Quality Accounts Update Claire Lea Background transparent and - - PowerPoint PPT Presentation

Quality Accounts Update

Claire Lea

Background

• transparent and accountable public reporting
• ensure that Boards have clear priorities
• achievable plans for driving improvement,
• inform the development of Quality Accounts

• Annual Report 2008/09 ‐ the Trust stated that it

would deliver on key quality targets in preparation for the delivery of its first Quality Account.

• This report sets out the progress against these

quality priorities.

Update

• The delivery of the quality accounts is closely

allied to the Trust’s CQUIN targets, which are monitored by the PCT on a monthly basis through the Clinical Quality Review Group.

• The following slides provide a short summary on

progress against each of the priority areas and a KPI overview of progress.

Update

Priority 1: To further reduce our MRSA and CDiff rates – including 100% elective and emergency screening targets

• Within the agreed trajectory for both infections
• Achieving agreed CQUIN targets for C.Diff
• Post ‐discharge notification service to GPs and

patients regarding MRSA and C.Diff results has been introduced

• Elective Screening ‐ achieving over 100% as

required by DoH.

• Emergency screening due to the delays in

reporting is 72.8% trust wide.

Priority 2: To introduce a nursing quality measurement system – with key focus on cleanliness, dignity and privacy

• The Nursing Metrics project consists of monthly

monitoring of performance in regard to 7 Nursing Care Indicators and 10 patient feedback questions has been piloted across all three sites.

• The results have been shared with the staff and

action plans are being developed.

Priority 2: To introduce a nursing quality measurement system – with key focus on cleanliness, dignity and privacy

• The next stage is to develop adapted indicators

for Maternity Services; Paediatrics; Outpatient Departments and Critical Care Areas, which will be piloted before the end of Q4.

• Questions are being added to the Nursing

indicators regarding privacy and dignity issue these will commence in November.

Priority 2: To introduce a nursing quality measurement system – with key focus on cleanliness, dignity and privacy

• The Hotel Services team are designing cleaning

monitoring initiatives across all sites with the primary objective recording both cleaning frequencies and cleaning standards.

• Once these are designed they will be presented

to Matrons and Infection Control groups for consultation before rolling out across the Trust.

Priority 3: To improve stroke management care - measured through monitoring of 3 hour thrombolysis times and access times to CT scan

• The main difficulty has been the ability to

monitor progress through effective data collection and monitoring of the stroke pathway.

• However there is now funding available through

the stroke network to recruit staff for 12 months to support the Trust in the delivery of this key target.

Priority 3: To improve stroke management care - measured through monitoring of 3 hour thrombolysis times and access times to CT scan

• A key measure for the monitoring of effective

stroke care is access to a CT scan with 24hours.

• A recent audit has shown that over 90% of

requests for CT are carried out within 24 hours, however there is a delay in the CT scan being requested – work is being undertaken within the directorate to improve this.

Priority 3: To improve stroke management care - measured through monitoring of 3 hour thrombolysis times and access times to CT scan

• The delivery of the national target to ensure

that patients who have had a stroke spend 90%

• f their time in hospital in a stroke unit, is

sometimes compromised through the admission

• f stroke patients to AMU rather than directly

to the stroke unit. The directorate is reviewing

• ptions for ring fencing and would anticipate

this being in place in Q3.

Priority 3: To improve stroke management care - measured through monitoring of 3 hour thrombolysis times and access times to CT scan

• 24 hour thrombolysis will commence in Q3

having secured additional funding to provide the service from the Solihull site.

• The Trust is actively working with PCT partners

to review and improve pathway and have agreed action plans in place.

Priority 4: To speed the process of hospital discharge – length of stay, delayed transfers of care,

patient surveys on pharmacy and the provision of information

The initiatives undertaken so far are:

• the opening of the Community Discharge Wards;

Ward 3 at GHH and Ward 29 at BHH for patients from NHSBEN.

• The commisioning of a review by Tricordant to

look at a whole systems approach to Delayed Transfers of Care within the trust and the barriers to timely discharge.

Priority 4: To speed the process of hospital discharge – length of stay, delayed transfers of care,

patient surveys on pharmacy and the provision of information

• Staffordshire NHS have started initial

communication to assist specific groups of patients, e.g. Neck of Femur and assist in Staffordshire patients being rehabilitated in a more appropriate setting away from the acute.

Priority 5: Patient feedback – focus on information, staff attitude, and respect and dignity

• The Patient Experience Tracker (PET) is now

fully operational at GHH with all clinical areas now being assessed using the electronic ‘Touch Book’ devices.

• A monthly sample of Good Hope patient

feedback is captured through a combination of volunteers and PPI staff spending, on average, two hours per month in each clinical area. P t d RAG t th thl ti t

Priority 5: Patient feedback – focus on information, staff attitude, and respect and dignity

• The Patient Experience Tracker (PET) is now

fully operational at GHH with all clinical areas now being assessed using the electronic ‘Touch Book’ devices.

• A monthly sample of Good Hope patient

feedback is captured and is then integrated with the electronic ‘nursing indicator’ report to identify any shortfalls and monitor delivery against resulting action plans.

Priority 5: Patient feedback – focus on information, staff attitude, and respect and dignity

• Introduction of a new ‘back to the floor’

programme for non‐clinical staff to capture the patient experience is expected to drive the capture of the patient experience with volunteers supplementing this ongoing work.

• Full coverage of the PET will include Heartlands

and Solihull by Q1 2010.

Priority 5: Patient feedback – focus on information, staff attitude, and respect and dignity

• The continued success of the GHH User Group

and the Consultative Healthcare Council has prompted a decision to establish two additional user groups. These will be set up for Heartlands and Solihull.