EMB ~ Quality Patient Safety Annual Report UHK · improvement of quality of care is central to all...

EMB ~ Quality Patient Safety

Annual Report UHK

Sign off Name

Signature Date

Fearghal Grimes General Manager University Hospital Kerry & EMB QPS member

23.05.2018

Dr Claire O’Brien Clinical Director University Hospital Kerry& EMB QPS member

23.05.2018

Kerry Mc Auliffe Director of Nursing, University Hospital Kerry & EMB QPS member

23.05.2018

Betty Murphy, Operations Manager University Hospital Kerry & EMB QPS member

23.05.2018

Dr Martin Boyd Lead Consultant Emergency Medicine & EMB QPS member

23.05.2018

Caroline Donnelly Risk Manager University Hospital Kerry & EMB QPS member

23.05.2018

Gráinne Rohan A/Quality Manager University Hospital Kerry & EMB QPS member

23.05.2018

Prepared By: Mareeda de Róiste, Date Last Updated: 01.05.2018 Version: 1.2

University Hospital Kerry ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

EMB Quality Patient Safety Annual Report

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Contents

Section Page 1. Introduction ...................................................................................................................................................................... 3

1.1 Who we are .............................................................................................................................................................. 3 1.2 Membership & Governance Structure..................................................................................................................... 3 1.2 Our Mission Statement ........................................................................................................................................... 4

2. Achievements during 2017: .............................................................................................................................................. 5 2.1 Patient Experience ................................................................................................................................................... 5 2.2 Staff Experience ....................................................................................................................................................... 5 2.3 Audit Plan ............................................................................................................................................................... 6 2.4 Meeting National Standards, Guidelines, policies, audit and report recommendations ......................................... 6 2.5 Implementation of national and local quality and safety initiatives ........................................................................ 7 2.6 Risk Management Processes .................................................................................................................................... 7 2.6.1 Clinical and Non Clinical Incidents ..................................................................................................................... 7 2.6.2 Medication Safety Management ........................................................................................................................... 9 2.6.3 Coroner’s Court .................................................................................................................................................... 9 2.6.4 Co-ordination of clinical and non-clinical claims ............................................................................................... 10 2.6.5 Freedom of Information ...................................................................................................................................... 10 2.6.6 Risk Registers and Departmental Risk Assessments .......................................................................................... 10 2.7 Prevention & Control of Health Care Acquired Infection ..................................................................................... 11 2.8 Better Health and well being for staff, patients and members of the public ........................................................... 11 2.9 Quality & Safety Reports from Committees / Directorates / Specialty Teams ...................................................... 12 2.10 Review of reports of service specific and mandatory education & training ........................................................... 12 2.12 Healthcare Records Management .......................................................................................................................... 13 2.13 Health & Safety ..................................................................................................................................................... 13



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1. Introduction

This annual report provides a high level overview of the work completed by the EMB Quality Patient Safety Division, at UHK, during the year 2017.

1.1 Who we are

The EMB QPS Division comprises the hospital Executive Management Board which includes the Quality Manager and the Risk Manager in addition to NCHD representative and AHP representatives as required. The QPS primary focus is the support and development of a culture that ensures improvement of quality of care is central to all services that University Hospital Kerry deliver.

1.2 Membership & Governance Structure

Membership of the EMB QPS is comprised as above. A number of changes in the EMB QPS membership took place during 2017. The hospital appointed a new General Manager in September 2017 and a new Operations manager in August 2017. Specifically to the QPS Department, a new Risk Manager was appointed on May 2nd

2017 and a new Quality Manager was appointed in September, 2017 – immediately prior to this, the post had been vacated for eighteen months.

The Clinical Governance Groups of each of the hospital specialties report into the EMB QPS either through annual meetings with the EMB QPS or written progress reports.

UHK Quality & Patient Safety Committee

Clinical Director General Manager

Operations Manager/ Manager Director of Nursing

Consultant/Medical representative Risk Manager Kerry Area

Quality Manager Kerry Area AHP representative (as required)

NCHD representative (as required)



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1.2 Our Mission Statement



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2. Achievements during 2017:

The EMB QPS schedule to convene on a monthly basis. During 2017, the Committee convened on nine occasions. A wide ranging EMB agenda across the various tenets of Quality & Safety is adhered to for these meetings. Key progress points across each agenda area are set out in this annual report.

2.1 Patient Experience

UHK participated in the National Patient Experience Survey

which took place during May 2017. There was 49% feedback from UHK patients (548 patients) which was broadly in line with the national average. An Overall National report has been prepared and also individual reports for the 40 hospitals are available online.

A number of issues are selected for improvement/follow up by the EMB / QPS locally. Quality Improvement Plans in these specific areas are being progressed for instance under Medication Safety, an Antibiotics Patient Safety leaflet has been produced through the Antimicrobial Stewardship Committee. Other Quality Improvement plans include

• Estimate Length Of Stay: Unscheduled Care Group • Patient Centred Care • Revising Protected Mealtimes to Assisted Mealtimes • Healthy Vending Machines in ED waiting area

In order to share the findings of the NPE, an NPE Information Poster board will be placed in the Canteen on Friday 20th

April 2018 for staff to see some of the report and responses that were received in this Survey.

The Survey has identified many positives within University Hospital Kerry and also many areas we can improve on, following on from this another National Patient Experience Survey will be carried out in May 2018 and same will be promoted in the coming weeks with Leaflets, Poster and Napkins similar to last year.

2.2 Staff Experience

Staff experience survey –

A dignity at work survey was conducted for NCHDs in late 2017. Findings of same formed part of the agenda of the Medical Council Survey and Medical Council visit to UHK. UHK has adopted the national Dignity at Work Policy and Procedures for the Health Service. While there are challenges in releasing managers for training every effort and encouragement is given to avail of training opportunities that support the prevention and management of Dignity at Work.



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As the QPS Committee of UHK, we are aware of the hospital’s obligations in relation to the prevention and management of Bullying and Harassment in the Workplace. Initiatives for future Progress Reports on the implementation of the People Strategy will be recorded. We understand our that learning from the national pilots will be shared with us all in due course.

2.3 Audit Plan

National Audit of Hospital Mortality

reports for UHK are produced on a monthly basis through the NQAIS system and brought to the EMB QPS by the executive support person. Where UHK is depicted as having a high SMR (standardised mortality ratio) when compared to the national average for all hospitals, an analysis of each case is conducted by one of the clinician members on the committee.

In line with the NOCA monitoring & escalation policy, a teleconference was arranged with NOCA in April 2017 to discuss particular findings which required review during the year. Regular reviews of high SMR are undertaken. NOCA were satisfied that UHK EMB QPS are actively monitoring the hospital mortality rate.

Hygiene : Various hygiene observational audits were conducted in 2017 including those Audits conducted by the Hygiene Quality co-ordinator, Management audits and self – audits conducted by wards / departments.A summary of learning was collated, such that areas can examine this and see areas where improvements are required in their own ward/ department.

Sample of Audits conducted during 2017

Localised audits are conducted at Dept/Speciality level at UHK – for instance Renal audit the yearly success rate of patients who have access for dialysis i.e. Arterio/Venous fistula created Nationally, UHK is involved in an audit of progress of all renal transplanted patients.

UHK ICU part-took in the EPIC III (A prospective multicentre international one day prevalence study) co-ordinated by the European Society of Intensive Care Medicine during 2017. This study involved a one day observational of all patients present on or admitted to the Intensive Care Unit on the 13th

of September 2017.

It is proposed that a proportion of meaningful audits will be conducted across the hospital in 2018.

2.4 Meeting National Standards, Guidelines, policies, audit and report recommendations

The newly appointed Quality co-ordinator is seeking to reconvene a working group such that the National Standards for Safer Better Healthcare are considered and a gap analysis derived with QIPs from same. For Q4, 2017 indeed the vast majority of both the Quality and Risk resource were applied to the SIMT which was set up to focus on the Radiology look back review.



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In terms of guidelines and policies, the role of Practice Development is central to ensuring UHK Policies, procedures and guidelines are in place, up to date and in so far as is possible in line with best international practice. This role has had a number of temporary occupants during 2017 and will have a new post holder in 2018. Arising from incident reports/reviews both internal and external, once signed off by the EMB QPS, recommendations are brought the relevant Clinical Governance Committee for dissemination and implementation accordingly.

2.5 Implementation of national and local quality and safety initiatives

A co-ordinator for the Theatre Quality Improvement Plan (modular system ) was appointed. The aims of TPOT were to drive out waste across all processes, to add value while ensuring safe reliable care and enhancing patient experiences and outcomes. The annual QPS Awards were held on Tuesday 21st

November 2017. Winner was a Community based Speech and Language Therapist – Community based speech therapy groups for adults with dyspasia.

2.6 Risk Management Processes

University Hospital Kerry primary purpose is to deliver safe, high quality care. Underpinning any such system is the requirement to have a system in place where risks are identified and managed and a system where incidents are reported, investigated and lessons learned. The purpose of risk management is to improve safety and quality by searching out risks proactively and reducing their potential impact to the greatest extent possible. The Risk Department continues to provide support and lead on the quality and safety management programme within the hospital. Clinical support services and advice is provided on risk and legal services, quality management systems and systems analysis.

The Risk Management Department has 6 distinct roles in the hospital; 1- The assessment and follow up of clinical and non-clinical incidents 2- Medication Management and Medication Safety 3- The preparation and management of Coroners cases 4- The co-ordination of clinical and non-clinical legal claims 5- In collaboration with the Medical Records Department co-ordination of FOI requests and

internal investigation 6- Risk Registers

2.6.1 Clinical and Non Clinical Incidents The Risk Management Department is involved in the collation of incidents through the risk management occurrence report forms. The hospital adopts a pro-active approach to Incident



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Management and Incident Reporting where patient safety incidents are identified, reported and managed in line with the HSE Safety Incident Management Policy. There are approximately 1,600 incidents reported annually. All of these incident report forms are reviewed by the Risk Manager, rated according to the severity of the incident and inputted by staff in the Risk Management Department onto the Clinical Indemnity Scheme’s (CIS). Track and trending of all incidents is performed by the Risk Manager and entered for monthly discussion at Quality and Safety Senior Management Meetings. The Risk Manager performs a preliminary review on all high rated clinical and non-clinical incidents and enters each case for discussion at monthly Senior Management Meeting. All serious reportable incidents are escalated and investigated through the appropriate process of Internal Review or Systems Analysis investigation. Following each investigation findings and lessons learned are entered for discussion and dissemination at Divisional Governance level, implementation at local level and tracked at performance senior management meetings to ensure recommendations are implemented with final sign off at monthly EMB Quality and Patient Safety meetings. Final Reports are shared with patients and staff involved in the trajectory of care.

- 6 Senior Multidisciplinary team members commenced Systems Analysis investigation training from the National Incident and Learning Team

- 11 System Analysis investigations were completed in 2017 and the reports were issued to the patients/families

- In September 2017 following a systems analysis review a Preliminary Risk Assessment was undertaken in the Radiological Department. UHK commenced a review of 46,000 radiological scans as part of a look-back review process commissioned by the General Manager and approved by the National Director of the HSE Acute Hospital Division utilising the Safety Incident Management Policy (2016). This process is expected to be completed Q2 2018.

In May 2017 the hospital adopted the report forms of the National Incident Management System which facilitates the timely and accurate reporting of incidents to the State Claims Agency. Recognising staff are central to the promotion and delivery of quality care, the Risk Management Department launched its inaugural “Annual Risk Awareness Day” in July 2017 and with the support of staff successfully held a staff survey on patient safety culture and organisational culture across all the different staff groups in the hospital. Results of this survey enabled senior management to gain a greater understanding of staff perceptions of quality and patient safety within the hospital and informed the hospital wide implementation of focused educational sessions delivered at departmental level on incident reporting and incident management. Throughout 2017 a number of quality and patient safety initiatives were undertaken and implemented;



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- A complete review and analysis of the processes in place for patients with swallowing difficulties. Mealtime Process on an acute ward- the aim of this project was to create a visible defined modified mealtime tray- the results of this project will hopefully set the foundation in place to ensure that patients across the organisation who require assistance with eating and drinking/the correct support/close observation/is receiving a texture modified diet.

- A complete review/implementation of change processes in place for retrieval of medical notes stored off site.

- Use of complimentary methods for detecting adverse events/medical errors to monitor for patient safety problems with the introduction of global trigger tools

Open disclosure is having a consistent open approach to communicating with service users when things go wrong in healthcare. Since 2014, UHK has adopted the National Open Disclosure Policy providing a series of talks to staff to raise awareness on the process of how to disclose openly.

Open Disclosure

Unfortunately in 2017 due to retirement and transfer of roles the number of staff awareness education sessions provided declined however plans are now in place to further educate open disclosure trainers and kick start the provision of periodic educational sessions within the organisation.

2.6.2 Medication Safety Management Medication incidents are discussed monthly at the Medication Incident Review Team meeting where preliminary investigations are conducted by the Risk Manager with relevant team members. Findings and lessons learned are entered for discussion and dissemination at Divisional Governance level, Drugs and Therapeutics Committee Meeting and EMB Quality and Patient Safety meeting. Throughout 2017 a number of quality and patient safety initiatives were undertaken and implemented;

- Inaugural Annual Medication Safety Management Report - Process change in the delivery of pain management medication in the theatre department - Introduction of prefilled emergency anaesthetic drugs - Introduction of the Cerner’s intelligent Electronic Medical Record in the Maternity Services

delivering comprehensive patient-centred information instantly and securely. - Patient involvement: Launch of phase 1 Patient medication record, designed for use by the

patient/carer to record pre-admission medication history as step one towards verification/medication reconciliation.

- Patient involvement: leaflet development/visual media display centre-know your medication/questions to ask

- Induction focused education initiatives on taking the best possible medication history

2.6.3 Coroner’s Court The Risk Management Department works closely with clinicians in their preparation for Coroners’ Court. All letters from the Coroner’s Office are issued to the Risk Department. The Risk Manager



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contacts the clinician and arranges legal advice prior to submitting their report to the Coroner’s Office if deemed necessary by the clinician. The Risk Manger performs a review of the medical record identifying any issues of concern. When the date for an inquest is set, the Risk Manager will co-ordinate meetings between the legal team appointed by the Clinical Indemnity Scheme and the consultants involved and arranges a further meeting to be held on the day of the inquest between the consultant, legal team and the risk manager. The Risk Manager enters coroner court cases for discussion at monthly senior management team meeting then following coroners court the Risk Manager enters issues specific to specialities for follow up with the teams involved in the care of the patient which are then further entered for discussion at Divisional Governance Meetings and EMB QPS. In 2017 four inquests were attended by clinician staff.

2.6.4 Co-ordination of clinical and non-clinical claims In 2017 there has been a significant change in the management of legal claims requiring a substantial amount of time being spent in actively managing each claim. The Risk Manager works closely with CIS and Medical Records and performs a preliminary review of each claim with a detailed clinical profile, identifying any issues of concerns. The Risk Manager works closely with staff and clinicians in their preparation for court and arranges legal advice when deemed necessary. The Risk Manager co-ordinates the meetings between the legal team, staff and consultants involved and enters all claims for discussion at monthly senior management team meeting. The total number of claims activated in 2017 was 16 of which 8 were clinical and 8 general non-clinical related claims.

2.6.5 Freedom of Information This year brought with it a very challenging time for the Risk Department and the Medical Records Department with an increase in the volume of FOI requests, queries and internal reviews following the introduction of the new FOI Bill in 2014 and Code of Practice. In 2017 there was a total 1,600 FOI requests received and managed in UHK

-Review of information Governance/Compliance with FOI and Data Protection Legislation Plans for future developments

- Introduction of Pre-Action Protocol -identifying and meeting emerging training needs of FOI officers - Updating/Revision of Standard Operating Procedures for FOI, Routine Access (Data Protection) and issues of Death Notification Forms.

2.6.6 Risk Registers and Departmental Risk Assessments The Risk Management Department continued its work on the delivery of training and provision of guidance in the development of Risk Registers at Departmental Level. The hospital operates an integrated process for the management of risk, maintaining a hospital Corporate Risk Register is a critical element of this process. The Risk Register assists the organisation to establish a prioritised and targeted agenda for managing its risks. The Corporate Risk Register provides the Executive Management Board with a high level overview and risk status of the organisation at any point in time



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and provides a tool for the monitoring of actions to be taken in order to mitigate risk to patients, staff and the organisation as a whole. In 2017 the Risk Management Department commenced a more enhanced ward/department risk management education based on individual needs in helping staff to develop their own local departmental risk registers. The Risk Management Department commenced hospital wide implementation of local departmental risk registers transition to local departmental electronic risk registers used to record, manage and where necessary escalate their own risks. Throughout UHK each department has their own Risk Register. In 2017 areas that have now completed this transition include the Maternity services, Emergency Department, Catering Service and Corporate Risk Register with plans to implement electronic Risk Register transition hospital wide. Staff at all levels within the organisation are involved in reviewing risks, introducing new controls with a view to reducing the risk and improving safety.

2.7 Prevention & Control of Health Care Acquired Infection An Annual Report of the activities in University Hospital Kerry relating to Infection Control for the year ended December 31st 2017 has been produced and is due for signoff at the next meeting of the ICC in June 2018. Infection Prevention and Control has always been and continues to be a high priority in University Hospital Kerry. The Infection Control Committee aim is to continue implementing the Health Service Executive 2006 ‘Say No to Infection’ infection control action plan and to achieve compliance with the HIQA Prevention and Control of Healthcare Associated Infections Standards (2017). HIQA inspection of PCHCAI standards University Hospital Kerry had an unannounced HIQA inspection in June 2017 non compliances with the some of the National Standards Prevention & Control of Healthcare Associated Infections were identified in the clinical areas visited on the day; Intensive Care Unit and Aghadoe Ward. As part of follow up post the HIQA inspection a Quality Improvement Plan was developed to address the deficiencies post the HIQA inspection which is available to access on the UHK website; progress has been made since the HIQA inspection which is an ongoing and the QIP is updated accordingly quarterly. The Infection Control Team continues to promote hand hygiene as everyone’s responsibility in an effort to improve overall hand hygiene compliance focusing on mandatory attendance at hand hygiene education, observational hand hygiene audit and feedback of audits to departments.

2.8 Better Health and well being for staff, patients and members of the public A range of support services /programmes tailored for healthcare staff to help support them throughout their working life are co-ordinated by the Kerry Community Services Health Promotion and Wellbeing division. The new national standards for quality and safety in Occupational Health Services were launched on 19th May 2017. Information for staff in relation to how to access supports was disseminated to line managers.



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Locally within University Hospital Kerry, ‘Healthy and Happy’ activities were initiated and successfully undertaken eg ‘Sync it for Sudan’, ‘Sickly Come Dancing’, Goal Jersey Day. Into 2018 Steps to Health Challenge plan initiatives such as Lunch Time Walks.

2.9 Quality & Safety Reports from Committees / Directorates / Specialty Teams

Each Clinical Governance Committee (CGC) were extended invitation to meet with the EMB QPS during 2017. The following CGC committees met with the EMB QPS and presented an overview of their key achievements in 2017 and priorities for the year ahead : Pathology / Laboratory Governance Group Radiology Governance Group Paediatrics Governance Group ED Governance Group ICU / Theatre Governance Group

Obstetrics & Gynaecology Governance Group General Surgical (April ) and Orthopaedics (May) are scheduled to attend over the coming weeks.

In addition to the above, a number of Committees returned update via standard template to the Quality & Patient Safety Office : Decontamination, Nursing PPPG, Wound Care, Falls, Radiation Safety, Nutrition, Sepsis / NEWS.

2.10 Review of reports of service specific and mandatory education & training Mandatory Education & Training are an ongoing facet of work at UHK. Training (mandatory and non mandatory) is provided on a frequent basis such that all disciplines are facilitated as appropriate Examples of the training provided at UHK during 2017; Fire Safety Moving & Handling Hand Hygiene Infection Control MAPA (Management of actual or potential aggression) Your Service Your Say Awareness Clinical Waste Training Comprehensive Induction Indeed into 2018, UHK aspire to progress towards use of centralised recording system for all mandatory training/education.



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Into 2018 also, National Child First Training will be closely monitored across all disciplines. For instance the Clinical Director and General Manager will meet individually with each member of the Consultant staff during which their compliance with mandatory training will be assessed.

2.12 Healthcare Records Management Significant Infrastructural works planned for Medical Records will bring about :

- A more efficient records storage solution (through reconfiguration of current MR Dept) - Security of current areas where MR are stored by providing keypad access - Minimisation of risk in context of unsafe storage of current charts in some areas - Minimisation of health & safety risk to staff in context of difficult accessing current MR eg

height restrictions At the time of writing this report (Q1 2018) these works are presently underway.

2.13 Health & Safety

The Safety /Infrastructural Risk Committee chaired by the Operations Manager convened on two occasions during 2017. As part of its remit, the H&S Committee considered matters such as the following during 2017 : Fire Safety Updates, Legionella Report, National H&S Audits, Hospital Safety Statemetns, Theft awareness, Fire Safety Training, Defective Equipments, Office Space difficulties, Parking Difficulties.

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