Quality Account
2012-13
Contents
Part 1 Introductions4
Statement from the Board5
An introduction to Bristol Community Health6
What is a Quality Account?7
Our approach to improving quality7
Part 2 2013-14 Priorities8
Our quality priorities for improvement during 2013-14
9
Priority 1: Clinical Effectiveness – Implementation of Shared Decision Making
9-10
Priority 2: Patient Experience – Improving information available to patients
10
Priority 3: Patient Experience – Improving the patient experience of end of life care
11-12
Priority 4: Patient Safety – Using the SSKIN bundle for patients
12
Priority 5: Patient Safety – Development of an early warning system for safety & quality 13-14
Developing quality improvements, capacity and capability to deliver priorities
14
Other areas of quality improvement14-15
Statements relating to quality of NHS services provided
Part 3 Review of 2012-13 achievements
15
16
Priority 1: Patient Safety – Pressure Ulcers17-18
2
Priority 2: Patient Safety – Frail Elderly Pathway
18-19
Priority 3: Clinical effectiveness – Productive Community Services
20-21
Priority 4: Clinical effectiveness – Urgent Care Strategy
21-22
Priority 5: Clinical effectiveness – To implement a diabetes pathway and
Single Point of Access (SPA) for Diabetes Services 22-23
Bristol Community Health | Quality Account 2012-13
Contents
Priority 6: Patient Experience – Telehealth services
24-25
Priority 7: Patient Experience – End of Life stage
25-28
Summary of year end successes 2012-1328-29
Performance on national quality priorities 2012-1329-30
Performance against national and local CQUINs and contracted activity
30-31
Areas of consistently good or improved performance in 2012-13
31
Awards received by Bristol Community Health 31-32
Case studies of quality improvements32-45
Part 4
Statements of Assurance
46
Statements of assurance relating to the quality of services provided in 2011-12
Information Governance Toolkit attainment levels47
Participation in clinical audits and confidential enquiries 47-49
Participation in clinical research 49
Research and development49-50
Goals agreed with Commissioners: Use of the CQUIN payment framework
50-52
Service improvement priorities for 2013-1452
How our regulator the Care Quality Commission (CQC) views our services 53-54
Who did we involve in developing the Quality Account?
54-55
Appendix What others say about us
56
Supporting statements
.
Bristol Clinical Commissioning Group 57-58
Bristol City Council’s Health, Wellbeing and Adult Social Care Scrutiny Commission
What others say about us
3
Bristol Community Health | Quality Account 2012-13
59
Part 1
Introductions
Part 1
Statement from the Board
Welcome to Bristol Community Health’s second annual Quality Account, since the
organisation became an independent Community Interest Company (CIC) in October 2011.
Producing this account provides us with the opportunity to share information about the quality of our
services with the public. In particular it lets everyone know what our priorities for quality improvement
are for the coming year and provides information on how well we have performed in meeting our quality
priorities identified in our last account. We hope it provides interesting and useful information to our
commissioners, partners, staff, and most of all, to our patients and the wider community.
Our Quality Account has been informed by analysis of information and the views of directors, managers,
staff, external stakeholders, the people who use our services and their carers.
Our priorities for improving patients’ safety, clinical effectiveness and the patient experience of our
services in 2013-14 are set out in Part Two of our Quality Account. Part Three demonstrates our progress in
the priority quality improvement areas identified in our 2011-12 Quality Account. In producing this Quality
Account, we have taken into account the following specific sources of information:
Monthly performance reports to the Board;
Annual reports of key functions such as infection prevention and control, health and safety, risk and
incident management, information governance and safeguarding;
Quarterly reports from the quality and assurance directorate;
Feedback from staff surveys;
Patient and public involvement surveys; and
Reports from our internal and external auditors.
As the main local provider of community based health services for the adult population of Bristol we are
committed to ensuring continuous improvements to the quality of care we provide. We will continue to
work closely with our health and social care partners, charities and patient representatives to identify
quality improvement priorities for the population we serve.
We have set ourselves ambitious targets to build on our achievements in future years, while reflecting
on the diverse nature of the population we serve when we design facilities and services, and when we
set priorities for improving our quality and performance standards. Included in our Quality Account are
examples of the feedback we continuously receive on the performance of our staff and services.
It gives us great pleasure to introduce our second Quality Account on our work and achievements this
year. To the best of our knowledge the information contained within this Quality Account sets out a true
and accurate representation of our achievements in 2012-13 and our priorities for continuously improving
quality in 2013-14.
Julia Clarke Mark Kingston
Chief Executive Interim NED and Chair of the
5
Quality Assurance & Governance Committee
Bristol Community Health | Quality Account 2012-13
Who we are
An introduction to Bristol Community Health
Bristol Community Health provides a range of
community healthcare services to a population of
around 430,000 people in Bristol, as well as some
services in South Gloucestershire and North Somerset.
With our long term experience of running NHS funded care in Bristol
and beyond, we are experts in providing clinical community services.
Our highly qualified nursing and therapy staff care for patients with
a wide range of complex health needs, including those with learning
difficulties and those detained in prison.
We also provide a range of specialist services including our Tuberculosis Screening and Contact
Tracing Service and The Haven, a primary care service supporting asylum seekers and refugees.
From Dermatology to District Nursing, Prison Healthcare to Physiotherapy, the Urgent Care Centre to
Wound Care, our 1,100 strong team helps people to live life well.
We take great pride in ensuring our patients are treated as individuals and receive the highest quality
care in, or close to, where they live or work.
For more information visit the Bristol Community Health website at: www.briscomhealth.org.uk
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Bristol Community Health | Quality Account 2012-13
What is a quality account?
This is our second published Quality Account and it follows the format and content
laid out in the Department of Health Guidance 2010-11, where relevant to independent
providers of community health services.
The Quality Account provides a structure for us to report on the three key elements of the quality of
care that a person using our services receives, as illustrated in the figure below.
Patient safety
Patient
experience
Clinical
effectiveness
Our approach to improving quality
We are pleased with our achievements to date but are far from complacent. We are
determined to make continuous improvements to our service.
We recognise that high quality services can only be delivered by motivated, skilled and engaged staff
and that we need to continue to support them to deliver improved quality of service.
Staff involvement is a key principle of the social enterprise model and as such we have well
developed staff and clinical forums to ensure the voice of the workforce is heard. This is essential to
maintain and improve quality. We have a rigorous process of internal performance management and
assurance of service quality, in all our services, across the area we serve.
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Bristol Community Health | Quality Account 2012-13
Part 2
2013-14 Priorities
Part 2
Our quality priorities for improvement 2013-14
In determining our quality priorities for 2013-14 we are continuing to strive to make
tangible improvements to the care of our patients. This is set within the context of
delivering care in the community or in patients’ homes avoiding unnecessary hospital
visits and admissions. This is an important element of improving the quality of patient
care.
To shape the areas that Bristol Community Health should focus on for quality improvements in 201314, we have sought the views of our patients, carers, staff and stakeholders in a number of ways,
including:
An analysis of themes from complaints received, incidents reported and concerns raised via the
Patient Advice & Liaison Service (PALS) during 2012-13;
Feedback from representatives of Bristol City Council, Bristol Clinical Commissioning Group (CCG)
and Bristol LINK; and
Discussions with our staff at all levels within the organisation in teams and committees.
After careful consideration of the main themes emerging from this feedback, and linked to the
national and local objectives, we have agreed the five key priorities for 2013-14:
1
2
Clinical effectiveness Implementation of Shared Decision Making;
Patient experience Improving information available to patients with particular
3
4
Patient experience Improving the patient experience of end of life care;
Patient safety Utilising the SSKIN bundle for patients with pressure ulcers or at
5
reference to services available and how to contact them;
Patient safety Priority
1
risk of developing one; and
Development of an early warning system for safety and quality.
for 2013-14: Clinical effectiveness
Implementation of Shared Decision Making
Shared Decision Making is a research based approach which empowers patients to
work in partnership with health professionals to manage their long term conditions
such as diabetes, heart disease or neurological conditions.
The government’s vision is for patients and clinicians to reach decisions about treatment together,
with a shared understanding of the condition, the options available, and the risks and benefits of
each of those.
9
Bristol Community Health | Quality Account 2012-13
Our quality priorities for improvement 2013-14
...continued
The Kings Fund report (2011) ‘Making shared decision-making a reality: No decision about me,
without me’ outlines some of the requirements to make this vision a reality. The objectives of Shared
Decision Making are:
• To support patients to articulate their understanding of their condition and of what they hope
treatment (or self-management support) will achieve;
• To inform patients about their condition, about the treatment or support options available, and
about the benefits and risks of each; and
• To ensure that patients and clinicians arrive at a decision based on mutual understanding of this
information and implement the decision reached.
Bristol Community Health is committed to implementing shared decision making and together
with commissioners, has agreed for this development to be monitored via a locally agreed CQUIN.
The aim is to improve the communication skills of clinicians by setting out an approach to patient
consultations where shared decisions can be achieved with patients. It also suggests tools to
help patients to make decisions and will help develop a culture where patient awareness and
understanding is just as important as clinical guidelines.
To evaluate the success of this priority we will:
• Carry out a questionnaire audit of three services.
• Use questions in the Patient Survey which measure any improvements in patients’ sense of
control and access to information.
• Carry out 15-20 in-depth semi-structured interviews with patients to find out how our Shared
Decision Making approach influences the management of their condition.
Priority
2
for 2013-14: Patient experience
Improving information available to patients with particular reference to services and
how to contact them
As part of the consultation process to define the quality priorities, LINK members
identified an area they felt could significantly improve. This was that Bristol
Community Health needs to develop an organisational approach to the development
and implementation of patient information leaflets.
Bristol Community Health had also identified, via patient feedback, that there is a need to improve
the availability of patient information about services, included how to contact them.
The plan for 2013-14 is to review all patient information leaflets, in consultation with patient groups,
to identify gaps and to improve the existing literature. This will be used to develop an action plan to
be reviewed throughout the year.
The 2013-14 patient survey will be an opportunity for Bristol Community Health to evaluate the
improvements made.
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Bristol Community Health | Quality Account 2012-13
Our quality priorities for improvement 2013-14
Priority
3
...continued
for 2013-14: Patient experience
Improving the patient experience of end of life care
This is a priority that we have retained from last year, and the significant
improvements which have been made will form the basis for the year ahead. The
vision of excellent end of life care - available to all who need it - is shared across the
teams and services in Bristol Community Health, as well as with our partners in other
organisations. We will be working together closely and listening to what patients tell
us so that we can further improve patient experience of end of life care.
The things our patients consider most important include thinking ahead and discussing and
agreeing what is most important. This is different for every individual patient, but usually includes
making sure that plans are put in place about where to receive care (and where they wish to die),
making sure that physical and emotional problems are addressed appropriately, as well as the
practical elements that are a part of this.
When patients are approaching the end of their lives it is really important to ‘get it right’ for them –
there is only one opportunity to do this, not only for the individual, but for those who are left behind.
We are already working to ensure we provide the best care possible, and achieve the best
outcomes for patients at end of life stage. We will build on the work already underway, across
Bristol Community Health services, and with our partner organisations.
In the year ahead we intend to do this by:
• Continuing to support patients to die at home, where this is their preference. The Palliative Care
Home Support team works closely with the Community Healthcare Teams (comprising nurses
and other healthcare professionals) to ensure that care is well organised and responsive to
changing needs. This year we will grow our service to support more patients to be able to die
at their place if choice. We are aiming to support an additional 44 patients compared to last
year. Throughout this year we will seek the views of service users in a range of ways, including
an annual survey, postcards and additionally by introducing a feedback slip in our patient
information folder so anyone can respond at any time. We will ensure that all compliments,
complaints or suggestions are collated and responded to, and that service users’ views help to
shape the service provided.
• Asking patients and their family members what they most value at end of life stage. Patients,
and their family members, are currently telling us that they value being treated with dignity and
respect, and want to feel that care is tailored to meet their individual needs. We intend to build
on this by ensuring that it is easy to contact the teams and services, and that we provide clear
information to support our care arrangements, including a patient information sheet, detailing
what the service provides and how to contact a team member or service manager.
• Working closely with our partners to streamline referral processes, not only to provide ease
of access to services, but to protect the time of clinicians so they have more ‘time to care’ for
patients, in line with our organisational strategy. This element of work is detailed in the End of
Life (EoL) CQUIN programme and includes the development of a single unified proforma for
referral to end of life care services (which provide care packages, rather than advisory services)
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Bristol Community Health | Quality Account 2012-13
Our quality priorities for improvement 2013-14
...continued
• Ensuring that our teams are properly trained to support patients, their family and carers
at all stages, to include care at the time of death, and post bereavement. This will include
verification of expected death, so that family members are supported by familiar teams at this
very important time. A training programme will run throughout the year to support staff in this
element of care.
To build upon previous work in meeting patients’ wishes, we will continue to measure:
• The numbers of people who have made specific plans about their end of life care in the form of
advance care planning, as detailed in the End of Life CQUIN programme.
• The numbers of people who actually achieve these wishes, particularly looking at helping
people to stay at home (and to die at home) whenever this is their wish. • The views of patients, and their family members, about the experience of care from Bristol
Community Health services at end of life stage, inviting views from everyone who receives the
services, in addition to snapshot sampling via surveys.
4
Priority for
2013-14: Patient safety
Utilising the SSKIN bundle for patients with pressure ulcers or at risk of
developing one
This is another priority that we have retained from last year. Significant improvements
have been made and this improvement needs to continue and grow. Last year’s work
in this area has ensured we now have almost complete implementation and training
on the use of the SSKIN bundle within our teams. This year we plan to demonstrate
the benefits and outcomes of this priority.
We are now in a much better position to monitor our incidence of pressure ulcers and the impact
of SSKIN as we move forward over the coming year. It is important for us to know how many
pressure ulcers were avoidable and how many were unavoidable and root cause analyses (RCAs)
are now in place for all category 3 and 4 pressure ulcers. Throughout 2013-2014 all the RCAs for
category 3 and 4 will be examined to determine which pressure ulcers developed, those that were
avoidable and any lessons learnt. Our aim is to empower our staff to be increasingly proactive in
the prevention of pressure ulcers.
The nutritional component of SSKIN has been developed with education for clinical staff on the
Malnutrition Universal Screening Tool (MUST) and local Bristol Community Health guidelines
on strategies to address identified at risk patients. Plans to provide MUST guides for staff and
nutritional advice leaflets for patients will be implemented this year.
The commitment to the reduction of pressure ulcers is a priority within Bristol Community Health as
an organisation and will continue to be so. In 2013-14 we will:
• Implement SSKIN in all appropriate services in Bristol Community Health;
• Have incidence data for pressure ulcers for Bristol Community Health patients; and
• Implement a system to share learning from all RCAs of category 3 and 4 pressure ulcers. 12
Bristol Community Health | Quality Account 2012-13
Our quality priorities for improvement 2013-14
Priority
5
...continued
for 2013-14: Patient safety
Development of an early warning system for safety and quality
In 2010 the government commissioned Robert Francis QC to report on the failings
of care at Mid Staffordshire NHS Foundation Trust between 2005 and 2008. This
report concludes with 290 recommendations for regulators, commissioners and care
providers.
Francis identified a prevailing negative culture, professional disengagement, the patient voice going
unheard, poor governance, lack of focus on standards, inadequate risk assessments, poor clinical
leadership and priorities of targets over patient care. These are themes that run throughout the
report and have been identified as the key issues that led to the failures in care.
The issues identified in the Francis Report are echoed within other documents (NHS Ombudsman
2010, South Gloucestershire Safeguarding Adults Board 2012, Kings Fund 2012, CQC 2012)
highlighting that it is unlikely the incidents described in the report would only have been found at the
Mid Staffordshire Foundation Trust.
There have been developments of early warning sign indicators for NHS organisations following
the publication of a review by the National Quality Board (NQB) in 2010. However these have
predominantly been for acute organisations. There are themes that translate to community services
and echo themes of the Francis report:
Creating an environment where staff feel supported enabling openness and compassion;
Creating time to care through the use of models such as the productive community series;
Pay progression linked to quality of care, behaviours and attitudes;
Minimum training standards for health care assistants;
Compliance with CQC standards; and
Listening to patients’ experiences and concerns.
The NQB highlighted that any early warning system is not about a single organisation or process
but would start with the provider. They acknowledge that measuring quality is a moving target and
we need to continuously review how this is measured and the evidence in this area.
They put great emphasis on the engagement of staff emphasising that the success of any system
or process is dependent on the values and behaviours of clinicians particularly in relation to raising
concerns about care. This was reiterated in the Francis Report as many clinicians viewed the
problems with care as being the managers’ responsibility.
13
Bristol Community Health | Quality Account 2012-13
Priority
5 Next steps
We intend to develop and evaluate a quality dashboard as an early warning signs
indicator with a traffic light scoring system. The components of this dashboard will
include:
Staff survey – particularly the ‘friends and family test’ for the care delivered by the organisation;
Reports of use of the whistleblowing policy/safeguarding policy – anonymised reports of
complaints or alleged harm to patients from Bristol Community Health staff – investigations and
actions to be reported to the Board;
Clinical Director’s quarterly report to include update on supervision structure and competency
framework;
Complaints about clinical care to be summarised with actions taken and reported to the Board
Board to consider how patient stories can be used to inform them about the quality of services;
Chief Nursing Officer’s Vision for Nursing to be implemented as part of the Making Their Day
strategy workstream;
Summary of incident reports detailing inadequate staffing levels to be provided quarterly to the
Board; and
Uptake of performance development reviews for the Bristol Community Health workforce.
Developing quality improvements capacity and capability to deliver
these priorities
At Bristol Community Health we believe that if quality is to be at the heart of everything we do, we
must strive to ensure we have the capacity, capability and competency to deliver quality services.
We will continue to develop the vision of improvement and innovation in our services to deliver better
outcomes for our service users.
The Bristol Community Health strategy as a whole demonstrates our commitment to improving our
capacity and capability to improve quality.
Other areas of quality improvement
Our five priorities for improvement for 2013-14 are not the only areas of quality enhancement planned
for 2013-14. We will also deliver the quality improvements outlined in our contract and across the
CQUINs (identified on pages 30-31).
We will also contribute to the overall delivery of the system-wide Quality Innovation Productivity and
Prevention (QIPP) plan. This outlines the opportunity of improving patient care experience through
offering care closer to home and avoiding unnecessary admissions. In particular we are committed to
introducing a wider range of Patient Related Outcome Measures (PROMs) to our portfolio of measuring
the quality of our outcomes.
We have identified PROMs as a tool which can be used to demonstrate quality and value in
community services. PROMs are self-reported questionnaires validated for a range of generic or
condition specific Health-Related Quality of Life (HRQoL) assessments.
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Bristol Community Health | Quality Account 2012-13
Other areas of quality improvement
...continued
Our Quality performance will be monitored through Bristol Community Health’s Quality Assurance
and Governance processes. This will include regular reports to the Board, Quality Assurance and
Governance Committee and the Clinical Governance Working Group.
Statements relating to the quality of NHS services provided
This section relates to a Department of Health mandate to report on a core set of
quality indicators so that this information is available to the public through the quality
account. The two indicators which are relevant for Bristol Community Health are:
1
Finding out from our staff whether they would recommend our services to friends and family.
Although this specific question was not included in the 2012-13 survey, we did ask staff if they
agreed with the statement: “In my opinion Bristol Community Health is committed to excellence
in patient customer care,” and 77% of staff responded positively. The friends and family test will
be included in the next annual Staff Survey and we will be able to report our findings in the 201314 Quality Account.
2
The number of patient safety incidents during 2012-13 and if any of these have resulted in severe
harm or death.
In 2012-13 we had 1,104 patient safety incidents. Of these, 22 were Serious Incidents Requiring
Investigation (SIRIs). None of these patient safety incidents resulted in severe harm or death
attributable to the incident.
The following learning points have been implemented:
Risk assessments are a crucial part of a prevention strategy;
Good communication with staff and patients is instrumental in good care;
Increasing availability of knowledge and training empowers staff to deliver good practice; and
An open and transparent culture promotes greater learning.
Information gathered from reported incidents is scrutinised in a number of regular meetings and
working groups where trends and learning are identified. These points are recorded to enable
progress with learning to be monitored by the senior management team.
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Bristol Community Health | Quality Account 2012-13
Part 3
Review of 2012-13
achievements
Part 3
Review of 2012-13 Quality performance Outlined in this section is a review of our quality performance against the priorities set
in the 2011-12 Quality Account.
Priority
1
for 2012-13: Patient safety
Pressure ulcers
Pressure ulceration causes pain and suffering and is costly in terms of resources. It has been
estimated that 4% of NHS spend is on pressure ulcer care in the United Kingdom (Bennett et al 2004)
and between 2005 and 2010 there were 75,000 patient safety incidents reported nationally to the
National Patient Safety Agency (NPSA) of patients developing pressure ulcers.
Pressure ulcer prevention in the community is extremely challenging with vulnerable and unwell
patients living alone and often with small or no packages of care making the reality of assisting the
patient to move regularly (which helps to avoid pressure ulcers developing), and monitoring their skin
condition, very difficult. It has been recognised that the implementation of prevention strategies such
as the ‘SSKIN’ care bundle (Quality Improvement Scotland), which addresses the key components
of pressure ulcer prevention, can be very effective. The components of the bundle are: Surface, Skin
inspection, Keep moving (repositioning), Incontinence and moisture and Nutrition and hydration.
Educating health and social care staff and patients on the key elements of SSKIN can be very effective
in the prevention of pressure ulcers. Working collaboratively with social care agencies is essential to
the success of this care bundle, as home carers are in a key position to monitor patients’ skin on a
daily basis and previously this has been a barrier to the success of preventative measures.
Our vision was to implement this strategy to safeguard patients under the care of Bristol Community
Health against the development of pressure ulcers and ultimately reduce pressure ulcer incidence.
The pressure ulcer prevention project entitled ‘Pressure Ulcers – everybody’s business’ involved the
development of 4 new protocols of care which are linked to the Waterlow assessment tool and
associated predicted level of risk. The protocols include all the preventative components of the SSKIN
care bundle. Health staff identify opportunities for repositioning, care of skin and nutrition and work
collaboratively with social care staff to implement the care plan. Important shared documentation is
used to evidence that the SSKIN care plan is being carried out.
SSKIN materials
•
•
•
•
•
Colour coded ‘protocols’ have been developed for ease of identification
SSKIN documentation for shared use with social care staff
SSKIN awareness postcards
Posters to raise awareness
Educational ‘flash cards’ for patients
This is innovative work, bridging organisational boundaries to ensure the success of this project for
the benefit of patients and has been very positively received by the care agencies.
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Bristol Community Health | Quality Account 2012-13
Part 3
Review of 2012-13 Quality performance ...continued
Patients and their families are being provided with educational laminated flashcards cards to show
how they can help look after their skin and prevent pressure damage.
Audit
Bristol Community Health has engaged in a CQUIN target around the project. Once the protocols,
documentation and educational initiatives were embedded with staff, the use of the protocols was
audited. A total of 200 patient case notes were audited in October 2012 with a result of 81.3% SSKIN
implementation and a further 226 case notes were audited in January with a result of 86.2% SSKIN
implementation, exceeding the 70% target. A further audit was carried out in April 2013 of which a
90% target has been set (95% achieved). A target is being developed for 2013-14 regarding improving
the reporting of pressure ulcer incidence.
While Bristol Community Health does have data on pressure ulcer incidence, we do not as yet have
any specific data on the impact of SSKIN on the incidence of pressure ulcers for our patients. A
secondary aim for the project, and for Bristol Community Health as an organisation, was to ensure
our reporting was more accurate, and the introduction of online reporting and training has helped
achieve this. Alongside the implementation of the project we have educated staff on the mandatory
reporting of all grades of pressure ulcers, and as we anticipated, the associated awareness resulted
in an initial rise in reporting.
Anecdotally, over this last year we have seen a considerable increase in the awareness of pressure
ulcer prevention both with our health staff and social carers since the SSKIN project. The wound care
service and project team are committed to maintaining the momentum of SSKIN and pressure ulcer
prevention and anticipate seeing a reflection of the impact in a reduction of avoidable pressure ulcers
over the coming years. The CQUIN performance indicator is being set up to monitor this.
Priority
2
for 2012-2013: Patient Safety
Frail Elderly Pathway
Bristol Community Health provided a leadership role in the development of the Healthy Futures
Frail Older People’s Project. The project group brought together representatives from social care,
commissioners, acute and community services in Bristol, South Gloucestershire and North Somerset.
The group has made significant progress in 2012-13 including:
• 360 degree feedback exercise to identify gaps and best practice in relation to services for frail
older people;
• A literature review of the evidence for models of care;
• Designing and implementing a rapid improvement event which was attended by 79 key
stakeholders where short term action plans were identified for Bristol, South Gloucestershire and
North Somerset; and
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Bristol Community Health | Quality Account 2012-13
Part 3
Review of 2012-13 Quality performance ...continued
• The development of a standard self-assessment tool which could be used by agencies individually
or collectively to identify gaps in the system and for individual providers. This tool defines the
stages of a pathway for frail older people including case finding, comprehensive geriatric
assessment, sharing information and end of life care.
There are some key themes which have been identified by the project group through this work:
• Definition of this group should not be age related;
• Case finding via a risk stratification tool is required;
• Comprehensive geriatric assessment is an evidenced based tool that will improve outcomes for
this group of patients;
• Care co-ordination both at home and in hospital is essential;
• Sharing information needs to be improved; and
• A tariff and funding review to reposition financial incentives is required.
The results of this project have led Bristol Community Health to embark on a number of projects to
improve care for older people with complex needs:
• We have conducted a joint pilot with Bristol CCG and North Bristol NHS Trust on the input of a
Consultant for Medicine for the elderly in our rapid response service which improved care to
patients and links with GPs. This model provided consistent and expert medical cover to the rapid
response service and improved care planning for those frail patients where accurate medical
diagnosis was most challenging. The consultant improved advance care planning, diagnosis
of delirium and dementia and the medical management of frail older people with complex
conditions, in addition to providing educational and supervisory support to the professionals in the
rapid response teams.
• We have integrated community healthcare teams to improve cover and to prevent duplication to
frail patients and those with long term conditions.
• An educational model and competency framework for nurses and Allied Health Professionals
(AHPs) has been developed, supported by a bursary, in comprehensive geriatric assessment to
improve quality of care and outcomes for people with complex conditions. A pilot module is being
run from April to August 2013 and evaluation will include outcomes in clinical practice. This was a
joint project with North Bristol NHS Trust whose consultants in medicine for the elderly have been
involved in the development and delivery of the module.
• Our falls pathway has been reviewed and the assessment tool updated to include additional
improvements such as nutritional screening and identification of memory problems. A training
programme to support this is currently being delivered to all Bristol Community Health clinical staff
who are required to provide falls assessments.
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Bristol Community Health | Quality Account 2012-13
Part 3
Review of 2012-13 Quality performance Priority
3
...continued
for 2012-13: Clinical effectiveness
Productive services
Fourteen community healthcare and learning difficulties teams across Bristol Community Health have
been undertaking the Productive Community Services (PCS) programme and have completed the first
module, making improvements to the working environment.
The aim of embedding the productive series at Bristol Community Health was to enable staff to
release more clinical time to undertake patient facing duties, to increase their effectiveness and our
understanding of our patients’ experiences.
As part of the national Transforming Community Services agenda, the transformation of community
services within Bristol Community Health has led to the development of eleven integrated community
nursing teams. These teams, together with the three locality learning difficulties teams and the HMP
Bristol team, attended a very successful Productive Community Services launch event led by the NHS
Institute for Innovation and Improvement. The NHS Institute for Innovation and Improvement has
highlighted improved patient safety and satisfaction, improved staff morale, reduced waste, and
more effective processes as successful programme outcomes.
The multi-disciplinary teams have begun to implement the following PCS modules:
•
•
•
•
•
Well organised working environment;
Knowing how we are doing;
Patient status at-a-glance boards;
Managing caseload and staffing; and
Working better with our key care partners.
Throughout 2012-13 teams have worked on module one: ‘Well organised working environment’ and
module two: ‘Knowing how we are doing’.
In November 2012 a workshop was held with facilitation from the institute to launch modules two and
three and a number of the teams have now completed the second module. In addition the Board has
held their own workshop which was attended by some of the team leaders and champions for the
programme. Additional support has also been sought through the facilitators and corporate services
(HR, PPI and Performance) to further develop the metrics for module two.
Some of the additional benefits realised during the early phase of this programme have been:
• A reduction in time spent searching for information during preparatory stages of patient contact or
visits.
• Development of new policies and standard operating procedures, for example a clean kitchen
and stationery replacement policy.
• Reorganising filing and improving the way in which information and records are stored.
20
Bristol Community Health | Quality Account 2012-13
Part 3
Review of 2012-13 Quality performance ...continued
• Timeliness of midday handover between teams has improved reducing the incidence of morning
visits needing to be reallocated in the afternoon and therefore improving team capacity planning.
• Standard operating procedures are now in place to sustain the storage of equipment and stock.
• Call handling processes have been centralised to improve recording of messages and
communication.
• Suggestion boards have been developed in offices to ensure ideas for ongoing improvement are
captured.
• Hot desking is operational within some teams which has improved the flexible use and availability
of desk space.
Priority
4
for 2012-13
Urgent Care strategy
• We have improved access to non-acute hospital alternatives by opening the Urgent Care Centre
at South Bristol Community Hospital.
• Patients with minor injuries and illnesses are now assessed and managed within the Urgent Care
Centre by experienced nurses and Allied Health Professionals (AHPs).
• Patients are referred to the right service provider thus smoothing demand and capacity across the
urgent care system for the benefit of patient care and experience.
Bristol Community Health continues its commitment as a key partner of the urgent care agenda by
supporting the management of more patients in the community and reducing the dependency placed
on acute trust emergency departments.
Bristol Community Health’s Urgent Care Centre (UCC) provides a non-acute hospital alternative by
enabling patient pathways to other primary care alternatives, while offering a cost effective service
and ensuring that secondary care referrals are appropriate.
At the heart of the urgent care agenda is a need to continue to respond to urgent care commissioning
requirements across the region, striving to provide the best possible treatment at the point of care
alongside ongoing collaboration with GP services and secondary care specialist services.
The UCC is compliant in all CQC outcomes and is committed to striving for excellence in care. The
Paediatric Lead Nurse Practitioner has continued to ensure safeguarding practices are high through
local education. There is now a lead for Adult Safeguarding within the UCC and a high risk domestic
abuse pathway has been developed.
The UCC has completed several positive internal and external audits of the new fracture pathway
enabled by collaborative secondary care partnerships with the emergency department (ED),
orthopedic and radiology teams. An ED audit carried out as part of the fracture clinic pathway set up
in April 2013 showed that 94% of UCC referrals to fracture clinic were appropriate.
21
Bristol Community Health | Quality Account 2012-13
Part 3
Review of 2012-13 Quality performance ...continued
It also showed that 70% of all medical and surgical referrals and 80% of other referrals were
appropriate. The UCC practitioners now refer weekday medical referrals via GPSU so that low risk
outpatient pathways can be accessed and referrals are sent with an audit feedback form. In July 2012
the orthopedic team at University Hospitals Bristol (UHB) showed that 81% of the fracture clinic referrals
they received from the Urgent Care Centre were appropriate; similar results were found with the
Bristol Royal Infirmary ED fracture clinic referrals. In September 2012 the orthopaedic team produced
guidelines for referral.
The UCC now refers the majority of soft tissue injuries to physiotherapy via the GP; the development
of a soft tissue clinic within the UCC would enhance the experience for patients further. Four internal
audits have identified a missed adult and paediatric fracture rate of less than 3%; comparison of initial
assessment was compared with radiology report. Having a reporting radiographer on site at South
Bristol Community Hospital (SBCH) has been invaluable in terms of teaching, support and has enabled
robust X-Ray reporting systems to support clinical governance. There are plans to incorporate fracture
clinics within the UCC by 2014.
Bristol Community Health is committed to responding to patient feedback and the UCC produces
quarterly reports and liaises collaboratively with lead providers, local community groups and
stakeholders. Next year’s priorities are to continue to improve waiting times for patients by developing
a more effective triage process. A dedicated triage room has been allocated near the waiting room
to enhance patient access to painkillers, diagnostics and advice. There is also an ongoing need to
improve access to patients from ethnic minorities and those with disability needs. This year we have
presented on community radio shows and attended several local community meetings to reach these
groups.
The UCC had developed a skilled workforce that is able to meet the needs of both adult and pediatric
attendees who have limb, soft tissue or bone injuries requiring x-rays and potential onward referral
through agreed clinical care pathways. This is supported by in-house clinical supervision and teaching.
The practitioners see a wide range of patients with undifferentiated, undiagnosed, minor illnesses
and injuries and have the benefit of near patient testing i.e. glucose testing equipment and pregnancy
testing. The UCC is committed to supporting and training practitioners in non-medical prescribing to
enhance the patient experience by widening practitioners’ scope of practice. Practitioners respond
to patients with a wider range of acute conditions and collaborate closely with local GPs and the GP
support unit to try and prevent avoidable hospital admissions and potentiate patient primary and
secondary pathways.
Priority
5
for 2012-2013
Diabetes Pathway and Single Point of Access (SPA) for Diabetes Services within Bristol
Community Health
After a successful move on 1 October 2012 the newly integrated Diabetes and Nutrition Services (DANS)
is now co-located at John Milton Clinic, Henbury. A central point of access is now in operation which
extends the office availability to Diabetes Education, Diabetes Specialist Nursing and Nutrition and
Dietetics to five days a week 8am-4pm as a minimum.
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Bristol Community Health | Quality Account 2012-13
Part 3
Review of 2012-13 Quality performance ...continued
Co-locating administrative staff has enabled clinical staff to focus on clinical delivery and improving
patient outcomes. A single DANS referral form was trialled with mostly positive feedback to date, then
amended and rolled out across Bristol. A mapping exercise is currently being undertaken to identify
gaps in referrals and to ensure that clinical availability matches clinical need.
Increased technology is currently being installed to enable us to electronically scan service user
feedback on our performance (particularly in diabetes education) which has allowed us to make more
detailed analysis of feedback.
Bristol Community Health has remained active participants in Bristol, North Somerset and South
Gloucestershire commissioning and development discussions to improve diabetes outcomes
particularly community diabetes provision and improving outcomes for diabetic feet, led by the Podiatry
Service.
The DANS team has been keen to address inequality and has worked on a number of projects with
the South Asian community, local Diabetes UK support groups and learning difficulties teams to ensure
that as far as practicable everyone can access our service. We are working alongside Public Health
colleagues in the coming year on a pilot to establish ‘Community Health Champions’ in diabetes for
black and ethnic minority groups.
As part of our ongoing commitment to support people with long term conditions to manage their
condition all of the DANS team (both clinical and administration) have undertaken training in Shared
Decision Making. We have also been instrumental in the introduction of the Personal Diabetes Care
Plan as a tool to support people with diabetes in their self-management. Our Community Diabetes
Specialist Nurses will also be working to support our telehealth programme to pilot a number of
telehealth systems for people with diabetes.
Comments from some of our service users include:
throughout my
Supportive and helpful
h more confident
treatment. I feel so muc
abetes - for which I
about managing my di
am very grateful.
Excellent course
. Both educators
explained
everything in de
tail and I now kn
ow more
in one month th
an the 10 years
I
have had
diabetes. Thank
you.
23
Bristol Community Health | Quality Account 2012-13
...first cla
ss s
improvem ervice, no
ent need
ed.
ry
...A good day, ve
it will
informative, and
nce to
give me confide
betes.
manage my dia
Part 3
Review of 2012-13 Quality performance Priority
6
...continued
for 2012-2013: Patient experience
Telehealth services
Telehealth services assist and enhance existing clinical roles through the provision of remote
monitoring of symptoms and vital signs, such as blood pressure and weight, for assessment and
prevention of exacerbations. Data is transmitted to a clinician’s computer where it is monitored against
parameters set by the patient’s clinician. Results falling outside the parameters trigger an alert, which
lets community nurses know when there is a problem.
Early project work in this area identified problems with clinician engagement and in developing the
clinical pathway. Therefore a number of actions were taken to improve this:
• A Clinical Champion for Assisted Technologies (CCAT) was appointed to support teams to identify
ways of increasing referral rates;
• The CCA works with a number of GP practices and secondary care to develop pathways for referral
and on-going support for patients who would benefit from the use of telehealth; and
• To increase confidence and expertise among clinicians, a number of training courses were
delivered at the beginning of 2013.
Early audit results with the population of two GP practices have shown a 50% and 70% decrease in
consultations respectively at 3 months and 6 months of telehealth monitoring for individual patients.
The audit results now need to be triangulated with patient experience data. An audit of the impact of
telehealth showed a statistically significant decrease in emergency admissions for those patients with
heart failure and chronic obstructive pulmonary disease who had been using telehealth for more than
3 months.
To facilitate a robust evaluation of the patient experience of telehealth a Patient and Public Involvement
exercise (jointly with Bristol CCG and Bristol Community Health) has been undertaken to identify
patients’ views of telehealth. The majority of patients (more than 80%) surveyed felt the devices are
easy to use. Patients also stated that it fitted in with their daily routine and overall satisfaction was
high. There was an overall value for the system with people feeling it had a positive effect on their lives,
including feeling that they were more confident to manage their own health.
Comments were very positive, and the survey showed that patients felt they had confidence to
manage their condition using telehealth:
ing I can
I’m more confident know
]... I’d
rse
nu
get in touch with [the
into
go
n
rather call the nurse tha
hospital.
I feel more confident. If anything goes wrong, I know they’ll pick
it up straight away - I know someone is at the other end. I used
to phone the doctor and was always hospitalised. Now they
[the nurses] come out to see me.
I had it for 3 months
, that was
enough to make a dif
ference
in change of habits.
24
Bristol Community Health | Quality Account 2012-13
...keeping a better eye on my
health and my own weight which has dropped.
Part 3
Review of 2012-13 Quality performance ...continued
A further evaluation of the service to include the impact of telehealth on healthcare professionals and
future planning is being undertaken and will be completed in quarter two.
The Telehealth team is currently working on a project plan to pilot telehealth with patients with
diabetes. The pilot is planned to start early summer 2013.
Priority
7
for 2012-2013: Patient experience
End of life stage
Last year, in order to improve care at end of life stage, we said we would:
•1 Measure the number of people who have made specific care plans about the end of life care in the
form of advance care planning:
Over the last year our understanding of the importance of advance care planning has increased,
across all services in Bristol Community Health. Our teams are talking to people about their
wishes, and with their permission are sharing that information with colleagues across the area,
for example the ambulance service and voluntary care providers) to ensure everyone who needs
to know has access to this important information. Some elements of information about advance
care planning are difficult to share electronically, especially when individuals are working through
the process of deciding on their wishes, in line with governance rules about sharing sensitive
information of this nature. Also, because there are a range of electronic systems used by our own
staff, primary care and voluntary and other partners, this element of work is challenging at times.
Work is however on going to streamline these systems wherever possible, supported by the end of
life care programme.
There is however increasing evidence that people who have recorded their wishes in the form
of advance care plans, and consent to sharing this information on the electronic register, are
more likely to achieve their preferences for care at end of life stage, and are more likely to avoid
unwanted and unnecessary hospital admissions.
•2 Record the number of people who actually achieve these wishes, particularly looking at helping
people to stay at home (and to die at home) whenever this is their wish:
In 2012-13 the proportion of people at end of life stage, living in the Bristol area and served by
Bristol Community Health, who died at home increased to almost half (48% based on latest
projected figures, compared with 46% in the previous year) (End of Life Programme Definition
Document, Version 01, 11/03/13). Our aim is always to help people achieve their aims at this very
important stage of life, understanding that sometimes these plans might change depending on
circumstances.
•3 Satisfaction of patients and their carers – knowing that compassionate care and being treated with
dignity are highly valued, and asking patients and carers about their experience of care from our
services at the end of life stage.
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Bristol Community Health | Quality Account 2012-13
Part 3
Review of 2012-13 Quality performance ...continued
At end of life stage, care is provided by a range of teams and services across our organisation
including the Palliative Care Home Support (PCHS) service. This service comprises registered nurses
and health care assistants and helps to support patients who wish to be cared for and to die at
home. We know that patients and their family members really value being treated with dignity, and
the cards and letters received over this year continue to tell us that.
The annual patient survey formed part of this work – out of 18 participants asked to complete the
survey 11 responses were received, giving a 61% response rate. Of these 100% felt the PCHS service
understood their concerns about their condition, and that they received a warm greeting. 100%
also felt that they were treated with dignity and respect and that the treatment or care plan was
tailored to their needs. 100% were happy with their appointment arrangements. Only 27% percent
of participants felt confident that they could manage their own health or condition, but this is
unsurprising given the nature of the service.
Compliments
The PCHS service received 36 cards and letters during the year, from relatives of patients who had died
at home. Examples of what people have written to us* this year include:
The words ‘Thank You’ seem so inadequate but
they are truly heartfelt from myself and my family
... We feel that Joseph was at peace during his
last few hours.
Thank you for the
kindness, compassion
and competence
when looking after my
husband, you enabled
him to stay at home.
le who nursed
To all the kind peop
husband. We will
and attended my
d
your friendliness an
never forget how
s
hi
ed
in
g ways ga
your happy, carin
.
tever was going on
ha
w
confidence -
I wish to express my deep
gratitude for the excellent
care given to my beloved
husband during his last few
hours, you all do such a
marvellous job as such a sad
time in peoples’ lives and I
feel privileged to have had
that support.
Please convey the family and
my grateful thanks to all the
nurses and carers who were
so
amazingly kind and caring,
and
enabled Craig to stay at hom
e
with his family which was wh
at
we both wanted.
In addition, the PCHS service asked patients or carers on their behalf, to complete a short questionnaire
to share their views about the service. The full survey results are available on the Bristol Community
Health website, including the following key points:
• Patients and their family members were very pleased with the service provided by PCHS and would
be extremely likely to recommend the service to others in similar circumstances.
• Very positive feedback was received on the way the team members communicate and treat patients
with dignity and respect.
• Although most people reported that they knew how to contact the team, there is some work to do to
ensure information is clear and accessible to everyone who needs it.
* Where patients’ names were given we have changed them to protect privacy.
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Bristol Community Health | Quality Account 2012-13
Part 3
Summary of services provided during 2012-13
During 2012-13 we provided 34 community healthcare services commissioned by the NHS in and
around Bristol. Please find below a list of our services:
Community Nursing services (including
multi-skilled teams):
•
•
•
•
•
•
•
Community Matrons
Community Nurses for Older People
District Nursing
Continence
Dermatology
Falls Prevention
Palliative Care and Cancer Help for Ethnic
Minorities (CHEC)
• Phlebotomy
• Tuberculosis Contact Tracing and Screening
Service
• Wound Care and Tissue Viability
Therapy Services:
• Domiciliary Physiotherapy (with specialisms
in neurological rehabilitation and elderly
care and fallers)
• Musculoskeletal Physiotherapy
• Musculoskeletal Assessment and Treatment
Service (MATS)
• Occupational Therapy (with specialisms
in neurological rehabilitation and seating
assessment)
• Podiatry
• Spinal Assessment and Treatment Service
Long Term Condition Services:
• Chronic Obstructive Pulmonary Disease (COPD)
including pulmonary rehabilitation
• Diabetes Education
• Diabetes Specialist Nursing
• Heart Failure
• Dietetics
• Parkinson’s Specialist Nurse
Intermediate and Urgent Care Services:
• Intermediate Care and Reablement
• Single Point of Access (SPA)
• South Bristol Community Hospital Urgent Care
Centre
Unique Services:
• Disabled Adults Resource Team (DART) now
integrated with the Community Neurology
Service
• Diabetic Eye Screening Programme
• The Haven
• Healthlinks
• Health Assessment and Review Team (HART)
• Infection Prevention and Control
• Learning Difficulties
• Prison Healthcare
• Safeguarding Services
We have a joint commissioning plan with Bristol City Council to integrate urgent, unplanned health
and social care. We will expand on this in the coming year and are looking to deliver further
integration of services this year, including through the submission of a bid to become one of the
‘pioneer’ areas for intergrated care.
We have reviewed all of our quality data in relation to providing these services. This information has
come from a range of sources including local and national audits, patient surveys, national targets,
locally agreed performance measures and last year’s CQUIN targets.
During 2012-13, the Board received monthly performance reports and quarterly quality reports which
provided evidence of progress against the performance indicators for safety, quality and performance
27
Bristol Community Health | Quality Account 2012-13
Part 3
Summary of services provided during 2012-13
...continued
across all of our services. The Board has overseen the development of a performance dashboard
which will provide an integrated approach to performance management and business planning by
implementing a reporting and documentation management solution for key performance information.
This includes managing evidence for our Quality Account and compliance with our key regulator for
safety and quality, the Care Quality Commission (CQC).
Summary of end of year successes for 2012-13
In this section of our Quality Account we report against our quality priorities by reviewing
our contract with commissioners at the end of this financial year.
We provide a summary of the report here, showing progress against our stated national targets. This
section is divided into four key themes for reporting our key areas of success:
•
•
•
•
Performance against national quality priorities 2012-13;
Performance against national and local CQUINs and contracted activity;
Awards received by Bristol Community Health;
Examples and local case studies of specific quality improvement initiatives relating to patient safety,
clinical effectiveness and patient experience.
Patient and Public Involvement
Our patient and public involvement work can be summarised under three main
headings: ‘Listening’, ‘Reaching out‘ and ‘Working together‘.
Listening
Our approach to ‘Listening’ this year included for the first time a survey of patients from all our services;
this will now be repeated annually. During November, 2,240 of our service users filled in a questionnaire
which asked nine questions about their experiences. The results from this provided an overall median
satisfaction score of 95%. During the year the rapid response teams, the walk in and urgent care
services issued pre-stamped postcards. The response from patients gave real-time feedback which
was useful and helped alert us to teething problems being experienced by patients using the Urgent
Care centre at the new South Bristol Community Hospital. Qualitative methods were also used including
in-depth interviews with patients of the telehealth service. In the future we plan to use volunteers to
interview patients to help us obtain continuous, real-time data.
We ‘reach out’ to our patients and the public in different ways. Two ‘learn and share’ discussion groups
were held with patients, carers and other stakeholders with an interest in urgent care services and long
term conditions. Health and Wellbeing events were held at HMP Bristol Health and HMP Eastwood Park,
which were also opportunities to engage with the prisoners and hear what they had to say.
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Bristol Community Health | Quality Account 2012-13
Part 3
Patient and Public Involvement
...continued
The Urgent Care Centre has carried out health checks at Asda supermarket to promote the service
amongst residents in the south of Bristol.
Reaching out to those who find it difficult to access mainstream services is something we are
developing. This year the Diabetes Education team delivered a number of sessions at Dhek Bhal, an
Asian Community Centre. In addition, several of our services took part in the Self Care Day held at
Charlotte Keel Health Centre to mark Self Care Week.
Working Together
We work collaboratively with a range of other organisations; Bristol Links has been a close partner and
we look forward to working now with Healthwatch since the changes that took place in 2012. We are
active members of the Bristol Equalities Health Partnership (BEHP), the Charlotte Keel Partnership Board
and we host the TB Awareness Group.
Working together with staff and hearing their feedback is also important. This is done through meeting
with teams, team training, and staff induction.
An important contribution is also made by members of the public who volunteer with us, as they are
key to providing feedback on our patient information leaflets and provide a patient’s perspective when
discussing forward looking plans.
Performance against national quality priorities 2012-13
The following table provides an at-a-glance look at Bristol Community Health’s performance against key
national indicators. We have used our 2011-12 figures as a baseline for comparison.
Indicator
2011-12 (baseline)
2012-13 reporting
Serious Untoward Incidents
Never events
Incidence of falls
Incidence of pressure ulcers
Medication Incidents
Adverse incidents
16
0
17
130
255
805
22
0
22
195
333
1104
Infection control
Pre 48 hour infections with Bristol Community Health services involved in patient care
MRSA
4
2
3
0
bacteraemias Clostridium difficile Infections
leading/contributing to Death or Colectomy
Complaints investigated and responded to within
100%
93%
28 days
29
Bristol Community Health | Quality Account 2012-13
Part 3
Performance against national quality priorities 2012-13
...continued
Issues of note here are the increase in the reporting of all incidents (detailed narrative on the incidents
and response to complaints can be found on pages 38-39.) Based on the total number of incidents
reported in 2012-13, the level of patient harm has remained constant in terms of percentages in
comparison to 2011-12, and this suggests that the increase in reporting can be attributed to improved
staff training and our new system for on-line reporting.
2012-13 saw a number of complaints needing to be extended due to their complexity or difficulty
in obtaining the necessary information for closure. In the past such complaints may have been coordinated by NHS Bristol but now this is done by Bristol Community Health and will be included in our
figures, hence a delay can be seen in a small number. In situations of this type we remain in contact
with patients and their families to ensure they are updated on the progress of investigations.
Performance against national and local CQUINs and contracted
activity
CQUIN (Commissioning for Quality and Innovation) targets
The Commissioning for Quality and Innovation (CQUIN) payment framework is an incentive scheme
between providers and their commissioners aimed at fostering innovation and improving quality in
service delivery. In 2012-13, 2.5% of the Bristol Community Health contract value commissioned by
the Bristol Clinical Commissioning Group (CCG) was linked directly towards the achievement of these
CQUIN targets. Our year end position shows that we met or exceeded all our targets and registered
some outstanding achievements in the following areas:
• Our annual patient survey showed that 97% of our patients felt they were treated with dignity and
respect and we are acting upon feedback to improve the way in which people can contact our
services and further improve confidence levels of patients in managing their own condition;
• A new screening process for patients with dementia has been successfully rolled out with partners
in Primary Care and Mental Health and evidence shows that over 90% of new patients referred are
being appropriately screened and referred to GPs for specialist diagnosis;
• We have embedded the Patient Safety Thermometer tool within our services and our monthly spot
checks for over 500 patients shows that in 89% of instances there is no patient harm;
• Almost 400 telehealth units have been installed in the community to empower patients with chronic
obstructive pulmonary disease (COPD) and heart failure to manage their own condition;
• Our mobile working pilot to increase patient facing contact time has been developed within the year
and we are expecting results to be available in 2013-14;
• Over 100 referrals have been made to support carers to the local authority based team that
assesses their eligibility for a break;
• Our urgent care services including rapid response, urgent care centres, REACT and intermediate
care have successfully contributed towards system-wide objectives to reduce the number of
emergency admissions to hospitals across BNSSG;
• Our end of life care services have supported system wide objectives to reduce the number of deaths
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Bristol Community Health | Quality Account 2012-13
Part 3
Performance against national and local CQUINs and contracted activity
...continued
in hospital and have improved processes for supporting people to die at their preferred place of
care;
• Our Productive Community Services (PCS) programme is underway in 14 of our locality teams which
has started to improve productivity, quality and staff wellbeing;
• Over 98% of the Bristol population eligible for a health check were signposted correctly by our
community learning difficulties teams which has subsequently improved the rate of health check
completion within Bristol GP Practices; and
• We have introduced new protocols and documentation for pressure ulcer prevention and the end of
year audit shows that our locality teams are 94.5% compliant with these principles.
Areas of consistently good or improved performance in 2012-13
• We have achieved all of our quality and innovation incentive scheme targets as outlined under the
2012-13 CQUIN programme;
• Our therapy services including the Musculoskeletal Assessment and Treatment Service (MATS) and
spinal, physiotherapy and dermatology have performed well throughout the year and exceeded all
national referral to treatment time targets while managing higher levels of demand;
• We have maintained high service standards in those areas which have also experienced growth
in demand including continence, phlebotomy, wound care, Disabled Adult Resource Team (DART),
palliative care, heart failure and rapid response;
• Over 94% of our patients seen by the enhanced Palliative Care Home Support Service are
supported to die at home;
• The Bristol and Weston Diabetic Eye Screening Programme and the Bath, Wiltshire and Somerset
Programme have achieved all invitation, screening and grading targets as specified by the National
programme;
• Both the Bristol and South Gloucestershire learning difficulties services are performing better than
the 75% waiting time target for patients seen within 8 weeks;
• Our Rapid Response service has increased the number of achieved prevention of admissions from
4,158 in 2011-12 to 4,307 in 2012-13;
• Our urgent care centres have exceeded the national waiting time standard of 95% seen within 4
hours and the local standard for 80% seen within 2 hours; and
• The latest prison health performance and quality indicator assessment shows HMP Bristol, HMP
Eastwood Park and HMP Leyhill as compliant overall.
Awards received by Bristol Community Health
This year we have continued to focus on the development of clinical leadership within Bristol
Community Health.
Our Deputy Clinical Director was successful in securing a place on the prestigious Leadership Academy
Clinical Fellows programme jointly run by the King’s Fund and University of Manchester Business
School. Places on this programme are highly sought after so this was a great achievement for Bristol
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Bristol Community Health | Quality Account 2012-13
Part 3
Awards received by Bristol Community Health
...continued
Community Health and in-house programmes will be developed from the learning from this programme
to support the development of clinical leadership within the organisation.
One of our General Managers has been successful in obtaining a place on the Leadership Academy
Aspiring Nurse Directors programme for 2013. This was a highly competitive process and so
demonstrates the calibre of this achievement.
We were successful in obtaining a Royal College of Nursing Professional Bursary to develop a
comprehensive geriatric assessment module and competency framework for nurses and Allied Health
Professionals. This was a service improvement project from Priority Two Frail Elderly Pathway 2012-13.
This training is also being used to provide increased clinical expertise to the Bristol Community Health
nursing home training team to enhance the care home training programme.
Bristol Community Health clinicians have been key participants in Department of Health working
groups to author the Vision for District Nursing and Making a Difference – the Dementia Nursing Vision
published in 2012. One of our team managers is the chair of the National District Nurse Network.
Bristol Community Health was a partner in organising a Safeguarding Conference in Bristol in February
2013 and led one of the workshops. This conference was rated as excellent by 75% of delegates.
There are a number of Bristol Community Health clinicians undertaking academic dissertations which
aim to improve care for our patients. These include the experience of telehealth and the development of
quality indicators for dementia care.
One of our dermatology specialist nurses was awarded a grant to travel to Australia to attend the
International Dermatology Nursing Conference in 2012.
Our consultant physiotherapist in neurology as part of the Chartered Society of Physiotherapists has
been key to a successful 10-year campaign to get independent prescribing rights for physiotherapists.
Our podiatrists have also joined the campaign and been successful. This is a landmark in the
development of AHP professions. The government has announced that physiotherapists and podiatrists
who have built up specialist knowledge and expertise in a specific clinical area will be allowed to
independently prescribe, after completing further training. This will begin in October 2013.
Case studies of quality improvements
Outlined in this section, is a selection of quality improvement initiatives at Bristol Community Health.
Medicines Management
Over the last year a new Medicines Policy and an updated Non-Medical Prescribing Policy have been
published to support staff in the delivery of safe and timely care to patients. A medicines management
page has been designed for the website to ensure that staff can easily access policies, guidance and
support material. Contact details for the Head of Medicines Management allow staff to direct queries for
a personal response.
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Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
The range of patient group directions available at the Urgent Care Centre and at the prisons has
been extended so that more people who use the services can have faster, safe access to medicines
they need. At the Urgent Care Centre Patient Group Directions (PGDs) ensure patients have access
to analgesia and antipyretics at triage which can improve patient comfort, aid diagnosis and reduce
waiting times when the patient is re-evaluated at the point of full assessment. Access to a non-medical
prescriber on duty at the Urgent Care Centre ensures that patients can be treated with a wider range
of minor illnesses which reduces the need for patients to attend the emergency department.
The Head of Medicines Management has continued to link with colleagues in the wider health
community through attendance at a range of meetings to ensure Bristol Community Health is fully
integrated into medicines management activities and developments across primary and secondary
care. Keeping up to date with the changes to the NHS structure has been challenging but important to
ensure compliance with changing legislation and accountability.
Promoting Safeguarding Services
Safeguarding Adults
All our staff have a duty to safeguard vulnerable clients, to act on any concerns, to support individuals
who are less able to protect themselves from harm or abuse, and to ensure that the concern is
appropriately assessed and investigated. To achieve this we develop policy and practice in line with
the National Framework of Standards of Good Practice and Outcomes in Adult Protection Work (ADASS
2005) and the Care Quality Commission (CQC) Standards for Safeguarding Adults (2009).
Meeting Standards
CQC Regulation 11 (outcome 7) relates to safeguarding people who use services from abuse.
Following CQC inspection in February 2013, the CQC reported that Bristol Community Health had met
this standard. The ADASS standards form the basis for an annual audit for Bristol Community Health
and all other Safeguarding Adult Board (SAB) partners. In 2012-13 Bristol Community Health was
compliant on all 14 standards.
Policy and Practice
For Bristol Community Health staff we have a Safeguarding Policy which sets out procedural guidance
to ensure we are effective in making suitable arrangements to safeguard and promote the welfare
of vulnerable adults. We are also responsible for incorporating the 6 key principles of safeguarding
(Safeguarding Adults: The Role of Health Service Practitioners 2011) throughout our work to achieve
good outcomes for vulnerable adults to whom we provide a service. We continue to be a partner
agency with the Bristol Safeguarding Adults Board (SAB) and are signatories to the No Secrets in Bristol
Multi-agency Policy which means we are committed to working in partnership with other agencies to
protect vulnerable adults and monitor and maintain the highest standards of policy and practice in this
area.
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Case studies of quality improvements ...continued
Reporting
The Safeguarding Adults Annual Report 2012-13 has been published on the Bristol Community Health
website and shared with the Bristol Safeguarding Adult Board. Early indicators are showing that the
numbers of cause for concern and safeguarding alerts have risen in comparison to last year’s figures.
The increase in reporting is mirrored across all partner agencies and is thought to be due to increased
awareness and improved response to allegations of abuse or harm.
Numbers of cause for concern and safeguarding alerts raised
Number of referrals
2011-12 / 2012-13 comparison
Period: April 2011 - March 2012
Period: April 2012 - March 2013
We are currently in the process of working towards implementing safeguarding supervision for the
community teams. The supervision is to support teams working with clients who are self-neglecting,
living chaotic lifestyles, and who pose a risk to themselves and others by refusing to engage or receive
treatment. The supervision paperwork has been devised by the team managers and safeguarding
leads and it provides a structure and framework for teams to work with. Feedback on this is managed
through the Safeguarding and Mental Capacity Group.
Training
Bristol Community Health is committed to ensuring that all adult services users are protected and
safeguarded from abuse. To achieve this, our safeguarding adults training is mandatory for all
our staff. Bristol Community Health is a member of the Safeguarding Adults Multi-agency Training
Group and contributes to the review and evaluation of all aspects of the safeguarding adults training
programme.
Our level 2 safeguarding adults training provides up-to-date information on national and local
Safeguarding Adults Policy. The training session provides the opportunity for staff to reflect and discuss
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Case studies of quality improvements ...continued
complex cases, provide peer support, share best practice and lessons learnt. We have also designed
a training session for managers, both sessions come with a training work book which was launched in
November 2012 during Bristol Community Health’s Safeguarding week.
Publicity and Information
As part of multi-agency and partnership working, all agencies have agreed to include a safeguarding
adults webpage on their organisational website. The information includes guidance to staff and the
general public if they suspect abuse. As social services is the leading authority for safeguarding
adults, the Bristol Community Health Safeguarding Adults webpage hosts the direct link to the Bristol
City Council Health and Social Care safeguarding adults web page.
‘Best Practice in Safeguarding’ conference
To show our support for safeguarding in Bristol, and within our membership capacity on the Bristol
Safeguarding Adults Board, we helped organise a conference to share and promote good practice
in safeguarding. The conference, which took place on February 2013, brought together nearly 200
delegates from local health and social care organisations, charities, and the police force.
Overall, 75% of delegates rated the conference as ‘excellent’ or ‘very good’. And 97% of delegates said
they would attend the conference again.
Delegates were able to choose to attend two case study based workshops, from a choice of eleven.
Our Safeguarding Adults and Care Homes Lead ran a workshop on safeguarding for nurses which
was rated by attendees at 97% for its level of engagement. A further seven of the workshops also
received scores of over 90%.
Promoting Safeguarding Services
Safeguarding Children
97% of Safeguarding confere
nce delegates would
attend again.
Bristol Community Health is an organisation that predominantly provides health services to adults
however we also manage services that provide healthcare to vulnerable children in particular through
the Urgent Care Centre, Belbrook which provides respite care to children with learning difficulties,
HMP Eastwood Park and the learning difficulties therapy teams. Therefore the Named Nurse for
Safeguarding Children is a key role. We have now developed a safeguarding team which includes
the safeguarding nurses for adults and children and Bristol Community Health staff are trained in
considering issues of safety for both children and adults.
This has been a challenging year to ensure that we improve and maintain training levels for staff.
Progress has already been made on improving training uptake on Level 1, 2 and 3 as the numbers of
staff requiring Level 2 and 3 increased dramatically as we improved the standard of training for these
staff. We are now working with partner agencies in the police and public health to develop an in-house
level 3 programme. This will ensure that additional places are available to improve level 3 compliance.
We now have an e-learning programme for all staff who require level 1 and level 2 training to improve
access to training.
35
Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
Percentage of relevant staff trained
Bristol Community Health has been invited to be a member of Bristol Safeguarding Children’s Board
from April 2013 so will be pleased to engage more fully with partners to keep children safe.
Percentage of staff who have completed the required level of
Safeguarding Children training
80%
60%
40%
20%
0%
1
2
3
Assigned training level
The policies for safeguarding children and the ‘did not attend’ policy have been reviewed and are now
on the Bristol Community Health website and we now have supervision sessions in place for our staff
working with vulnerable children carried out by the Named Nurse for Safeguarding Children.
Promoting Infection Prevention and Control
Our Infection Prevention and Control (IPC) Team consists of two experienced community infection
prevention and control specialist practitioners. They are led by the director responsible for infection
prevention and control.
Work in this area is steered by an Infection Prevention and Control Group, which includes clinical
leaders and an active lay member. Each clinical team has a nominated IPC link practitioner who is
supported by the IPC practitioners. They meet as a group four times a year, and at every meeting are
provided with support and additional training around IPC. They receive regular updates between these
meetings.
The team strives to keep community infection prevention and control high on the agenda locally and
nationally, being involved in regional and local groups and the national Infection Prevention Society.
Both practitioners are involved in workstreams across the organisation including the Clinical Forum.
They spend time supporting clinical teams in the field, shadowing clinical staff, providing individualised
training for specialist services and providing updated guidance as and when it is required.
Key national updates have been published during this year, such as the updated NICE guidance on
prevention and control of healthcare-associated infections in primary and community care.
They also support the development of safe systems of work and investigate any reported infection
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Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
prevention incidents.
The IPC practitioners promote infection prevention in the general community, taking part in health
promotion and education, including events for prisoners at HMP Bristol, education for young adults
and promotion on local radio. They have also provided training sessions for local GP practices and for
the Avon Local Medical Committee.
Activities to ensure quality and compliance in infection prevention
Ensuring compliance with The Health and Social Care Act 2008 Code of Practice on the Prevention and
Control of Infections and Related Guidance (The Hygiene Code) (DH, Last revised 2010) is a key driver
for Bristol Community Health, as part of the assurance required for registration with the Care Quality
Commission (2008).
The team is committed to ensuring infection prevention and control is a priority for all our staff, and
that this commitment is embedded in service planning and in everyday practice. The team
works proactively to identify problem areas and to develop strategies which will improve practice and
performance. These include the use of active communication, audit activity, involvement in surveillance
and analysis of the causes of infections where they do occur. To ensure services are provided from
a clean, safe environment, the practitioners visit the buildings from which Bristol Community Health
provides clinical services, and check infection prevention standards are being maintained.
The importance of good hand hygiene in preventing the transmission of infection is reinforced through
education and the use of a web-based hand hygiene compliance tool which supports all clinical staff
to undertake regular hand hygiene audits.
The team has also worked with the Health and Safety Advisor to ensure that the organisation is
prepared for the European Directive on Sharps which comes into force in May 2013.
Root Cause Analysis (RCA) Activity
We are working with our partners to meet the local infection prevention and control targets, by
monitoring trends and undertaking investigation of infections when required. Where cases are under
the care of a Bristol Community Health service, the team undertakes the community part of the root
cause analysis investigations on pre-72hr Clostridium difficile Infections (CDI) leading to death or
colectomy, and on pre-48hr MRSA bacteraemias.
They also investigate trends in pre-48 hr Methicillin sensitive Staphylococcus aureus (MSSA) and
Escherichia coli bacteraemias.
In this period we were notified of five pre-48 hr MRSA bacteraemias, four of which had no contact with
Bristol Community Health services.
One case we were notified of by a hospital had been seen by our learning difficulties service for
wheelchair assessment. This patient had numerous risk factors including residence in a nursing home
and having in-dwelling invasive devices. The other case involved a patient with chronic diabetic foot
37
Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
ulcers and had been seen regularly by the podiatry service.
We were informed of 25 cases of pre-48 hr MSSA bacteraemia, all by UHB. 15 of these were not active
cases for Bristol Community Health services. Of those which were active cases, the only trend identified
was the number of cases with diabetes. This is an expected trend as this group is more vulnerable to
infections. However the numbers are too small to accurately predict. For 2013-14 Bristol Community
Health is exploring benchmarking options to enable us to compare data with other community
organisations.
We were informed of 74 cases of pre-admission acquired E coli bacteraemia during this period. 46 of
these patients had no recent contact with Bristol Community Health services. Of those patients who we
had treated recently, most had a history of diabetes, chronic wounds or UTI.
No issues or trends around service delivery or care were identified during investigation of these
infections.
Learning from Complaints
Bristol Community Health views its complaints process as an integral part of its toolkit for achieving
excellent patient service. The system is present to enable service users to interact and become part of
the whole solution while empowering them to be instrumental in the continuous improvement process.
The complaints system is at the heart of learning without blame and is viewed as a tool to assist
service users and staff alike in taking forward customer concerns in an environment where excellence
in service provision is an everyday quest.
Bristol Community Health endeavours to resolve complaints within 28 days but sometimes because
of complexity this is not possible. When this is the case the complainant will be kept fully informed at
every opportunity and consulted on the extension of deadlines.
52 complaints were received during 2012-2013. This represents an increase from 2011-12, in which we
received 36 complaints, but is attributed to Bristol Community Health’s first full year as a Community
Interest Company receiving complaints in its own right. Complaints are often complex but can be
broadly categorised as follows:
• Delays in appointments
• Service provision
• Attitude of staff
All complaints put into the formal complaints system are responded to as per the NHS complaints
procedure recommended timescale.
38
Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
Learning from complaints implemented during the year included:
•
•
•
•
•
Improved methods for booking appointments;
Better understanding of customer expectations;
Greater understanding of the organisation’s policies by staff;
Better support mechanisms for staff during difficult times; and
Better customer service skills.
Specific actions taken from the learning have been:
• A review of appointment booking and introduction of customer choice and introduction of
dedicated NHS email address for customer contact and bookings which reduced the numbers of
complaints from six in 2012 to two in 2013.
• The design and introduction of ‘Listening to You’ leaflets for prisoners to facilitate access to the
complaints system. The results of this will be reported in 2013-14 Quality Account.
• Inclusion of learning from complaints in staff induction training.
Complaints are reported monthly and quarterly at the quality meetings and the senior management
team risk group meetings. Each complaint is seen by the Chief Executive and signed to confirm any
actions taken.
Celebrating our compliments
The search for continuous quality improvement brings to Bristol Community Health a considerable
number of compliments from a wide variety of service users. These are seen to truly motivate and
inspire staff to higher levels of achievement. Outlined below is a selection of compliments we have
received:
I write to thank you for the recent care you have
provided following my accident at the end of July.
All your team have been excellent, kind and helpf
ul
and have enabled me to take over control again
with more confidence. Would you please pass
on my sincere appreciation to the team for all
their friendliness and advice. Everyone has been
kind and caring and given of their best. I have
welcomed their visits.
sincere
We would like to express our
vided
pro
e
car
thanks for the splendid
e
hav
y
The
by your excellent team.
are
and
been towers of strength
ent made
responsible for the improvem
from
rge
by Joan since her discha
managed
hospital. We could not have
weeks.
six
t
without them over the pas
has
m
the
Each and every one of
sure and
proved to be an absolute trea
a real star.
Please accept our grateful appreciation and thanks for
your wonderful service. It has been of enormous value to
us all at a very difficult time in our family circumstances.
39
Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
Patient Safety - learning from incident reporting
A key element of high quality service provision is delivering services professionally and very safely.
Patient safety is a prime objective for Bristol Community Health and to this end the organisation
encourages staff to report incidents to the risk department.
Incidents are logged on our online incident reporting system, Ulysses, and management reports are
generated from the data. These reports are shared with staff and senior management to enable trend
analysis and improvements.
The incident reports are in a ‘no blame’ environment to maximise reports received. In
2012-13 we recorded 1104 incidents and the graph below outlines the types of incident recorded.
Number of incidents
Incidents by cause group 2012-13
t
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Reporting trends
The above graph shows that ‘drug incidents’ were the most frequently reported category. This is
because all staff are encouraged to report all incidents however small, including a near-miss incident,
to ensure mistakes are not made in the future.
In summary, the highest reporters were prison establishments. All of these incidents are discussed at
the Incident Review Group which exists in HMP Bristol and a joint one in HMP Eastwood Park/Leyhill.
These groups meet regularly to review all incidents, share learning, and improve patient outcomes.
The HMP Bristol Incident Group report into the Integrated Clinical Governance Group led by NHS Bristol.
The HMP Eastwood Park/Leyhill Group report to the Provider Governance Forum led by NHS South
Gloucestershire (from April 2013 the group is led by NHS England). Bristol Community Health’s Prison
40
Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
Healthcare Manager reports to the Quality and Assurance Working Group where any incidents would
be escalated if the prison Clinical Governance Group were unable to resolve them. Outcomes, actions
and learning from these groups included a review of medicines management standard operational
procedures and associated staff training, a review of processes to prevent duplication of prescriptions
and the updating of reception procedures concerning the new arrival of patients.
The current level of reporting from HMP establishments reflects the somewhat enclosed nature within
the prison environment. It was also noticeable that the introduction of the online incident reporting
pilot scheme in one of the prisons saw a considerable increase in reporting levels. This was expected
due to raising awareness of incident reporting and the comparative ease experienced by users with
the new system.
Drug incidents
It was identified from drug incidents that there were a number involving patients on insulin under the
care of the community healthcare teams. There were insufficient numbers to identify trends or specific
problems with one team or practitioner so an analysis of all the incidents was carried out with the risk
team, clinical lead for nursing, diabetic specialist nurse and community healthcare teams. This showed
that the guidance to support patients on insulin was not standardised across all teams and that
expertise to manage complications of this therapy was variable. A working group is now in progress
which has seen the provision of an integrated diabetic care pathway to all teams supplemented by
an educational session from the diabetic specialist nurses. The next stage for the group is to identify
diabetic link nurses for each locality who will be supported by the specialist nurses to audit and
improve practice against guidelines.
Pressure sores
‘Injury/ill health to patient’ was the second highest reported category. This category remains highly
reported owing to Bristol Community Health logging and monitoring all grade 2 pressure sores.
Pressure sores categorised as grade 2 or below account for a significant number of incidents. Pressure
sores graded 3 and 4 are the deeper pressure ulcers and have a far lower incidence. Root cause
analysis (RCA) is undertaken for incidents that result in grade 3 and 4 pressure sores where Bristol
Community Health services are involved.
There are two issues which have been highlighted to date from root cause analyses that impact on
the development of pressure ulcers. Concordance from patients is one issue which is very difficult
to address as people are reluctant to make lifestyle changes even when warned of their risk of
developing pressure ulcers. Consideration has been given to the fact that it is difficult for people to
understand what a pressure ulcer is and the significance of developing one. To address this Bristol
Community Health has developed A5 laminated cards with a colour image of a cavity pressure ulcer
for staff to show patients in this circumstance to be sure that Bristol Community Health patients fully
understand what a pressure ulcer is and are making informed choices when advice is given.
The other issue is nutrition and weight loss that often precedes the development of a pressure ulcer.
41
Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
Community staff are now being asked to weigh at risk patients where possible and Bristol Community
Health has launched a joint MUST screening tool with local guidelines, developed in partnership with
Bristol CCG. The importance of monitoring weight and nutrition will be embedded within teams.
As previously discussed in this Quality Account Bristol Community Health has implemented a pressure
ulcer prevention strategy with the aim of safeguarding patients against the development of pressure
ulcers and ultimately reducing pressure ulcer incidences.
The wound care service and project team are committed to continuing the momentum of SSKIN and
pressure ulcer prevention and anticipate seeing a reflection of the impact in a reduction of avoidable
pressure ulcers over the coming years. The CQUIN performance indicator is being set up to monitor
this.
Staffing issues
‘Staffing issues’ was the third most prolific type of incident. On examination of the detail, two issues
contributed to this:
1.
1 One was the significant increase in staff movements to address temporary accommodation
issues. It was established that these incidents were having no effect on patient care or safety. It is
expected that the circumstance will be fully resolved in the forthcoming year.
22.
The other issue was staffing levels at one of the HMP establishments. This has now been fully
resolved with a considerable number of staff being recruited.
One of our main achievements in 2012-13 has been the introduction of the online reporting system. For
2013-14 this will ensure that we are able to provide more analysis of trends to identify and disseminate
learning from incidents.
‘Degree of harm’ of incidents
Every incident is profiled to ascertain the degree of harm, classed in terms of the effect on patients,
staff or services. The organisation records, investigates and learns from a range of incidents including
those which have impacted on the delivery of services, issues with buildings and infrastructure and
information technology. In 2012-13 Bristol Community Health reported the degree of harm arising from
the incidents reported.
During the latter part of 2012 a new risk management group was formed consisting of senior manager
and representatives from key services. The group meets on a monthly basis and examines not only
incidents but complaints and risk indicators from various departments such as HR and operational
services. The group is chaired by the CEO and looks in depth at all risk indicators to assure themselves
that appropriate actions are being taken and are considered in light of patient safety and a wider
business viewpoint.
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Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
Severity of Harm
Severity/Degree of harm
180
180
160
160
Number of
of Incidents
incidents
Number
140
140
120
120
100
100
80
80
60
60
40
40
20
20
00
Q1 1
Quarter
Q2
Quarter
2
Q3 3
Quarter
Q4 4
Quarter
Quarters during
Quarters
during2012/2013
2012-13
Severity
ofharm
Harm0-6
0 to 6
Severity of
Severity of
Severity
ofharm
Harm7-12
7 to 12
Severity of
Severity
ofharm
Harm13-25
13 to 25
The above graph shows that the reported incidents during 2012-13 fell broadly as predicted, whereby
the majority fell into the centre section of the scale relating to severity 7-12, followed by those rated 0-6,
with the smallest proportion related to the most serious severity of harm score, 13-25.
Each incident is recorded and logged on our incident database and is monitored for suitable actions.
Management reports are generated from the database to ensure that senior management are kept
aware of incident patterns and trends which could be adverse for patients and staff alike.
Learning from Serious Incidents Requiring Investigation (SIRIs)
In 2012-13 Bristol Community Health launched 22 SIRIs. 15 of these were pressure ulcers; one was
an accident involving a patient; two related to deaths in custody; one related to a loss of confidential
information; one was a case of alleged abuse; one was an alleged inappropriate relationship between
a staff member and a patient and one was a concern about resuscitation practice. These incidents
were thoroughly investigated and the following learning points have subsequently been implemented:
•
•
•
•
43
Risk assessments are a crucial part of a prevention strategy;
Good communication with staff and patients is instrumental in good care;
Increasing availability of knowledge and training empowers staff to deliver good practice; and
An open and transparent culture promotes greater learning.
Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
Information gathered from reported incidents is scrutinized in a number of regular meetings and
working groups where trends and points for learning are identified. These points are recorded, to
enable progress with learning to be monitored by the senior management team.
All reported SIRIs have a root cause analysis carried out to enable closure on the Department of Health
STIES system. The root cause analysis is required within a tight deadline, dependent upon grade, and
the major points are also all recorded on STIES.
Pressure ulcers account for the majority of Bristol Community Health SIRI investigations, and because of
this the major learning impact will come from this area.
As well as the general learning points above the following specific learning points have been
observed:
1.
1 Patients who are non-compliant require a far greater level of detail in the explanations given
to them by clinical staff. To this end, the tissue viability team is now more deeply involved with
individual cases and with proactively sharing any learning observed with other professionals.
2
2. Community nursing staff are now becoming more active with the overall management of pressure
ulcers as a result of their raised profile and are sharing the benefit of their experience with care
agency staff as appropriate.
3 The value of shared learning across various teams is now being recognised and as a result copies
3.
of all completed root cause analysis documents are now forwarded onto the Tissue Viability Service
for their comments and to ensure the learning is incorporated within training and communicated to
teams.
Data Quality
A high level of data quality underpins the effective use of information in decision making to improve the
quality of Bristol Community Health services. In 2012-13 a data completion and data validation exercise
showed the following:
• Over 98% of our patients have the correct name, date of birth and GP Practice recorded.
• 99.88% of our patient records have an NHS number recorded.
• The percentage of our appointments recorded that have not been correctly outcomed has reduced
from 3% to 2% year on year
• 69% of our electronic clinical record progress notes have been validated and verified
• Our median waiting time between referral and first appointment is 6.86 weeks and performing
better than the national standard of 95% of referrals seen within 18 weeks.
Data quality is also systematically reviewed as part of ongoing monthly reporting arrangements to
commissioners and the Bristol Community Health Board. This includes the following:
• A programme of performance and finance reviews with service leads and budget-holders to
review areas where under-performance is linked to data quality;
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Bristol Community Health | Quality Account 2012-13
Part 3
Case studies of quality improvements ...continued
• Monthly sense checking of activity information and key performance indicators against data quality
key lines of enquiry;
• Monthly IT User Group and Avon IM&T Consortium meetings to review data quality issues either
from an inputting ‘front-end’ or reporting ‘back-end’ perspective; and
• Ongoing peer review of coding scripts and data collection processes as part of the overall Bristol
Community Health reporting framework.
As part of our strategy to improve data quality Bristol Community Health has implemented new
processes to demonstrate compliance with the Information Standards Notice in 2011. This informed
all community providers funded or provided by the NHS about the introduction of the Community
Information Data Set (CIDS).
CIDS is a patient-level, output-based, secondary uses data set. ‘Secondary use’ functions include
use for commissioning, clinical audit, research, service planning, inspection and regulation and
performance management. The data set itself outlines required data items, national definitions and
associated values to be extracted or derived from local systems.
The key milestones within the information standards notice are:
i From April 2012 providers of community services should capture the information within the
•
community.
ii By April 2012 suppliers of community IT systems should capture or derive the required data items,
•
including mapping of local codes and national codes, and be able to extract it locally. This must be
completed by August 2012.
iii By August 2013 suppliers of community IT systems must ensure their systems are fully compliant
•
without interim workarounds.
iv By April 2014 providers of community services must be fully conformant with the standard,
•
capturing the information required by the standard, for local use as envisaged and without interim
workarounds.
Bristol Community Health is fully compliant with the milestones outlined above for data capture and is
progressing well to achieve the future milestones in 2013 and 2014.
45
Bristol Community Health | Quality Account 2012-13
Part 4
Statements of
Assurance
Part 4
Statements of Assurance relating to the quality of services provided in
2011-12
Bristol Community Health is required to report on statements prescribed for inclusion in
all NHS Quality Accounts as detailed in the following sections.
Information Governance Toolkit attainment levels
An assessment has been conducted which indicates an overall baseline score for 2012-13 of 74%,
compared to 70% for 2011-12.
Participation in National Clinical Audits, National Confidential Enquiries and Local Clinical
Audits
Clinical audit provides a means of measuring how well care is provided compared to expectation of
good practice. It is a process which seeks to improve patient care and outcomes through systematic
review against explicit criteria and the implementation of change.
National Clinical Audits refer to a group of audits, enquiries and related projects, which collect data
from local clinicians on compliance with evidence based standards. Analysis is undertaken centrally,
and the comparative findings are fed back in the form of benchmarked reports which help participants
identify necessary improvements for patients.
These audits include the National Clinical Audit and Patient Reported Outcomes Programme
(NCAPOP) which is a centrally funded national clinical audit project, and other national audits which
the Department of Health wishes to have reported in the Quality Accounts, but which are separately
funded.
Local Clinical Audits are carried out on topics which are chosen by individual healthcare professionals,
evaluating aspects of care that they themselves have selected as being important to them or their
team. Most Clinical Audit activity with NHS Trusts and provider organisations is ‘local’, which supports a
“bottom-up” approach to quality improvement.
National Audits
During 2012-13, there were two National Clinical Audits covered NHS services that Bristol Community
Health CIC provides. They were as follows:
Audit Code
Audit Name
National Clinical Audit and Patient Reported Outcomes Programme (NCAPOP)
LTC002
Diabetes (Adult)
Other National Clinical Audits
N/A
Intermediate Care Audit
47
Bristol Community Health | Quality Account 2012-13
Participated?
No
No
Part 4
Statements of Assurance relating to the quality of services provided in
2011-12 ...continued
Bristol Community Health did not take part in these audits in 2012-13 however will be actively involved
in them in 2013-14. The reasons for this were that the diabetes service were participating in two local
audits. The National Audit of Intermediate Care was proposed in 2011 as a joint commissioner and
provider audit. As the commissioning body did not engage with this, a decision was made to not
participate due to the cost and uncertainty about the national level of engagement and therefore the
usefulness of the data that would be provided.
Bristol Community Health and Bristol CCG will both be participating in 2013-14.
Local audits
During 2012-13, Bristol Community Health produced a Clinical Audit Framework, which set out all
the local priority areas for Clinical Audit in 2012-13. These priorities are closely linked to the priorities
identified within our Quality Accounts, service priorities, and the implementation of NICE guidelines.
Progress is monitored by the Clinical Governance Working Group, and reported on in the quarterly
Quality Report.
Type of audit
National Clinical Audits (not part of National Audit Programme)
Audits of NICE Guidance
Interface Audits (with another Trust)
Local audits
Total
Total number to report stage
1
3
7
91
102
Bristol Community Health has undertaken 102 completed audits during 2012-13. We intend to take all
the recommended actions from the audits, to improve the quality of the heathcare we provide.
Auditing has highlighted several areas where
Psychologists’ work is very good,
but it also identified areas where there has been
uncertainty. These areas
have been addressed as learning points for our
team.
An example of local audit
The occupational therapists within our community learning difficulties team (CLDT), recently undertook
an audit to test compliance with the College of Occupational Therapists’ professional practice
standards on consent. Key to the occupational therapists’ work is that their service users (or people
acting on the service users’ behalf) are provided with sufficient information, in an appropriate manner,
to help them understand the nature and purpose of the proposed treatment, including any possible
risks involved.
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Part 4
Statements of Assurance relating to the quality of services provided in
2011-12 ...continued
The occupation therapists wanted to make sure they were complying with their professional standards,
and that a consistent approach was used when working with their service users.
The audit showed good compliance with referencing consent evidence in the clinical notes, but that
there wasn’t a consistent approach to uploading the documentation to RiO (the computerised records
system). In addition to this, the current occupational therapy consent form did not clearly evidence
situations where consent was refused, or if decisions were taken in someone’s best interests.
Following this audit, plans have been made to devise a single form that records consent, best interest
issues and capacity in relation to the community learning difficulties occupational therapy team. This
form will be uploaded to RiO case notes within a clearly defined period.
Audit for 2013-14
All clinical services and teams within Bristol Community Health will be expected to carry out
documentation, infection prevention and control, and data validation audits during the 2013-14 Audit
Framework Period. Our chronic obstructive pulmonary disease (COPD), heart failure, diabetes, falls,
physiotherapy, occupational therapy, and intermediate care services will all take part in national audits.
A range of NICE guidance will also be tested via a series of audits across all Bristol Community Health
services and audits will also be completed to support CQUIN outcomes, for example, Shared Decision
Making.
Participation in Clinical Research
175 of our patients receiving NHS treatment from Bristol Community Health in 2012-13 were recruited
during the same period to participate in research approved by a Research Ethics Committee.
Bristol Community Health was involved in ten research studies during 2012-13, which were approved
by a Research Ethics Committee. The research projects covered the following areas: community district
nursing, urgent care, continence, service managers, prisons, diabetes, musculoskeletal assessment and
treatment, podiatry and community learning difficulties.
Bristol Community Health works hard to increase the level of participation in clinical research,
recognising the part this plays in the wider health improvement of the nation. Bristol Community Health
also works closely with our research partners, the Avon Primary Care Research Collaborative, Bristol
University, and the University of the West of England.
Research and Development
The Avon Primary Care Research Collaborative provides a research governance service to Bristol
Community Health, via a Service Level Agreement. In addition to this, Bristol Community Health’s Clinical
Cabinet reviews all research projects that involve Bristol Community Health’s staff or patients, prior to the
being given formal approval by the Avon Primary Care Research Collaborative.
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Part 4
Statements of Assurance relating to the quality of services provided in
2011-12 ...continued
The following is a breakdown of all the research projects approved by Bristol Community Health during
2012-13:
Research title
Hep B Baby Vaccine
Group / Service
Community District Nursing and Urgent
Care Centres
Continence and Multiple Sclerosis
Continence
NHS Networks
Service Managers
Risk Assessments in HM Prisons
Healthcare records
Dietary Assessments for T2 Diabetics Diabetes
Telehealth as a Case Management Community Matrons
Approach
Azellon Stem Cell Medial Meniscus
Musculoskeletal Assessment and
Study
Treatment Service (MATS)
Feet with Rheumatoid Arthritis
Podiatry
N-Alive, Prison Based Pilot of
Prison Healthcare
Naloxone
Macmillan One-to-One Support
Community District Nursing
Unplanned Hospital Admissions for Community District Nursing
Heart Failure
Nutritional Screening in Learning
Community Learning Difficulties Teams
Difficulties
(CLDTs)
Physiotherapy Exercise Programme Physiotherapy
Clinical or non-clinical?
Clinical
Clinical
Non-clinical
Non-clinical
Non-clinical
Non-clinical
Non-clinical
Clinical
Non-clinical
Non-clinical
Non-clinical
Non-clinical
Clinical
Clinical Effectiveness
All of the guidance released during 2012-13 by the National Institute for Health and Care Excellence
(NICE), which is relevant to services providing NHS care by Bristol Community Health, is reviewed by our
Clinical Cabinet, and checked for compliance by our service leads. Compliance is then tested via routine
Clinical Audits. The Clinical Cabinet also review the new NICE Standards.
Goals agreed with Commissioners
Use of the CQUIN payment framework
Bristol CCG, our main commissioner, has set quality performance measures for our community health
services. CQUINS for 2013-14 reflect national reports and recommendations, patient satisfaction surveys
and local needs and priorities. Our agreed quality and innovation goals are included below and it
should be noted that at this point in time the actual measures for these quality targets are still to be
agreed with our Commissioners.
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Part 4
Statements of Assurance relating to the quality of services provided in
2011-12 ...continued
Our CQUIN objectives for 2013-14
Bristol Community Health has passed the CQUIN pre-qualification assessment for 2013-14 which
requires organisations to demonstrate compliance with several Department of Health objectives for
healthcare innovation before they can become eligible to receive CQUIN monies. These areas include:
• 3 Million Lives – Bristol Community Health has committed to sustaining between 375 and 425 active
telehealth units in the community;
• International and Commercial Activity – Bristol Community Health has outlined its intentions to work
with TotalMobile to promote mobile working technology to other community providers should the
2013-14 pilot be successful;
• Digital First – Bristol Community Health has submitted the mobile working project and text reminder
project as innovations which will reduce inappropriate face-to-face contact and ‘did not attends’
(DNAs); and
• Dementia Carers – Bristol Community Health has committed to identifying more than 60 carers of
people with dementia to be referred into the Bristol Council Integrated Carers Support service in
2013-14.
In 2013-14 the CQUIN scheme is worth 2.5% of our contractual income from commissioners. At the time
of writing these goals were being finalised but are likely to include the following areas:
i Nationally mandated objectives
•
• Improving patient experience within our Urgent Care Centres by understanding the reasons that
influence patient decisions in recommending the service to their friends and family, and improving
upon this;
• Expanding the use of the National Patient Safety Thermometer and better understanding the
incidence of level 3 and level 4 avoidable pressure ulcers in the community and ways in which we
can reduce it; and
• Expanding the work we have done in 2012-13 on the dementia ‘find, assess and refer’ pathway and
ensuring there is appropriate clinical leadership for its development and appropriate support for
carers.
•
ii Regional system change objectives that we aim to achieve by working collaboratively with our
partners across health and social care and the third sector
• Demonstrating that our End of Life Care Strategy is fit for purpose in achieving an outcome across
the whole health community that results in a higher proportion of patients dying at their preferred
place of care; and
• Demonstrating that our Urgent Care Strategy is fit for purpose in achieving an outcome across the
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Statements of Assurance relating to the quality of services provided in
2011-12 ...continued
whole health community that improves adult inpatient flow by reducing the number of occupied bed
days.
•
iii Bristol Community Health’s organisational objectives
• Continued implementation of the NHS Institute for Innovation and Improvement modules for
‘Productive Community Services’, focusing specifically this year on ways to better understand the
performance of our teams and to more easily identify patient needs at a glance;
• Improving the way in which we make shared decisions with our patients by improving the skills
of our staff and evaluating the impact that this has on patient confidence to manage their own
condition;
• Implementation of an outcome framework for patients with learning difficulties to improve the
personalisation of priorities and ways of measuring those outcomes, particularly for people who
may lack the capacity to do this themselves; and
• Reducing waiting times for some of our planned services including Occupational Therapy and
Domiciliary Physiotherapy.
Service Improvement Priorities for 2013-14
Based on our end of year performance outturn we have identified the following areas as service
improvement priorities in 2013-14:
• CQUINs – Programme management of all schemes to improve quality and innovate in the
delivery of community healthcare services;
• Podiatry Service – Improvement to referral to treatment times including reduced levels of ‘did not
attends’ (DNAs) and cancellations;
• Health Assessment and Review Team – Improvement to timescales for reviewing continuing
healthcare and funded nursing care eligibility and reducing any backlog of overdue reviews;
• Community Healthcare Teams – Increase efficiency by 5% from 2012-13 so that more time is
available for delivering higher quality patient care;
• Care Planning – Improvements to the way in which our paper based clinical documentation is
held within our electronic care record system so that communication of patient needs is improved
between our teams and with our partners;
• Marketing – Improved marketing strategy for services with lower referral rates than planned
including the South Bristol Urgent Care Centre, Dietetics and COPD Pulmonary Rehabilitation
provision in North Bristol; and
• Prison healthcare – Improving our understanding of demand and capacity within our Primary
Care and Integrated Drug Treatment Services so that our service standards can be improved.
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Part 4
Statements of Assurance relating to the quality of services provided in
2011-12 ...continued
How our regulator the Care Quality Commission views our services
Bristol Community Health is required to register with the Care Quality Commission (CQC) for the
regulated activity we undertake in delivering our healthcare services. We also have to ensure CQC
has an up to date Statement of Purpose describing services provided at its various locations.
The Statement of Purpose can be found on our website at:
www.briscomhealth.org.uk/about-us/our-care-quality-commission-cqc-registration.
Our current status is that we are registered with the following condition:
Condition of Registration: Terms of this registration relating to carrying out this regulated
activity are that the Registered Provider must ensure that the regulated activities - ‘treatment
of disease, disorder or injury’ and ‘diagnostic and screening procedures’ - are managed by
an individual or individuals who have registered with CQC as a manager in respect of the
activity(ies) at or from all locations.
To comply with the above condition on our registration as an independent healthcare provider, we
recruited and trained a new ‘nominated individual’ and new ‘registered managers’ throughout the
year to enable communication with CQC. In total, three new registered managers were appointed
by CQC in 2012-13 and a further three applications were submitted. Together with our operational
teams, these individuals monitor and report on the status of the organisation regarding compliance
with the CQC Essential Standards of Safety and Quality, particularly relating to issues that legally need
to be notified to CQC.
Our registration has changed during the past year. As a result of a CQC visit to our Withywoodbased Community Learning Disability Team in January 2013, we consulted with the local CQC senior
registration assessor and undertook a review of our registration. This resulted in applications to
de-register the five locations for our Learning Difficulties Teams in Bristol and South Gloucestershire.
These services are now registered at South Plaza instead. Our five registered locations are now:
Registered location
South Plaza
HMP Bristol
HMP Eastwood Park
HMP Leyhill
Urgent Care Centre, South Bristol Community
Hospital
Service
All community health services and community
services for people with a learning difficulty
Prison healthcare services
Prison healthcare services
Prison healthcare services
Urgent care services
During the year, CQC inspectors visited HMP Leyhill, HMP Eastwood Park (jointly with Her Majesty’s
Inspectors of Prisons) and Withywood Community Learning Difficulties Team. All services were
compliant with standards on the outcomes inspected.
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2011-12 ...continued
An unannounced visit was carried out in February 2013 to look at selected services registered at
South Plaza. The three day visit covered the Haven, Rapid Response, COPD Service, Community
Healthcare Teams, MATS (Musculo-Skeletal Assessment and Treatment Service) and Palliative Home
Care Support.
The inspection focused on the following CQC outcomes and Bristol Community Health were judged
compliant in the first six listed below:
Outcome
Outcome
Outcome
Outcome
Outcome
Outcome
Outcome
11
14
17
18
1
14
1
16
1
21
Respecting and involving people who use services
Care and welfare of people who use services
Safeguarding people who use services from abuse
Cleanliness and infection control
Supporting workers
Assessing and monitoring the quality of service provision
Records
A compliance action was noted under Outcome 21 for record keeping, connected with the quality of
some care plans viewed during the visit. The inspectors commented that the issue observed had a
minor impact and did not present a risk to patients. A detailed action plan was submitted in April
2013 to CQC and we will be re-inspected later in the year to ensure that the reported concerns have
been addressed.
Reports from the visits showed how well our services comply with the standards and are published
on our website at www.briscomhealth.nhs.uk and on the CQC’s website at www.cqc.org.uk.
The CQC has not taken enforcement action against Bristol Community Health during 2012-13. Bristol
Community Health has not participated in any special reviews or investigations by the CQC during
the reporting period.
Who did we involve in developing the quality account?
In the development of this account we engaged with our staff, the public, patients and carers and
our partners. Firstly in helping us to establish our quality priorities for 2013-14 and secondly as part of
a consultation process in the production of this account.
Bristol Community Health staff also attended the Bristol LINK Older People’s group to understand their
views. Members of voluntary sector organisations and Bristol Community Health volunteers were
also invited to comment on the draft quality priorities and on the account. The Quality Assurance and
Governance Committee, Bristol Community Health Senior Management Team and Board were fully
engaged and involved in developing the account.
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Statements of Assurance relating to the quality of services provided in
2011-12 ...continued
The view of Bristol Clinical Commissioning Group (CCG), who commission the majority of our services,
was also included in our account because of their monitoring of our performance against a range
of quality standards via regular monthly meetings. Bristol CCG was also involved in the consultation
process.
Bristol City Council’s Health, Wellbeing and Adult Social Care Scrutiny Commission was also involved
in the consultation process.
Overleaf are comments from both Bristol CCG and from Bristol City Council’s Health Overview and
Scrutiny Committee.
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Bristol Community Health | Quality Account 2012-13
Appendix
What others say
about us
What others say about us
Bristol Clinical Commissioning Group
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
           
            
          
              




              




              





             

 
              
             
           





         

          

 
 




57
Bristol Community Health | Quality Account 2012-13
What others say about us
Bristol Clinical Commissioning Group

           

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



58
Bristol Community Health | Quality Account 2012-13
What others say about us
Bristol City Council’s Health, Wellbeing and Adult Social Care Scrutiny
Commission
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

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
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


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
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Bristol Community Health’s response to the comment
regarding complaints:
We can assure patients and the Bristol Health, Wellbeing and Adult Social Care
Scrutiny Commission that all complaints have been responded to and when
there has been a delay due to the need for thorough investigation we always
communicate with complainants to let them know what is happening. We have
also now included more detail on the subject of complaints and the actions taken
to add greater clarity to the account.
59
Bristol Community Health | Quality Account 2012-13
Contact us
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
www.briscomhealth.org.uk