resuscitation status. New clinical documentation has been introduced and patients’ CPR status is reviewed only on a weekly basis; doctors are to be included as part of the discharge planning process to ensure that patients, where appropriate, are aware of their resuscitation status The recommendations from the audit are to review the destruction procedures of controlled drugs currently in place within the inpatient unit at EMH The audit highlighted that the discharge planning paperwork was too onerous and did not meet all requirements. It is recommended to revise discharge-planning paperwork to include medical input at the point of discharge to ensure that patients are fully informed of their condition and options available to them. Good practice points included 100% of patients receive appropriate referrals to other teams prior to discharge from the EMH inpatient unit, 75% of patients are referred for palliative care day services at the EMH John Cheverton Centre A clinical audit programme has been developed and agreed following identification by staff and Trustees within the organisation of the need for quality information and feedback. This has been obtained from the service users, the staff and significant others by using audit tools, real time patient surveys, ideas and suggestions from visitors, volunteers and any other people who may come in contact with the hospice services. Their input has proved invaluable in endorsing the areas where we do well, together with suggestions for any possible areas of improvement. The clinical audit programme gives ownership and empowerment to staff by encouraging them to conduct the audits and implement any changes required following presentation of results and team discussion. This is a rolling programme and quality standards will be affected by gaining, evaluating and publishing valuable data, thus enabling an informed and coordinated approach to care provision. 9 2.2.3 Trustee Unannounced Provider Visits Members of the Board of Trustees regularly undertake unannounced visits to gain insight into our hospice services. Members of the Board talk to patients, their relatives/carers and staff members and ask them to share their views and experiences; the following two examples are from the past twelve months: “Several members of staff, when asked, were very impressed by the preparations being made for the new information centre within the new day services centre” “On the wall in the relatives room is a ‘suggestions tree’ dedicated to a past patient; this is a new and excellent addition to gain feedback” 2.2.4 Participation in Clinical Research There were no opportunities for Earl Mountbatten Hospice to participate in any local or national ethically approved research or clinical trials. 2.2.5 Goals Agreed with Commissioners The Commissioning for Quality and Innovation (CQUIN) payment framework enables commissioners to reward excellence by linking a proportion of provider’s income to the achievement of local quality improvement goals. A proportion of Earl Mountbatten Hospice’s income in 2012/13 was conditional on achieving quality improvement and innovation goals agreed between EMH and the Isle of Wight PCT. The two organisations entered into a contractual agreement with the provision of NHS services, through the CQUIN framework. During 2012/13 Commissioning for Quality and Innovation offered EMH the opportunity to secure 1.5% of its funding set aside by commissioners against CQUIN measures, to be paid annually in Quarter 4 on provision of satisfactory reports. EMH successfully achieved all three of the CQUIN measures for 2012/13. CQUIN Schemes 2012/13 Achieved Increase referrals to the specialist palliative care service for noncancer patients. Visit every GP practice on the Isle of Wight to promote referral criteria for non-malignant diagnosis patients at the end of life, including community, day services and inpatient admissions Yes Assessment of patients’ needs on admission to the Hospice will include a documented assessment of tissue viability, VTE risk assessment and nutritional needs Yes Record and audit Out of Hours (OOH) telephone calls for specialist palliative care advice to establish recommendations and action plan to improve OOH advice service Yes 10 2.2.6 What Others Say about the Provider Statements from the Care Quality Commission Earl Mountbatten Hospice is required to register with the Care Quality Commission (CQC) and its current registration status is registered. Earl Mountbatten Hospice has no conditions on registration. The CQC has not taken enforcement action against Earl Mountbatten Hospice during 2012/13. Earl Mountbatten Hospice has not participated in special reviews or investigations by the CQC relating to the following areas during 2012/13. During October 2012 Earl Mountbatten Hospice was subject to a routine unannounced inspection by the CQC. During that inspection the inspectors confirmed that the Hospice was compliant with five of the seven standards that were reviewed at that time. There were two areas of concern identified. These two areas related to respecting and involving people who use services and the care and welfare of people who use the service. The CQC stated in their report that people told them the standard of care was ‘fantastic’ and that although staff at times were a bit rushed they were always kind and respectful. People told the CQC inspectors that staff were available when people needed them, knew what care they required and that they felt safe and their privacy was respected. The CQC found that people were not always fully consulted about their preferences and fully documented care plans were not in place for all people. Earl Mountbatten Hospice has taken the following action to address the recommendations reported by the CQC. Immediate action was taken to review the issues identified with the clinical teams at the Hospice and an action plan put in place. The actions included a series of workshops with a senior nurse advisor and the development of new patient records to support easier care planning at the Hospice. Actions were also taken to ensure that patients’ needs and preferences were clearly documented and appropriate written care plans put in place. As at 31st March 2013, Earl Mountbatten Hospice has introduced a new set of patient records and provided staff with additional education and training to address the concerns identified. 2.2.7 Data Quality Minimum Data Set The Minimum Data Set (MDS) for Specialist Palliative Care Services is collected by the National Council for Palliative Care (NCPC) on a yearly basis, with the aim of providing an accurate picture of hospice and specialist palliative care service activity. It is the only annual data collection to cover patient activity in specialist services in the voluntary sector and the NHS in England, Wales and Northern Ireland. The MDS was developed in 1995 by the NCPC in association with the Hospice Information Service at St Christopher’s Hospice and is now coordinated by the NCPC’s Information Analyst. The questions included in the MDS have been revised recently so that it remains as relevant and useful as possible. Collection of the revised MDS data began in 2008/09. The Minimum Data Sets for specialist palliative care services are now being collected annually to achieve an accurate picture of the activity within hospice and specialist palliative care services for the Isle of Wight community. For the year 2012/13 the Earl Mountbatten Hospice submitted audit data to the National Minimum Data Set for specialist palliative care. More information on the minimum data set is available from the National Council for Palliative Care: www.ncpc.org.uk 11 The most recent data available from National Council for Palliative Care was made available in December 2012 and relates to the year 2011/12. Review of this information, which includes benchmarking with similar sized services and inpatient units, highlights the following information about Earl Mountbatten Hospice Services: • Inpatient services during 2011/12 - 269 patients were admitted compared to a national average of 217 placing Earl Mountbatten Hospice above the 75th percentile. The majority of patients were aged 65 years or over, with 13.9% of patients being over 84 years of age (national average 11.2%). Only 4.8% of patients had a non-cancer diagnosis (national average 9.9%). The length of stay for cancer patients was just under the national average at 11.5 with the national figure being 12.6. • Day care services had a total of 106 patients against a national average of 84. The age profile was similar to that of the inpatient services. • The Community Specialist Palliative Care Nurses saw more patients than most services, being above the 75th percentile, with 531 patients compared to a national average of 416. The average length of care was almost in line with the national average with a figure of 93 (93.6 national average). • The Hospital Palliative Care team saw 319 patients, 47 more than the national average, with an average length of care of 13.0 (national average 10.2). • All patients attending an outpatient clinic were seen by a medical consultant compared to a national average of 57.3%. • Hospice @ Home services saw 32 patients with a non-cancer diagnosis, in line with the national average. The average length of care provided by the team was 57.0 compared to a national average of 37.5. Information Governance Information Governance allows organisations and individuals to ensure that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care. It provides a framework to bring together all of the requirements, standards and best practice that apply to the handling of personal information, allowing: • Implementation of Department of Health advice and guidance • Compliance with the law • Year on year improvement plans. The focus is on setting standards and giving organisations the tools to achieve these standards The goal is to help organisations and individuals to be consistent in the way they handle personal information and to avoid duplication of effort. This will lead to improvements in: • Information handling activities • Patient confidence in healthcare • Employee training and development Earl Mountbatten Hospice clinical staff meet the information governance requirements set down by the Isle of Wight NHS Trust, which is their employer, as the staff are outposted to Earl Mountbatten Hospice. During 2013/14, the Hospice intends to develop an action plan to achieve information governance training for the whole organisation by 31st March 2014. 12 Payment by Results The Payment by Results clinical coding system is not applicable to Earl Mountbatten Hospice and therefore was not subject to such an audit during 2012/13 by the Audit Commission. 2.2.8 Quality Indicators Earl Mountbatten Hospice has reviewed the latest Quality Account guidance issued by the Department of Health in January 2013 and the following quality indicators are relevant to the services it provides. Earl Mountbatten Hospice considers that this data is as prescribed for the following reason: it has been gathered from hospice information systems and validated by the Governance and Risk Manager. Earl Mountbatten Hospice intends to take the following actions to improve this number and thus the quality of its services by instigating into its staff survey a question about recommending the Hospice as a provider of care to their family and friends during 2013/14. The table below represents the number of patient safety incidents during 2012/13. Outcome 5 Treating and caring for people in a safe environment and protecting them from avoidable harm Number of patient safety related incidents reported in 2012/13 80 Number of such patient safety incidents that resulted in severe harm or death 0 The 80 patient safety related incidents relate to medication, slips trips and falls, infection control and pressure ulcers. Not all these incidents relate directly to the Hospice as some were reported within the first 24 hours of admission and the problem is likely to have occurred preadmission. PART 3 3.1 Review of Quality Performance for 2012/13 As this is the first Quality Account for Earl Mountbatten Hospice, three areas of development during 2012/13 have been selected for the review of quality performance. 3.1.1 Priority 1: Patient Safety Out of Hours Telephone Advice Staff working on the inpatient ward at Earl Mountbatten Hospice have always freely given advice and support to any person asking for help; however, this was not a formally monitored service until 1st April 2012 when a data collection form was introduced to capture the advice given in a more quantifiable way. How was this identified as a priority? This priority was identified as one of our CQUIN targets for 2012/13. An audit of the out of hours telephone advice was agreed which would capture not only the number of calls received but the type of advice requested, and the people asking for that advice. The purpose of this priority was to assess the current practice regarding out of hours calls taken by the nursing office in the inpatient unit at the Hospice. The aim was to gain baseline knowledge of existing practice as there was no evidence available of the quality and type of previous advice and support given. With the new specialist palliative care quality measures being introduced by the National Cancer Action Team there was an identified need to enhance the service to ensure that patients and their carers were receiving high quality support and advice. 13 The CQUIN was worded as follows: Increase the number of out of hours telephone calls to the Hospice for specialist palliative care advice. How was this priority achieved? An initial audit of telephone advice was carried out on a draft form and once this had been analysed a more comprehensive carbonated form, allowing copies for known patients and audit purposes, was designed. The advice given to the person calling in can be patient-related, equipment-related or for symptom control, the persons calling in can range from the patient themselves to an on call General Practitioner. Any call that is received after 1700 hrs and before 0900 hrs Monday to Friday, and any time over the weekend, is recorded as out of hours. There are a series of questions and free text boxes on each form to ensure that a good overall record of each call can be documented. If the patient is known to the service the top copy of the form can be placed in the patient’s notes for reference, any follow ups can be highlighted and an audit trail developed. The out of hours forms are triple-carbonated and record the time, the person requesting advice, the kind of advice given and whether the patient is known to the service. The forms are audited quarterly and the results are analysed, reported, shared with the senior team and actioned as necessary. One recommendation put forward and actioned was that not only out of hours advice should be recorded, but all advice given at any time should be captured and audited. This is now in place and a quarterly audit of this process will continue as part of the annul audit programme. 3.1.2 Priority 2: Clinical Effectiveness To provide 7 day week cover from the Palliative Care Clinical Nurse Specialist Team (Community and Hospital) How was this identified as a priority? One of the strengths of the service Earl Mountbatten Hospice provides is that the clinical frontline staff constantly strives to find ways of improving the patient experience. The Board of Trustees and Senior Management Team of the Hospice fully recognised the importance of adapting to changing needs and finding more effective ways of achieving those aims. Reflecting a key purpose within the Earl Mountbatten Hospice Business Plan and building on the aims and objectives set out in the Hospice Strategic Direction, there was an identified need to enhance nursing innovation, efficiency and service development. More recently, through a recognition that needs of people at the end of life cannot be met in a standard nine to five model of clinical nurse specialist service delivery, it became necessary to review and adjust patterns of established working for the Hospital and Community Clinical Nurse Specialists. The aims of this priority were: • • • • • • Ensure service users have access to palliative care services seven days a week, in line with National Institute for Health & Care Excellence Ensure service users are cared for in their place of choice Reduce the number of inappropriate hospital admissions for end of life care patients by ensuring adequate services are provided in the community Help increase the numbers of deaths at home (including care homes) Ensure effective service coordination through improved communication between services and response to advice and support from the Urgent Care Hub Provide practice-based training to support the implementation of the End of Care Life Care Training Programme. 14 How was this priority achieved? The Clinical Nurse Specialist (CNS) community and hospital rosters were re-organised and extended in order to provide one CNS to cover both St Mary’s Hospital and the community at weekends and bank holidays. The service offers specialist assessment, advice and support to patients, carers and the multi-disciplinary team. The CNS is supported by the on call Consultant in Palliative Medicine and Hospice at Home senior nurse. The new service provides an extension to community care services offering support and care in the community, allowing service users to remain in their place of choice. It also supports the avoidance of inappropriate hospital admissions through the provision of palliative care advice and support, seven days a week. Additionally it has facilitated prompt discharge from hospital to ensure patients die in their place of choice, fulfilling the relevant end of life care targets. Finally there has been training provided to a range of groups, helping to implement the End of Life Care Training Programme. The service commenced in May 2012 and has been successfully implemented. One of the CNS’s commented: “The service has been a real success, patients and professionals feel more confident knowing that someone is there if needed. We have managed to keep a number of patients at home who would have otherwise been admitted to hospital. We do go out on calls to see patients where appropriate and ensure that we are contactable by mobile phone when we are away from the Hospice. It has been a really valuable service and I don’t know why we didn’t do it sooner.” 3.1.3 Priority 3: Patient Experience Real Time Patient Survey How was this identified as a priority? Earl Mountbatten Hospice staff aspire to deliver the highest quality patient care and wish to be informed of any suggestions of how care delivery may be enhanced. The most effective way to achieve this information is by asking for feedback. Undertaking a real time patient survey was felt to be appropriate as the annual survey completed previously had a poor response rate and there is more value in gathering patient views at the time rather than some time after their admission. How was this priority achieved? The questions were decided by a group of senior managers who were tasked to think about what matters most to the patient and how we could gain that valuable information using the least amount of questions. Once the questions were agreed upon, a meeting to discuss outcomes was planned to be held six weeks after the launch. The real time patient survey is carried out via Survey Monkey and consists of nine questions plus one free text box for any comments that a patient wishes to share. This ensures that any actions identified can be actioned straightaway without the 12-month gap in-between surveys. The survey is given to as many patients as possible who are inpatients. Volunteers carry out the survey as it was felt that this would give a more robust non-bias result as the nursing staff could possibly influence answers as they would be organising the individualised patient’s care. The survey is carried out on paper, and is also available for patients to fill in on the ward iPad should they desire. The survey is anonymous, although the patient’s room number is logged on the survey and dated, to exclude repetition. 15 Once completed, the surveys are given to the Governance and Risk Manager who then writes a report that is shared with the senior managers for actions as appropriate. The resulting themes and identified actions planned are reported to the Patient Services Committee, which meet quarterly to discuss the service we deliver to our patients and those around them. The graph below outlines the responses in detail and it is good to note that on three questions over 90% of patients were very satisfied; these questions relate to the patient’s room, the engage-ment with the patient and their relatives and the privacy and dignity afforded to patients by staff. The survey commenced in September 2012 and 28 patients have completed the questionnaire since that time. The results suggest that overall patients are satisfied or very satisfied with the care they received. One patient had concerns about contact with medical staff and this was resolved with the patient at the time. The survey can be updated at any time and questions changed to reflect what the service needs to know; this gives a thorough and up to date picture of how we are doing through the eyes of the patient and is invaluable in our mission to provide the very best individualised patient care. These surveys will continue as the consistent quality provided by our services is always our priority. Patients also have space to add comments, some of the comments received so far include: 1. Overall, the facility is wonderful, better than expected 2. I could not ask for better care, friendly and caring staff 3. Has not seen a doctor since Monday (four days) 4. They are all brilliant! 5. Would like longer visitation from visitors 6. Hospice much better than St Mary's, staff have more time for patients 7. Unaware that I could ask for different food that was not on the menu 8. Generally satisfaction all round, kind, caring staff 9. Could not be better, very impressed 10. The view from Bedroom 1 would be nicer with some greenery such as shrubs/pot plants 11. Wonderful 16 Actions to date: 3. Concerns highlighted to inpatient consultant 5. Visiting outside of normal hours can be made by arrangement with the ward staff or nurse in charge. This information is located within the Inpatient Booklet. 7. The Housekeeping team leader has been informed and this information has also now been included in the Inpatient Booklet. 10. This comment has been passed to the Facilities Manager for action. During 2013/14 Earl Mountbatten Hospice will continue to monitor performance against these survey results and drive improvements in patient satisfaction. From the 1st April 2013 the ‘friends and family’ question will be added to the survey in line with national requirements. 3.2 Statement provided by NHS Isle of Wight Clinical Commissioning Group Commissioning CCG Statement in response to Earl Mountbatten Hospice (EMH) Quality Account 2012/2013 The Isle of Wight Clinical Commissioning Group (CCG) welcomed the opportunity to participate in the governance ‘sign-off’ process and provide a statement in response to the presented Quality Account. The Quality Account was widely shared with Heads of Commissioning and Clinical Leads within the Clinical Commissioning Group for their comments. The CCG recognises that this is the first Quality Account to be produced by EMH; they commend EMH for reflecting on their achievements and challenges within 2012/2013, as well as identifying key priorities for 2013/2014 which will take the service forward, recognising some of the unmet palliative care needs of Island residents with non-malignant conditions and those of children, their families and carers. The CCG supports the three priority areas, which touch on all aspects of quality: • • • Patient Safety – documentation Clinical Effectiveness – non-malignant diagnosis referrals Patient Experience – the new EMH John Cheverton Centre Day Services With respect to clinical audits, the CCG note the development of a clinical audit programme and would be interested to see examples of proposed audits cited within the Quality Account. The Quality Account presents data on the number of patient safety incidents recorded in 2012/2013 and provides an insight into the types of incidents. It would seek reassurance on how EMH acts upon and learns from these incidents and how patients and their relatives and carers are made aware of such incidents. Arising from the subject of patient safety incidents, the CCG would also like EMH to acknowledge pressure sore prevention and management as an important aspect of patient care for the population they serve, which is in line with the quality aspirations of other health providers on the Isle of Wight. With regard to this the CCG would ask EMH to consider engaging with the National Safety Thermometer CQUIN and the National Requirement of reporting grade three and grade four pressure ulcers in accordance with the National Patient Safety Agency’s Serious Incident Requiring Investigation (SIRI) guidelines, during 2013/2014. One comment also suggested that the Quality Account took into consideration risks associated with the loss of staff and the challenge of recruiting replacement staff. 17 The real time patient survey reports that the questions were decided by a group of senior managers. Whilst a good starting point, in the future it might be seen as good practice to involve patients and carers in the formulation of these questions. Overall, the Isle of Wight Clinical Commissioning Group would commend the Quality Report as a fair reflection of the Hospice’s positive achievement across the quality agenda and the high level of commitment and effort to constantly improve the quality of services provided. As a consequence of this Quality Account, the priorities set within will be monitored by Commissioners as part of the CCG performance management of EMH through Contract Review Meetings, which will also review EMH CQUINS and other NHS contractual quality outcomes. This process is intended to support EMH in continuing to improve the services they provide. 3.3 Statement of Directors’ Responsibilities The Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 requires the Directors to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the above legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010, (as amended by the National Health Service, (Quality Accounts) Amendment Regulations 2011). In preparing the Quality Account, Directors are required to take steps to satisfy themselves that: • • • • • The Quality Report presents a balanced picture of the Trust’s performance over the period covered the performance information reported in the Quality Account is reliable and accurate there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review, and the Quality Account has been prepared in accordance with Department of Health Guidance The Directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account. 3.4 How to Provide Feedback on this Quality Account This important document sets out how we continue to improve the quality of the services we provide. Your Views on Quality We welcome your views and suggestions on our Quality Priorities for 2013/14 as set out in Part 2 of this Quality Account. We welcome feedback at any time on our Quality Account; please contact Mrs Tina R Harris, Chief Executive on 01983 529511 or email chiefexec@iwhospice.org. You can read more about the national requirements for Quality Accounts on the NHS Choices or Department of Health websites. 18 You can download a copy of this Quality Account from http://www.hqip.org.uk/list-of-nationalclinical-audits-for-inclusion-in-quality-accounts-confirmed/ 19