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
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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%
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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
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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.
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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:
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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.
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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.
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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
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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:
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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.
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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:
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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.
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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/
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