Annual Report and Accounts - The Great Western Hospital

No. Audit Title
Audit Summary/Learning and Action
Neighbourhood
Teams
43. Services in the
Swindon
Community for
Children with
Continuing
Healthcare Needs
44. Management of
Suspected
Cardiac Chest
Pain in the
Emergency
Department
45. Compliance with
Discharge
Summaries Audit
Report-Quality &
Timeliness 2011-
12
46. Compliance with
Out Patient Clinic
Letters-2011-12
47. Continuing Health
Care (CHC)
Review Process
48. Community
Patients have an
Estimated Date of
Discharge (EDD)
in their Care Plans
(Re-Audit)
49. Congenital
Hypothyroidism
Excellent practice demonstrated around identifying acting upon and
documenting the children’s clinical need. Further work includes improved
documentation of care for children with complex healthcare needs and
development of local guidelines.
Very high compliance. Actions include changes to a few sections of the
“Chest Pain Proforma”.
The re-audit showed that the Trust has demonstrated high compliance
with the vast majority of the standards. ALL electronic discharge
summaries currently submitted now have values for the data on: Action by
GP requested / For GP info, Urgent / Routine, Medication Changed (Y/N).
Finally, compliance with the timeliness of inpatient discharge summaries to
be with GPs within 1 working day of discharge was 73% (Target-90%).
Actions include: dissemination of results, weekly monitoring on timeliness
of eDS and educating all clinicians to ensure discharge summaries include
all relevant information.
The re-audit demonstrated that the vast majority (94%) of the patient
records checked reflect a high standard of compliance. Considering that
changes to the OP clinic template were implemented on 12th Jan 2012,
the compliance with data on: Action by GP requested / For GP info, Urgent
/ Routine, Medication Changed (Y/N), is 80% (Target-98%).Furthermore, it
was observed that the actions in the boxes did match the content/sense of
the OP clinic letter. Even though there is some improvement with the
availability of clinic letter on Medway within 2 working days, there is further
improvement required to achieve compliance (% Achieved- 71%, Target-
90%).
Actions include: Dissemination of results, continue work on improving
timeliness of clinic letters and re-evaluate the effectiveness of the
mandatory boxes.
Audit identified that, although improvements have been made, further work
is required in order that all documents are completed ensuring that all
areas of patient need are being met.
7 Neighbourhood Teams have achieved 100% compliance with EDD set
and documented within 24 hours. Action includes, non-compliance NT’s to
benchmark against each other to improve compliance.
There is clear evidence of good documentation and institution of treatment
and investigation in children born with CHD. In addition, the follow-up is
also managed regularly.
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