Quality Account 2010/11 - James Paget University Hospitals

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(NHSBT UK Transplant Registry) Audit Name Applicable Trust Lead Percentage of Cases Submitted Patient transport (National Kidney Care Audit) Renal Colic (College of Emergency Medicine) Cancer Lung cancer (National Lung Cancer Audit) Bowel Cancer (National Bowel Cancer Audit Programme) Head & Neck Cancer (DAHNO) Trauma Hip fracture (National Hip Fracture Database) Severe trauma (Trauma Audit & Research Network) Falls and non-hip fractures (National Falls & Bone Health Audit) Psychological conditions Mark Prentice 100% Donna Wade Dr Mahadevan Linda Hayes Steve Wright Mr Premachandra Tracey Church Data collection ongoing Data collection ongoing Data collection ongoing 100% Louise Hebdon 100% Louise Hebdon Dr Zaidi Data collection ongoing Data collection ongoing Depression & anxiety (National Audit of Psychological Therapies) Kirk Lower Occ Health No participation Prescribing in mental health services No participation – (POMH) Mental Health National Audit of Schizophrenia (NAS) No participation – Mental Health Blood Transfusion O neg blood use (National Comparative Audit of Blood Transfusion) Platelet use (National Comparative Audit of Blood Transfusion) Julie Jackson Julie Jackson 9 cases submitted 27 cases submitted James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 22 of 62
Locally developed clinical audits are reviewed at various multidisciplinary meetings across the Trust. During 2010/11 the following numbers of local audits were reviewed and discussed at internal meetings and actions to improve clinical services were subsequently agreed: Paediatric Audit Meeting 13 Perinatal Morbidity & Mortality Meeting 2/3 case presentations per meeting Emergency Clinical Governance Meeting 4 Combined Audit Elective Division 7 (+ Surgical Mortality Review cases) The following case studies provide examples of where clinical audits have directly led to improvements in patient services. Case Study 1: Re-audit Compliance with Trust Antibiotic Guideline Objectives • To investigate compliance with the Trust Antibiotic Guideline • To highlight any possible areas of improvement. Following this audit the following actions were agreed: Action Plan • Educate new doctors in the right way of prescribing antibiotics via induction training sessions. • Drug chart to be redesigned for antibiotic prescribing which would include a space for review date and indication for the antibiotics. • A separate antibiotic sticker to be trialled in EADU which indicates a review/stop date and the indication for prescribing. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 23 of 62
Page 1: James Paget University Hospitals NH
Page 4 and 5: Contents Page Foreword by Chief Exe
Page 6 and 7: The old and the very young are know
Page 8 and 9: Statement of directors' responsibil
Page 10 and 11: Current position: Patient Falls 120
Page 12 and 13: Priority 1b: Patient safety - Reduc
Page 14 and 15: Five work streams have been agreed
Page 16 and 17: No Commissioning for Quality and In
Page 18 and 19: No Commissioning for Quality and In
Page 20 and 21: The services provided by James Page
Page 22 and 23: Clinical Audits Audit Name Applicab
Page 26 and 27: Case Study 2: Upper Gastrointestina
Page 28 and 29: The Trust has a dedicated lead for
Page 30 and 31: NHS number and GMC code validity Ja
Page 32 and 33: What others say about the Trust Car
Page 34 and 35: Current Position: Inpatient Pressur
Page 36 and 37: Metric 3 - Venous Thromboembolism (
Page 38 and 39: Monthly CVC BSI Rates 14 12 Rate of
Page 40 and 41: Metric 8 - Nutrition & Hydration Ma
Page 42 and 43: Patient Safety Incidents As at 18 t
Page 44 and 45: Never Events Never Events are serio
Page 46 and 47: Existing Commitments and National P
Page 48 and 49: Patient Experience National In-pati
Page 50 and 51: An action plan has been developed f
Page 52 and 53: Maternity National Survey The respo
Page 54 and 55: Question Area Conclusions Recommend
Page 56 and 57: Case Study: Health Service Ombudsma
Page 58 and 59: Patient Experience Measures Patient
Page 60 and 61: • 100 Key Scores Comparison 90% 8
Page 62 and 63: NHS Great Yarmouth & Waveney NHS Gr
Page 64: Glossary of Abbreviations A&E C dif

Quality Account 2010/11 - James Paget University Hospitals

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