Annual Report and Accounts - The Great Western Hospital

The reports of 273 local clinical audits were reviewed by the provider in 2011/12 and Great Western
Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of
healthcare provided.
No. Audit Title
Audit Summary/Learning and Action
1. Antibiotic Missed
Doses
2. Image Guides
Musculo-Skeletal
Injection Review
The audit was aimed identify the reasons behind missed antibiotic doses
and to try to see any trends or educational issues with an aim to address
these issues and look at the need for a possible change in procedure or
for further education. The results demonstrated partial compliance. Actions
include- Antibiotic working group to promote training for staff groups. Look
into possibility of adding a feature to the antibiotic newsletter. Ward stock
lists to be made available on the pharmacy intranet.
The overall patient experience is good and results demonstrate patient
satisfaction with information provided regarding the procedure in majority
of cases.
Actions include- Continue with the practice and work on improved
explanations of procedure and re-survey.
3. Surviving Sepsis The results demonstrate that there are areas for improvement Trust wide.
Actions include- Developing & implementing sepsis proforma, change in
practice with first dose of antibiotic, information dissemination and
education.
4. Compliance to In-
Patient Consent
Policy
5. Compliance to Out
Patient Clinic
Letters (10-11)
6. Compliance with
In- Patient
discharge letters
(10-11)
7. Stem Cell
Transplant-Patient
Satisfaction
Survey
Audit results demonstrate that there is a high level of compliance in areas
of practice i.e. stating demographics, intended benefits, risks. However
lower levels of compliance can be seen in respect of consenting children
compared both to consenting adults. Actions include inserting “check box”
into Consent Form 1-4 to require a positive affirmation from the health
professional that they are either competent to do the procedure or have
undertaken procedure specific training. Raising targeted awareness
amongst paediatric surgeons to improve compliance with consenting
children. These actions have been implemented and the re-audit is
planned in June 2012.
Audit results demonstrate that there are only a few areas for improvement
pertaining to quality of Outpatient Clinic letters. Areas of good practice
include secretaries within the directorates are now pooling the work to
enable speedier transcription, voice recognition has proved really
successful although cost implications if taken forward for all specialties,
letters being sent ‘unsigned to hasten delivery’ to speed up the process.
Actions include monthly monitoring on timeliness of clinic letter; continue
work on improving timeliness of clinic letters and re- audit.
Audit results demonstrate that there are only a few areas for improvement
pertaining to quality of Discharge Summaries. The area that needs to be
largely improved is the time frame the discharge summary is sent to the
general practitioner. Actions include appropriate changes to eDS system
to allow automatic population of ‘source of admission’, colour coding to
inspire timely completion, monthly monitoring on timeliness of eDS,
education for junior doctors. Encourage clinical engagement within
Directorates at each stage of the audit, review data collection proforma
and re-audit.
The survey was designed to obtain information about the patient
experience of stem cell transplantation, including follow-up support. 100%
of patients felt involved in decisions about their treatment and felt
comfortable to ask questions. They were all able to meet the dietician
prior to their transplant. There were positive responses with regard to the
role of clinical nurse specialist. 50% of patients felt they would benefit
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