.
Greenwich & Bexley Community Hospice
2012–2013 Quality Account
Son and daughter of patient, Blackheath
Version: 2.0 – June 2013
GBCH 2012-2013 Quality Account
Contents
Page
Part 1 – Chief Executive’s Statement
3
Part 2 – Priorities for Improvement and Statements of Assurance from the Board 4-16
2.1
Priorities for Improvement 2013 – 2014
4
2.2
Priorities for Improvement 2012 – 2013
9
2.3
Statement of Assurance from the Board
12
2.3.1
2.3.2
2.3.3
2.3.4
2.3.5
2.3.6
12
12
12
13
14
Review of Services
Income Generated
Participation in National Clinical Audits
Participation in Local Audits
Research
Quality improvement and innovation goals agreed with
our Commissioners
2.3.7 What others say about GBCH
2.3.8 Data Quality
2.3.9 Information Governance Toolkit Attainment Levels
2.3.10 Clinical Coding Error Rate
Part 3 – Review of Quality Performance
3.1
15
15
16
16
16
16-25
Comparison with National Minimum Data sets
16
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.1.6
17
18
19
20
22
23
Inpatients
Day Care
Home Care / Hospice at Home
Hospital Support Teams
Bereavement Support
Outpatients
3.2
Clinical Governance
24
3.3
Training
24
3.4
Supportive Care
24
3.5
Peer Review
25
3.6
Challenges
25
Appendix
Appendix 1: Greenwich
Appendix 2: Bexley
Appendix 3: London Cancer Alliance
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26
28
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GBCH 2012-2013 Quality Account
Part 1 - Chief Executive’s Statement
The Hospice has been serving the communities of Greenwich and Bexley boroughs
for 19 years and throughout this time, alongside the development and growth of the
services we provide; the organisation has tried to ensure that people who have a life
limiting illness receive the best possible quality of care. It is my pleasure to present
the Hospice’s first Quality Account which sets out our achievements for 2012/13 and
aspirations for the coming year.
The Hospice has moved from a service which focuses on delivering care within the
main building to providing flexible care and support in whatever setting it is required;
this includes care in people's homes, care homes, in hospital and at the Hospice. The
new Hospice integrated end of life care service for Greenwich residents has
enabled us to provide care which is tailored to each individual person’s needs and
has enabled more people to be supported at home surrounded by their family,
friends and their own environment. We hope that we will be able to work with others
in Bexley borough to deliver similar improvements for people with life limiting illness.
The Hospice is registered with the Care Quality Commission who carried out an
unannounced inspection on 16th January 2013 and the Hospice was compliant
against all of the Outcomes inspected.
We continue to work hard to ensure that Hospice premises reflect the quality care
we provide, and we are pleased that we were successful in a recent application to
the Department of Health for a grant towards more improvements in our building.
This dedicated capital funding will allow the Hospice to deliver some important
improvements to benefit patients, including the refurbishment of our kitchen and
courtyard garden, improvements to access to the Hospice building, provision of a
purpose-built rehabilitation gym and development of a community hub and care
coordination centre.
To the best of my knowledge, the information reported in this Quality Account is
accurate and a fair representation of the quality of healthcare services provided by
the Hospice.
Kate Heaps
Chief Executive
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Part 2 – Priorities for Improvement and Statements of Assurance from the Board
2.1 Priorities for Improvement 2013 – 2014
The following key Priorities for Improvement 2013 - 14 have been identified. These
cover the three quality domains of Clinical Effectiveness, Patient Experience and
Patient Safety:
Improvement Priority 1: Development of a Quality and Governance Dashboard
Why this was chosen as a Priority
The development of clinical dashboards was a key recommendation from both
Lord Darzi’s Next Stage Review (NSR) and the Health Informatics Review. The
concept of the “quality or clinical governance dashboard” is to ensure a clear
and visual tool to demonstrate that services being delivered are safe, effective
and have high levels of patient satisfaction. Patients, providers, commissioners and
policy makers need to have the best and most up to date information the Hospice
can produce and the dashboard is an effective way to monitor and report on
performance, activity and the quality of care in a transparent way that can
reassure patients, professionals and the public or improve confidence, for
example, MRSA rates etc
What is a Quality and Governance Dashboard?
The dashboard allows clinical staff, managers and Trustees to identify potential
problems that they need to focus on, which they otherwise may not know about
until they arrived in a clinical area. Quality and Governance Dashboards help to
drive this process by providing timely and relevant information for clinical teams,
presented in easy to understand formats, with high visual impact.
A variety of appropriate quality and activity markers are identified and reported
on at regular predefined intervals and can help to drive improvements by
encouraging a focus on specific areas.
What are the plans for this Priority?
To develop a common dashboard reporting format covering the four key areas of:
Patient Safety – CAS Alerts, NICE Guidance, Trips, Slips and Falls
Clinical Effectiveness – Incidence of Clostridium Difficile, MRSA, Pressure Sores
Patient Experience – Compliments, Complaints, Results of Patient & Carer Surveys
Workforce Data – Mandatory Training, Recruitment, Vacancies, Appraisals
In addition, the Hospice intends to report the level of clinical activity which is
delivered as part of the Dashboard.
How progress against the plan will be measured
Monthly and quarterly Dashboard templates have been agreed by the Quality and
Safety Committee. These will be used to populate the relevant information for the
specific areas and also report comments, updates and progress against action
plans. Quarter by quarter comparisons will be made, highlighting trends and
potential areas of concern.
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How progress will be reported
Monthly and quarterly Dashboards will be reported to the Quality and Safety
Committee and quarterly Dashboards will be presented to the Board of Trustees.
Improvement Priority 2: Launch a Patient & Carer Survey Programme
Why this was chosen as a Priority
Although Greenwich & Bexley Community Hospice (GBCH) collects and receives
various forms of feedback on services from patients and carers (for example
compliments, complaints, thank you cards, satisfaction surveys, comments and
focus groups), to date there has not been a standard and formalised approach to
capturing feedback. As part of the Hospice’s Clinical Strategy for 2013/2014, it has
been identified that the Hospice would benefit from a routine focussed process for
obtaining feedback. This will also allow the Hospice to assess, review and evaluate
the outcomes and impacts of the services it delivers to patients and their families,
to celebrate and share good practice and to act on suggestions made for
improvement.
In addition, the Hospice is one of the partner organisations of the London Cancer
Alliance (LCA), a collaborative partnership of NHS providers providing cancer
services across South and West London. A subgroup of the LCA is the Palliative
Care Pathway Group, which has also identified as one of its first priorities to
“improve the access, experience and outcomes for patients requiring palliative
care, irrespective of diagnosis, across the population the LCA serves”.
What is a Patient & Carer Survey Programme?
GBCH have decided to adopt a variety of formal approaches to collating patient
and carer feedback.
To capture patient feedback and outcomes, GBCH will trial the St Christopher’s
Index of Patient Priorities questionnaire (SKIPP). This tool was developed in
collaboration with Professor Julia Addington-Hall at Southampton University. SKIPP is
an outcome measurement tool which enables hospices/palliative care providers
to assess the impact on patients of the care they deliver and show changes in
symptoms over time. It is an established and validated tool.
To capture feedback from bereaved carers, GBCH has chosen to trial the VOICES
(Views of Informal Carers) questionnaire. This is a postal questionnaire which
collects information from bereaved Next of Kin a few months after the patient has
died. This is also a well established and validated tool which was originally derived
from the 1991 Regional Study of the Care of the Dying and then further developed
by Professor Julia Addingtion-Hall, as part of the End of Life Care Strategy in 2008.
VOICES is used on a national level as a proxy measure of the care experience of
people who die with Cancer.
Following a recommendation from the Nursing and Care Quality Forum in May
2012, the Government announced the introduction of a national standardised
measure of patient satisfaction, “The Friends and Family Test”, (FFT) which will be
mandatory for all acute adult providers of NHS funded services from 1st April 2013.
GBCH has also decided to adopt this tool.
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The FFT is a simple, comparable test which, when combined with a follow-up
clarification question, provides a way of recognising good and bad performance.
The standardised question will be ‘How likely are you to recommend “Woodlands”,
“Shornells”, “The Greenwich Care Partnership” etc. to your friends and family if they
needed similar care or treatment?’.
There is a descriptive six point scale to answer the question, from 1-Extremely likely
to 5-Not at all likely and 6-Don’t know. The second question invites a free text
response by asking ‘Please can you tell us the main reason for the score you have
given’.
What are the plans for this Priority?
The VOICES questionnaire will be launched in July 2013, initially being sent to the next
of kin of those patients who received the services of the Greenwich Care
Partnership.
The patient questionnaire (SKIPP) will be rolled-out in July 2013 for patients utilising
Shornells (Day Hospice) and then August 2013 for the Greenwich Care Partnership
and Woodlands (Inpatient Unit) patients.
The Friends & Family Test (FFT) will be launched in July 2013, with Let’s Get Moving,
Stepping Stones (see section 3.4) and patients being discharged from Woodlands.
Proposed timescales:
Next of Kin (VOICES) survey launched – July 2013
Patient questionnaire (SKIPP) launched in Day Hospice – July 2013
Patient questionnaire (SKIPP) rolled out in GCP – August 2013
Patient questionnaire (SKIPP) rolled out in Woodlands – August 2013
Friends & Family Test (FFT) launched in Let’s Get Moving, Stepping Stones and
Woodlands – July 2013
How progress against the plan will be measured
An Initial Review will be held after 3 months of implementation of each
questionnaire. This will cover the response rate (%), review of the tool and processes,
and common response themes.
A Formal Review will be carried out after 6 months. Along with the areas detailed in
the initial review, this will also consider outcomes and trends, refinements to the
process and the viability/usefulness of the scheme.
How progress will be reported
Initially progress reports will be reviewed at Clinical Leads meetings, with quarterly
reports taken to the Quality & Safety Committee meetings, which are held bimonthly and monthly respectively, prior to a report on the project being presented
to the Board of Trustees bi-annually.
It is anticipated that once fully implemented, the patient and carer satisfaction
results will form a part of the Quality and Governance Dashboard.
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GBCH 2012-2013 Quality Account
Improvement Priority 3: Access to Hospice Services
Why this was chosen as a Priority
In 2012 Help the Hospices (HtH) commissioned Cicely Saunders International to
produce an evidence-based report on the future level of need for hospice care.
The fundamental aim of this project, conducted under the auspices of HtH’s
commission into the future of hospice care, was to predict the likely impact of
demographic changes on the future demand of care provided by hospices. The
report made the following conclusions:
UK mortality trends have and are changing towards people living longer
and dying with more complex needs and diseases at an older age.
Hospices will therefore need to optimise their capacity to care for older
people at the end of life
Evidence from the UK shows that home is the most frequently chosen place
to die, however the Older Old (85+) and non-cancer patients are less likely
to die at home than patients with a cancer diagnosis. Hospices therefore
need to better understand why this is and assess patients “preferred place
of care” in order to respond to the needs of the local population
Current models of end of life care provision have been based on past
assumptions and provide “deluxe dying for the few” (Douglas 1991),
hospices therefore need to review the way they do things
GBCH has an ethnically and socio-economically diverse catchment area. Like
most other hospices, the Hospice does not see people across the range of the
population accessing hospice care; however recent changes to the model of
care provided by GBCH appear to have made some in-roads in this area.
What does the Access to Hospice Services Priority mean?
The Hospice has developed its services over recent years to ensure that care is
provided across patient pathways in a variety of settings. Opportunities to provide
integrated care in hospital, at home or in a care home and in the Hospice building
have already helped to improve accessibility for people regardless of their
diagnosis, age, ethnicity, preferred place of care etc. However the Hospice
recognises that we still have a long way to go in providing access to Hospice
services for all who need it.
GBCH has identified that as part of its response to the ever increasing need for
Hospice and End of Life Care for people who may not have traditionally accessed
these services, it wishes to redesign referral pathways, integrating existing elements
of service further and developing new areas of provision.
As part of this, the concept of the Hospice as “a hub” will be developed, this
enables the physical space to not only be used by patients, families and staff, but
also to be a “hub” for the local community. For example, the Hospice may provide
a space for socialising, rehabilitation, volunteering, receiving new kinds of care
and support and training and education. By opening up the Hospice to other
members of the community, we aim to challenge people’s perceptions of who
and what hospices are there for, opening up the doors to support more people
throughout their lives.
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What are the plans for this Priority?
The Hospice strategy has identified this as a key area for development over the next
3-5 years and as such this is a long term strategic goal. There are a number of
elements which sit under the goal and a number of developments already in
progress. These include:
Embedding Advance Care Planning into the care pathway within and
outside of Hospice services
Developing social support services including befriending, groups and drop-in
services
Developing the Hospice medical and nursing staff to better manage older
people, people with life-limiting non malignant disease including dementia
and those who are living with long term conditions
Integrating community liaison and discharge planning across all Hospice
services
Delivery of integrated end of life care, working with other local providers
(currently in the Royal Borough of Greenwich only)
Reviewing ambulatory care services to enable access to the Hospice for reablement, complementary therapies, financial and housing advice,
psychological support etc.
Increasing provision of education and training to local health and social care
partners
In addition, the Hospice will review its referral pathways, and ensure that patients
receive the most appropriate care in the most appropriate setting in a timely
manner.
As part of this strategic goal, GBCH intends to develop new facilities on the Hospice
site including a purpose built rehabilitation gym, a new education and training
facility and a coordination centre where we will provide a first contact centre,
integrating specialist community services, our end of life care services and enabling
our partnerships with other health and social care providers.
How progress against the plan will be measured
Evaluation of Advance Care Planning (ACP) across the Hospice and the
impact of the ACP project using patient feedback and activity related data
Evaluation of social support services using patient feedback and activity data
(befriending project to be launched summer 2013)
Scoping of strengths and weaknesses of the clinical team relating to non
malignant disease, survivorship and older people and development of a
workforce development plan – autumn 2013
Report produced for commissioners on the impact of the discharge/
community liaison roles including place of death and patient/ carer
satisfaction
Feedback on GCP service through SKIPP, VOICES, FFT questionnaires and
activity data
Review of Ambulatory Care Services including Day Hospice, lymphoedema,
rehabilitation – using SKIPP and FFT questionnaires
Review activity and impact of education and training to external colleagues
through evaluation of teaching
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GBCH 2012-2013 Quality Account
Minimum Data Set reports show increased activity and report increased
accessibility for “hard to reach” groups
Project plan for capital project developed and work commenced
How progress will be reported
Progress on this priority will be regularly reported to Clinical Leads meetings, the
Quality & Safety Committee, relevant project boards and to the Board & Trustees.
In addition, formal written reports will be submitted to commissioners and grant
funding bodies.
It is anticipated that the capital project will commence in the autumn of 2013, the
project plan is currently being finalised and a specific Capital Project Board
established. This group will report to the Board of Trustees.
2.2 Priorities for Improvement 2012 – 2013
The key Improvement Priorities for 2012/13 were:
Progress against Improvement Priority 1: Implementation of an Electronic Patient
Record system
What are Electronic Patient Records?
GBCH implemented an Electronic Patient Record (EPR) system, accessible
throughout all of our services to further improve assessment, communication and
integration of care. Patient details are securely stored electronically, can be
viewed and updated, letters to GPs and others automatically generated, patient
lists easily created and viewed and commissioner and regulator reports generated.
What was planned / achieved
The EPR system went live on 12th April 2012.
The Greenwich Care Partnership service was added to the EPR system and they
have been using it since February 2013.
Benefits/outcomes of this Priority
The implementation of EPR helps the Hospice to:
Utilise space better
Utilise staff time better
Improve recording and control of patient information
Better comply with legislation and standards
Reduce administration costs
An EPR User group meets monthly, to oversee the integrity of the system.
Any outstanding area to be addressed in 2013/14
The following areas still need to be progressed to improve the effectiveness of the
EPR system:
Activation of N3 connection - summer 2013
Allocation of roles for ongoing maintenance of EPR –summer 2013
Provision of regular EPR training and updates - ongoing
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GBCH 2012-2013 Quality Account
Improve routine and ad-hoc reporting – summer 2013
Progress against Improvement Priority 2: Service Information
What is Service Information?
In 2012, GBCH produced a standardised suite of Hospice information in the form of
booklets, leaflets and factsheets which detail the range of services provided as
well as information on specific topics. This information has been developed in line
with the corporate style and mirrors that available on the Hospice website.
Information has been tailored to existing and potential patients and their carers,
professionals and supporters. User views have been sought to ensure that it is clear
and provides the information that people need.
What was planned/achieved?
The Hospice identified the areas of information already provided as well as any
gaps. It was identified that as well as providing a range of “service” leaflets, it would
be important to develop more general “topic” themed leaflets on areas such as
consent, complaints etc. In addition, it was agreed that a template would be
developed for a factsheet which could be used in-house where more specific
departmental information was required.
Patient and carer feedback was gathered before any of the leaflets were printed.
A leaflet for Health and Social Care Professionals was also developed giving a
detailed overview of all hospice services and providing a directory of useful
numbers.
Leaflets were distributed in house and new displays created in reception and in
Shornells. Additionally, leaflets were distributed to GP surgeries, advice centres etc.
Benefits/outcomes of this Priority
By reviewing all of the information resources at once, the Hospice can be confident
that information is accurate and communicates the core aims of the service. In
addition, all patients now receive standardised information about how to make a
complaint, policies on confidentiality and how the Hospice is funded.
The Hospice image has been improved by standardising the professional image of
our materials and we also have a standard style that can be used in-house where
required.
Any outstanding area to be addressed in 2013/14
In 2013/14 we plan to review the Hospice leaflet on Volunteering as well as
producing a general Hospice leaflet giving information on our services for people
who wish to support us.
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GBCH 2012-2013 Quality Account
Progress against Improvement Priority 3: Greenwich Care Partnership
What is the Greenwich Care Partnership?
The Greenwich Care Partnership was established to deliver an integrated end of
life care service to people in the Royal Borough of Greenwich. The service is
designed to work alongside and support established core services (GPs, district
nurses, specialist nurses etc.) in order to support the provision of high quality care
for dying people.
The GCP was commissioned by NHS Greenwich as a partnership and is delivered
by the Hospice as the prime contractor with Marie Curie Cancer Care (MCCC)
and Oxleas NHS Foundation Trust as subcontractors.
What was planned/achieved?
The Greenwich Care Partnership provides four key elements of care:
Care co-ordination through a Palliative Care Co-ordination Centre
Out-of-hours Rapid Response Service
Multi-visit personal care and support
Planned night care service
Although the elements of the service are provided by different providers, they work
together to ensure care is provided seamlessly around the clock, 365 days a year.
In 2012/13 the partnership entered its second year of delivery as a “test and learn”
project. In March 2013 the contract was awarded to the Hospice for another 3
years.
Benefits/outcomes of this Priority
The GCP service received 273 referrals in 2012/13 for care coordination, nursing care
and personal care and enabled over half of its patients to die at home.
In 2012/13 55% of people under GCP died in their usual place of residence, this is set
against a benchmark of 19% of all deaths in the Royal Borough of Greenwich. It is
anticipated that results will show that by providing more care for people at home,
quality improves and costs across the whole health and social care system have
been reduced.
Patients and families reported a high level of satisfaction of the GCP service
Wife of patient, West Greenwich
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Any outstanding area to be addressed in 2013/14
The Hospice will continue to deliver services provided by the GCP in 2013/14 and
plans to carry out the following developments:
Provision of education to District Nurses and GPs in the Royal Borough of
Greenwich
Review of GCP team leader role and introduction of a band 5 nurse
Implementation of ongoing care for category 1 funded patients after the end
of the fast track period
Development of a plan for service improvement to facilitate rapid discharge
from hospital
2.3 Statement of Assurance from the Board
The following are a series of statements that all providers must include in their Quality
Account. Many of these statements are not directly applicable to specialist
palliative care providers.
2.3.1 Review of Services
During 1st April 2012 to 31st March 2013, The Hospice provided the following services:
In-Patient Care
Day Hospice Services
Specialist Palliative Care Community Services in Greenwich and Bexley
Boroughs
Hospital Support Team at Queen Elizabeth Hospital
Greenwich Care Partnership
Rehabilitation
Lymphoedema Treatment and Care
Psychological, Spiritual and Social Care
Education and Care Homes Support
The Hospice has reviewed all the data available to them on the quality of care in all
its services.
2.3.2 Income Generated
The income generated by the NHS services reviewed in 2012/13 represents 100% of
the total income generated from the provision of NHS services by GBCH for 2012/13.
The income generated from the NHS represented 45% (unaudited) of the overall
cost of running these services.
The above mandatory statement confirms that all of the NHS income received by the
Hospice is used to towards the cost of providing patient services.
2.3.3 Participation in National Clinical Audits
During 2012/13, The Hospice was ineligible to participate in any national clinical
audits or national confidential enquiries.
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2.3.4 Participation in Local Audits
The following audits were carried out during 2012/13:
Subject Matter
Outcomes of Audit
Follow-up Actions
Transfer of patients out
of hospice to hospital
and reasons why
From this audit of inpatient
admissions in 2012, only a small
percentage resulted in transfer
out of the hospice to hospital for
acute intervention. In the
majority of these cases this was
appropriate either due to
unforeseen clinical issues or
predictable clinical
complications that could not be
managed safely in the hospice.
None. This is a hard area to audit
as there is no gold standard to
compare our activity against.
Liverpool Care Pathway
for the care of the
dying
An LCP audit tool had to be
developed. Two audits were
performed during 2012
Hand Hygiene
Hand hygiene is now part of
Mandatory training for all staff,
improvements have been seen
as s result of training and regular
inspections
Additional training needs were
identified.
LCP Guidelines to be
developed.
Audits are regularly performed
as part of the annual
programme for infection control.
Use of Morphine and
Oxycodone
This audit was carried out to
review the use of injectable
Oxycodone in the hospice.
Out of Hours contacts
Problems outside core service
hours can be mitigated by
having an effective overnight
advisory service that facilitates
good collaboration with other
services and prompt in-hours
follow-up the next day.
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The case notes should;
Describe Pain type –
neuropathic, nociceptive or
complex regional pain
syndrome, or recognised pain
syndrome description.
Attempt to ascertain why
Oxycodone specifically being
used.
Justify rationale for commencing
syringe driver.
Justify rationale for any opiate
switch.
Consider alfentanil first line in
syringe driver in patients with
renal impairment/failure.
If the above is clearly recorded
and acted upon then use of SC
Oxycodone will be clinically
appropriate.
Audit is being repeated in 2013.
Audit to be repeated annually
to track any evolutionary trends,
year-to-year, or to compare with
the accessibility of the
Greenwich outreach team via
integrated GCP service and
single point of access.
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GBCH 2012-2013 Quality Account
Mental Capacity Act
documentation
Evolution of the Mental
Capacity Act and Hospice
documentation and the move
from paper to electronic patient
records has given the team
opportunities to reflect on how
they are applying the Mental
Capacity Act in day to day work
without it preventing staff from
having the time to give good
clinical care.
Refine electronic patient record
to:
indicate if there is a decision
that needs to be made at that
point or not.
include specific reference to
court of protection orders and
independent mental capacity
advocates.
Audit to be repeated in 2013
Unannounced Hygiene
Inspection
Audits performed by Lead for
Infection Control and a Trustee
on a regular basis throughout
2012
Action List updated after every
audit and reviewed at Quality &
Safety Committee meetings
2.3.5 Research
The Hospice is currently participating in the following research projects:
Assessment of accuracy of prognosis prediction by the Palliative Prognostic Index
(PPI): a prospective multi-centre study. Could the accuracy of prognosis prediction
by PPI be improved by two assessments and could the rate of change of PPI score
be used to prognosticate better?
The aims of the study are to assess the accuracy of prognosis prediction by PPI in a
larger population, multi-centre population to consolidate the results and to assess
inter centre variability, and assess whether multiple assessment, rate of change of
the PPI improve accuracy of prognosis prediction. To date, 100 patients have
completed assessments.
Exploring patient perception of treatment success and benefit in self-management
of breast cancer-related arm swelling (lymphoedema).
Secondary Lymphoedema is a common problem following treatment for breast
cancer and many people have to do daily self-care to treat their arm swelling, for
example wearing a compression arm sleeve. The research project aims to learn
more about the patient experience of daily lymphoedema self-care, i.e. carrying
out their own care at home, which usually means wearing a compression arm sleeve
or glove, how the patient decides whether their swollen arm has got better or worse,
and how they know if the treatment is helping the swelling. Several Lymphoedema
Clinics in the London area (including Greenwich & Bexley Community Hospice
Lymphoedema Clinic) have agreed to identify 25 people who are happy to
participate in an interview for the research.
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2.3.6 Quality improvement and innovation goals agreed with our Commissioners
Hospice NHS income in 2012/13 was partly conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation (CQUIN) payment framework.
The agreed Bexley CQUIN was:
To develop an innovative proposal to increase the number of patients who
die in their preferred place of death
The agreed Greenwich incentive payment related to the GCP was:
Reduction of 5 hospital deaths per month for the Royal Borough of Greenwich
residents
2.3.7 What others say about Greenwich & Bexley Community Hospice
The Hospice is required to register with the Care Quality Commission and its current
registration status is that we are registered to carry out the following legally
regulated activities:
Diagnostic and screening procedures
Treatment of disease, disorder or injury
The Care Quality Commission has not taken any enforcement action against the
Hospice during 2012/13.
On 16th January 2013, the Care Quality Commission carried out an unannounced
inspection as part of their routine inspection schedule. The following standards were
inspected:
Outcome 1 - Respecting and involving people who use services
Outcome 4 - Care and welfare of people who use services
Outcome 7 - Safeguarding people who use services from abuse
Outcome 13 - Staffing
Outcome 16 - Assessing and monitoring the quality of service provision
The Hospice was compliant against all of the above Outcomes. The CQC stated in
their report:
Patients and relatives we spoke with told us that the care on the ward at the
hospice was "second to none" and that staff were "always at hand". We were
not able to speak to patients or staff from the day care facility which was
closed during our visit. However, we saw that the same policies, governance
arrangements and training apply throughout the hospice.
People we spoke with told us that communication was good amongst staff
and patients, and between the hospice service and the outreach services in
the community. Patients said they felt secure and well cared for. We saw that
people were treated with respect and involved and supported in decisions
about their care and treatment. Quiet rooms were readily available for
patients and relatives, and we saw that individual needs had been assessed
with patients and recorded in their care plans.
Patients were protected from abuse and staff respected their human rights.
The hospice had made suitable arrangements to ensure that people are
safeguarded from the risk of abuse, including policies and guidance, meeting
with local safeguarding boards and training for all staff.
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Patients at the hospice are cared for by staff with the right knowledge,
qualifications and skills to support people. There is work in progress for further
training during 2013.
The hospice has systems in place to monitor the quality of the service and has
shown how patient, relative, and staff feedback has informed and
developed practice.
2.3.8 Data Quality
The Hospice did not submit records during 2012/13 to the Secondary Uses Service for
inclusion in the Hospital Episode Statistics, which are included in the latest published
data.
In accordance with agreement with the Department of Health, the Hospice submits
a National Minimum Dataset (MDS) annual return to the National Council for
Palliative Care.
2.3.9 Information Governance Toolkit Attainment Levels
Throughout 2012/13 we have been working towards compliance of the Information
Governance toolkit requirements. This work is still ongoing and we aim to reach a
minimum of level 2 for each relevant item of the toolkit by summer 2013. Information
Governance is part of annual Mandatory Training for all staff.
2.3.10 Clinical Coding Error Rate
The Hospice was not subject to the Payment by Results clinical coding audit during
2012/13 by the Audit Commission.
Part 3 - Review of Quality Performance
The Hospice has chosen to present a number of key quality indicators to
demonstrate the level of care that the Hospice services provide:
3.1 Comparison with National Minimum Data Sets
Comparison with the National Minimum Data Sets (MDS) for Palliative Care, provide
a National and local context to Hospice performance over time.
The most recently published National Minimum Data Set for Palliative Care covers
2011/2012. Data for the Hospice for 2012/13 has been collated but currently there is
no comparative National MDS data available.
The Hospice has benchmarked data reports for 2011/12 under the following
headings:
Inpatients
Day Care
Home Care / Hospice at Home
Hospital Support
Bereavement Support
Outpatients
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3.1.1 Inpatients
MDS data for Inpatients is given in Table 1. Based upon our return, the Hospice was
included in the Large category (more than 16 beds).
Nationally, data was received from 58 Large units. For London, data was received
from 9 Large units.
Table 1 Inpatient MDS data
2012-2013
GBCH*
2011-2012
GBCH
320
2011-2012
National
Median
313
2011-2012
London
Median
433
New Patients
309
% New Patients
92.7
92.8
90.2
91.1
% New Patients with Ethnicity 94.2
Recorded
88.8
94.2
94.3
% New Patients with a Non- 16.1
Cancer Diagnosis
12.5
9.8
12.7
Average
Cancer
stay, 15 days
11 days
13 days
12 days
Average Length of stay, Non- 18 days
Cancer
11 days
13 days
13 days
% Occupancy
75.5
78.3
80.4
Length
of
80.8
The Inpatient unit has 19 beds, caring for and supporting people who have symptom
control needs, complex psychological support needs, respite needs and/ or end of
life care needs. The unit also provides significant support to the families and friends
of those that we care for.
The average length of stay increased in the inpatient unit this year. The Hospice took
a strategic decision not to discharge a small group of patients who would have
historically been discharged to a care home in their last few weeks of life, plus the
absence of a discharge coordinator for much of the year are both likely to have
had an impact on length of stay, however this post has now been filled.
On a positive note, the proportion of patients with a non malignant disease who
access the inpatient unit continues to increase and recording of ethnicity of patients
has improved with the introduction of the electronic patient record system.
Sister of patient
* 2012-2013 figures are unaudited, based on our submission. These are not MDS
figures.
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3.1.2 Day Care
MDS data for Day Care is given in Table 2. Based upon our return, the Hospice was
included in the Medium category (between 114 and 177 patients).
Nationally, data was received from 47 Medium units. For London, data was received
from 9 Medium units.
Table 2 Day Care MDS data
2012-2013
GBCH*
2011-2012
GBCH
95
2011-2012
National
Median
89
2011-2012
London
Median
113
New Patients
129
% New Patients
74.1
56.9
64.1
59
% New Patients with Ethnicity 98.4
Recorded
91.6
91.0
91.6
% New Patients with a Non- 18.6
Cancer diagnosis
22.1
16.9
17.8
Day Care Attendances
2686
2267
1761
2495
% Places Used
74.6
62.8
57.8
62.8
163 days
137 days
128 days
Average
Attendances
Length
of 158 days
Completion of the Day Care refurbishment has enabled more services to be
provided including a broader range of treatments and activities such as blood
transfusions and art therapy.
There has been a 38% increase in new patients attending the day hospice and a
significant increase in activity overall, changes to the model of care for specialist
community support and improvements in transport are likely to have had a positive
impact on this.
As with other services, the proportion of people with their ethnicity recorded has
increased following the implementation of EPR.
* 2012-2013 figures are unaudited, based on our submission. These are not MDS
figures.
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3.1.3 Home Care/Hospice at Home
MDS data for Home Care/Hospice at Home is given in Table 3. Based upon the
Hospice return, GBCH was included in the large category (more than 839 patients).
Nationally, data was received from 11 large units. For London, data was received
from 4 Large units.
Table 3 Home Care/Hospice at Home MDS data
2012-2013
GBCH*
2011-2012
GBCH
968
2011-2012
National
Median
911
2011-2012
London
Median
1195
New Patients
895
% New Patients
71.7
69.7
69.7
68.1
% New Patients with Ethnicity 91.6
Recorded
85.4
80.9
68.8
% New Patients with a Non- 19.3
Cancer diagnosis
25.0
14.0
23.3
% Home and Care Home 48.8
Deaths
50.6
52.5
50.4
% Hospice Deaths
27.2
24.8
-
-
% Hospital Deaths
23.1
24.0
-
-
Visits per Completed Series
4.9
4.4
6.8
4.9
5.9
4.7
6.4
Telephone
Contacts
Completed Series
per 18.5
Nurses, Doctors, Allied Health Professionals, Counsellors and Health Care Assistants
provide care and support for people in their own homes, including advice and
support to their carers and to other primary care professionals involved in their
support.
The Hospice has been awarded the contract for provision of an integrated end of
life care service for the Royal Borough of Greenwich for the next 3 years. Due to
funding constraints, the Hospice provides a different model of care in the two
boroughs it serves. Recent mapping conducted by the London Cancer Alliance
Palliative Care Pathway Group highlighted that the caseload/staffing ratio for
clinical nurse specialists in Bexley Borough is the lowest in South and West London.
The Hospice is currently working with NHS Bexley to address this.
This year the number of new patients decreased in the main due to reduced
resources in the specialist community teams, however the number of contacts
significantly increased. Overall the number of deaths increased and the total
number of home deaths increased, however the proportion reduced as did the
proportion of hospital deaths. The number of Hospice deaths increased1.
1
See activity report for inpatient unit for further commentary.
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The proportion of patients with a non malignant disease who access the specialist
palliative care service has reduced, it is not clear why. The recording of ethnicity of
patients has improved with the introduction of the electronic patient record system.
Daughter and husband of patient, Abbey Wood
* 2012-2013 figures are unaudited, based on our submission. These are not MDS
figures.
3.1.4 Hospital Support Team
MDS data for Hospital Support is given in Table 4. Based upon the Hospice return,
GBCH was included in the large category (more than 721 patients).
Nationally, data was received from 43 large units. For London, data was received
from 19 large units.
Table 4 Hospital Support Team MDS data
2012-2013
GBCH*
2011-2012
GBCH
654
2011-2012
National
Median
822
2011-2012
London
Median
683
New Patients
730
% New Patients
92.4
89.3
90.5
89.4
% New Patients with Ethnicity 84.5
Recorded
69.0
95.0
97.2
% New Patients with a Non- 26.7
Cancer diagnosis
33.3
24.1
30.8
% Discharged to Home
68.0
51.4
52.5
53.2
Average Length of Care
8 days
8 days
9 days
9 days
The Hospice hospital support team based at Queen Elizabeth Hospital, Woolwich,
provide support, advice and education to staff in the hospital on end of life care
and symptom control issues, as well as supporting patients and their families directly
and helping to ensure their wishes for care are met.
There has been an 11% increase in new patients seen by the team, the majority of
whom have a cancer diagnosis. This is likely to be due to the continued impact of
the closure of the A&E service at Queen Mary’s Hospital. A greater proportion of
discharges were discharged home or to a care home than in 2011/12.
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GBCH 2012-2013 Quality Account
As with other services, the proportion of people with their ethnicity recorded has
increased with the implementation of EPR.
Macmillan Acute Oncology Lead Nurse
* 2012-2013 figures are unaudited, based on our submission. These are not MDS
figures.
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3.1.5 Bereavement Support
MDS data for Bereavement Support is given in Table 5. Based upon the Hospice’s
return, GBCH was included in the large category (more than 250 services users).
Nationally, data was received from 40 large units. For London, data was received
from 10 large units.
Table 5 Bereavement Support MDS data
2012-2013
GBCH*
2011-2012
GBCH
172
2011-2012
National
Median
305
2011-2012
London
Median
190
New Service Users
202
% New Service Users
92.6
68.0
67.4
68.7
with 38.6
70.3
34.4
68.0
% of Deceased with a Non- 14.8
Cancer diagnosis
8.1
10.8
11.5
Contacts per Service User
12.7
9.5
4.0
6.1
% Discharged
68.8
53.3
57.5
47.0
% New Service Users
Ethnicity Recorded
Bereavement Support is provided by the Hospice’s multi-professional team including
Counsellors, a Social Worker, volunteer Chaplains and volunteer telephone
bereavement support workers. With the introduction of EPR, data collection has
improved, however recording of ethnicity for clients who are not patients appears to
have deteriorated. This will be addressed with the team for future years. More new
referrals were seen and the number of contacts has increased, in addition, the
proportion of clients who were discharged in the year has increased.
Bereavement service client
* 2012-2013 figures are unaudited, based on our submission. These are not MDS
figures.
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3.1.6 Outpatients
MDS data for Outpatients is given in Table 6. Based upon the Hospice return, GBCH
was included in the large category (more than 272 patients).
Nationally, data was received from 49 large units. For London, data was received
from 11 large units.
Table 6 Outpatients MDS data
2012-2013
GBCH*
2011-2012
GBCH
158
2011-2012
National
Median
271
2011-2012
London
Median
116
New Clients
255
% New Clients
39.8
24.3
48.1
62.2
% New Patients with Ethnicity 90.5
Recorded
89.2
80.0
91.7
% New Patients with a non- 31.7
cancer diagnosis
50.0
20.3
30.9
Total
Outpatient
Attendances
1320
1019
227
2.0
2.0
2.7
Attendances per Patient
Clinic 1496
2.3
The heading “outpatients” includes Hospice Lymphoedema, Rehabilitation and
Social Worker support. The Lymphoedema team has recently been restructured and
now includes additional resource. The rehabilitation service was also restructured in
2012/13and the breathlessness nurse post disestablished. As a result of these
changes and as a result of the introduction of new treatments in lymphoedema,
more new patients have been seen, but proportionately less patients with a non
malignant diagnosis.
As Hospice staff try to use limited resources as efficiently as possible, we have seen
the number of outpatient clinic appointments increase.
Lymphoedema patient
* 2012-2013 figures are unaudited, based on our submission. These are not MDS
figures.
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3.2
Clinical Governance
The Hospice underwent a re-structure in 2012/13 in order to better support the recent
development of clinical services as well as to ensure the best use of precious
resources towards patient care. Following this restructure, a review of the
subcommittees of the Board was also carried out. This resulted in the dissolution of
the Health and Safety Committee and the Clinical Governance and Development
Committee and the formation of the Quality & Safety Committee. The Quality &
Safety Committee is supported by a number of topic/ project based advisory groups
e.g. medicines, EPR, education, GCP.
The Quality and Safety Committee has a rolling agenda with regular reports which
now include the Clinical Dashboard and in 2012/13 was also responsible for the
review of existing and development of new policies and for monitoring the clinical
audit programme. The new Quality & Governance Officer is a member of the
committee as is the new Estates Manager who is operationally responsible for Health
& Safety across the organisation.
In 2012/13 the Hospice invested in new T34 syringe pumps and training of staff in their
use in response to a patient safety alert. The Hospice also introduced new annual
drug competency tests for all RNs and negotiated a service level agreement with an
outside contractor to support infection control.
3.3
Training
The Education team was restructured as part of the Hospice restructure in 2012/13
and this has enabled the continuation of significant external education to be
delivered particularly for care home staff and community nurses, as well as the
development of a new mandatory training programme for clinical and non clinical
staff. Links with external organisations including the University of Greenwich and
Kings College London have been further developed in the year.
3.4
Supportive Care
As part of the Hospice restructure, some changes to supportive care services were
made. In particular:
Shornells, the Day Hospice, was refurbished to improve the patient
environment and regular multidisciplinary team meetings were established in
Day Hospice.
The Rehabilitation team continue to support all areas of service delivery within
the Hospice, including GCP. The team now runs a 6 week rolling
‘Rehabilitation Programme’ for patients attending Day Hospice, to support
their mobility, function and management of symptoms. They have also
developed a number of new initiatives including a rehabilitation programme ‘
Let’s Get Moving’ for people with lymphoedema, as well as supporting and
developing ‘Stepping Stones’ a drop-in service for patients, carers and those
who have been bereaved, with in excess of a 1,000 attendees over the past
year.
A review of the Lymphoedema team took place enabling more capacity
and improvements to the patient pathway.
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3.5
Peer Review
From 2013 it was mandated that Hospices participate in The National Cancer Action
Team’s Peer Review process. The Hospice’s self assessment was completed within
required timescales and the Hospice has fed into the development process of the
measures for the next round.
3.6
Challenges
A number of challenges have been encountered in 2012/13, in particular:
The Hospice encountered difficulties in recruiting sufficient quality staff throughout
the year, a problem which was mirrored across the whole local health economy.
Some progress has been made with this over recent months and we are now
optimistic that where services have had to be adapted to ensure they are safe with
reduced staff, they will soon be able to return to full capacity.
The difficult economic climate has had an impact on Hospice services in 2012/13
with some areas being reduced until additional resource has been secured. We are
pleased that NHS Bexley has provided some additional investment to support the
increased workload in the community in order to improve quality and outcomes for
dying people living in the borough. The Hospice’s voluntary income has also been
impacted by the external economic climate and we continue to work hard to
maintain voluntary income.
The changes in NHS and social care structures locally and at a national level have
had an impact on the way that hospice staff work, from relationships with
commissioners, to communication with referrers, GPs, district nurses, etc; every
element of the health service has been impacted. The Hospice is maintaining its
efforts to link with external professionals in all settings.
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Appendix 1: Greenwich
NHS Greenwich
Simon Shenton-Tan – nominated person within NHS Greenwich
The accounts are clear, and give a good analysis of targets and achievements. In
future we would like to see more quantitative/ performance analysis, against the
standards we have in our contracts.
Royal Borough of Greenwich Healthier Communities and Older People Scrutiny Panel
Alain Lodge - Scrutiny Officer for our Healthier Communities and Older People
Scrutiny Panel
Introduction
The panel supports the work of the Hospice and is impressed by the quality of the
services provided for Royal Greenwich residents. The panel would like to develop
stronger links with the Hospice during 2013/14 and identify possible areas of joint
working.
Part 1- Chief Executive’s Statement
The Panel strongly support the aim of the Hospice to ensure that people who have a
life limiting illness receive the best possible quality of care. The Chair of the Panel has
visited the Hospice on several occasions and was impressed by the Integrated End
of Life Care Services for Greenwich residents. This new service which is tailored to
each individuals needs will have an important positive impact on the experience of
care that people receive. The Panel is pleased to note the successful application for
Department of Health funds and the improvements that will result from this funding
including the provision of a purpose built rehabilitation gym and the development of
a community hub care coordination centre.
Part 2- Priorities for Improvement and Statements of Assurance from the Board
2.1 Priorities for Improvement 2013-14
The Panel recognises the importance of the priorities for 2013-14 particularly as the
Dashboard will be an effective way of monitoring performance activity and quality
of care and the feedback from the Patient and Carer Survey Programme will allow
the Hospice to assess, review and evaluate service outcomes. The Access to
Hospice Services will improve accessibility for people regardless of their diagnosis,
age ethnicity, and preferred place of care. However, the Panel shares the Hospices
view that there is still scope for further improvement. Also developing the concept of
the Hospice as a Community Hub will be an important step in challenging and
changing people’s perceptions of the role of a Hospice.
2.2 Priorities for Improvement 2012-13
The Panel noted the good progress the Hospice has achieved against its 2012-13
priorities and the ongoing work they are undertaking. Particularly continuing training
on the Electronic Patient Records system; reviewing the Hospice leaflet on
volunteering and producing a general leaflet giving information on services for
people who wish to support the Hospice; and provision of education and training on
the Hospice services to District Nurses and GPs in Royal Greenwich.
2.3.7 What others say about Greenwich and Bexley Community Hospice.
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GBCH 2012-2013 Quality Account
The Panel were pleased to note that the Hospice was compliant against all the
outcomes following the Care Quality Commission (CQC) unannounced inspection in
January 2013. They were particularly pleased to note the favourable comments in
the CQC report from patients regarding care on the wards; communication
between staff and patients; and the respect shown to patients by the staff.
Part 3- Review of Quality Performance
3.1.1-3.1.6 Benchmarked data reports 2011/12
The panel noted that the Hospice was using the data reports on inpatients; day
care; home care/ Hospice at home; hospital support team; bereavement support;
and outpatients to improve services. They were also pleased to note that there had
been a 38% increase in new patients attending the day Hospice and a significant
increase in day care activity overall. And the positive impact on data collection of
the introduction of the Electronic Patient Record system.
3.6 Challenges
The panel shared the Hospices concern regarding the difficulties in recruiting
sufficient quality staff and the impact of the external economic climate on the
Hospice’s voluntary income. The panel strongly supports the Hospice’s actions to
recruit high quality staff and to maintain their voluntary income.
Healthwatch Greenwich
Rosaline Ha - nominated person within Healthwatch Greenwich
See Healthwatch Bexley response.
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GBCH 2012-2013 Quality Account
Appendix 2: Bexley
NHS Bexley
Anjum Fareed – nominated person within NHS Bexley
I am pleased to say that the accounts were helpful and informative and easy to
read. Congratulations on the glowing CQC inspections also.
The benchmarks applied were particularly useful. I noted you have said there is an
absence of comparable MDS data in some areas, it might be good though if you
could explore your own internal trend data in relation to hospital admissions or
percentage that choose to die at home for next year’s report.
The higher than average length of stays and the explanations for this are also noted
and appreciated. Having only recently taken on the management of this contract I
can’t really add much further.
Bexley Overview and Scrutiny Committee
Cllr Ross Downing - Chair of the Health OSC
Louise Peek – Support Officer for the Health OSC
No response provided.
Healthwatch Bexley
Anne Hines-Murray – nominated person within Healthwatch Bexley
The Healthwatch organisations for Bexley and Greenwich welcome the opportunity
to comment on the Greenwich and Bexley Community Hospice’s Quality Account
for 2012-13. Please note that Healthwatch was established on 1st April 2013,
replacing Local Involvement Networks (LINks). Recognising that Healthwatch is in its
embryonic stage, we are unable to provide a detailed commentary this year. We
look forward to compiling a full and thorough commentary next year.
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Appendix 3: London Cancer Alliance
London Cancer Alliance
Dr Nigel Sykes - Chair of the Palliative Care Pathway Group
Thank you for sending me a copy of the latest GBCH Quality Account. I appreciate
your thoughtfulness in including the LCA in your consultation exercise.
The document appears to me to be very well put together and to meet the
requirements of the Quality Accounts exercise. I am particularly pleased to note the
congruence of your service's key 2012-2013 Priorities for Improvement - User
Feedback and Access to Hospice Services - with the priorities of the LCA Palliative
Care Pathway Group. On a personal level I will be interested to hear of the hospice's
experience with SKIPP.
The LCA is keen to encourage participation by palliative care units in audit and
research, particularly collaborative research, and it is good to see the efforts of
GBCH in this regard so clearly stated. The EPR and N3 connection initiatives are also
exactly the facilities that need to be in place if we are going to be able to
implement and demonstrate high quality, integrated palliative care across London.
Getting these in place is challenging and it must be a relief that you are nearly
there. Also on the subject of information, it is pleasing that GBCH contributed to the
MDS exercise, in which London units were relatively poorly represented.
I note the challenges that GBCH is facing and suspect that these would ring true for
most hospices - I wish you well for 2013/14.
Congratulations on both a well presented Quality Account and also the work and
achievement that it reflects.
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