Quality Account 2010/11 - James Paget University Hospitals

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Case Study 2: Upper Gastrointestinal Bleed Audit Aim A re-audit of the management of Upper Gastrointestinal bleeds (UGIB) according to the SIGN (Scottish Intercollegiate Guidelines Network) guidelines (also adopted by Royal College of gastroenterology and NICE) in view of implementing Trust guidelines. Objectives 100% of patients admitted with suspected upper GI bleed should meet the criteria set out below: 1 Assessed using an upper GI bleed scoring system to categorise risks 2 Observations including BP and pulse 3 Blood tests including Hb and Urea 4 Rectal examination performed at time of first assessment 5 Patients scoring 0 on Blatchford score are discharged for outpatient endoscopy 6 Clo test results clearly documented and acted on 7 Receive early endoscopy, defined as being performed on the day or following day of request being made 8 Use of proton pump inhibitors (PPIs) if there is no 24 hour endoscopy service available or PPI have been recommended post endoscopy by the endoscopist Conclusions • Significant improvement in use of UGIB scoring system • Education of junior doctors required regarding rectal examination at first assessment, awareness of significance of Clo Testing and treatment • Documentation throughout medical notes could be improved • Concise Trust guidelines for the management of patients admitted with Upper GI Bleed are required. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 24 of 62
Case Study 3: Patient Hospital Paper Health Records Documentation Audit 2010 Objectives Comparative audit for Trust and specific areas; to highlight adherence to NHS and JPUH policy criteria Rationale: Ongoing audit (NHSLA) of correctness of Patient Paper Health Records Audit Sample: 5 sets of notes were reviewed per Specialty; covering 31 Specialties, out of a possible 46 (67%), which resulted in 319 professional entries being individually assessed for compliance with criteria Data collection: Data Source: Data Collection: Retrospectively (admissions reviewed from 10th June to 8th December 2010) Patient Paper Health Records Undertaken by Junior Doctors, Nurses and Clinic Staff Results compare 2008, 2009 + 2010 audits Conclusions • There has been a year on year improvement since 2008 in the quality of Health Care Files • Timings of entries is only 70% • All entries (including alterations/additions) identify author by reference to Nursing Accountability Record is only 55% • Common anecdotal complaints of numerous documents not filed correctly, not in chronological order or loose etc are untrue with 90%+ being correct. Still room for improvement! • Allergy notation has greatly improved Overall conclusions • Shows that progress made with the documentation work streams around the Trust and that the importance of correct documentation can now be shown to be a vital part of improving patient safety and patient outcomes Recommendations: • To evaluate the audit paperwork to make it easier to understand • To evaluate the audit process so it is embedded into the Trust and that key staff groups are signed up to undertake the audit work rather than the ad hoc approach at present • To disseminate the findings and create an action plan of actions and hence improvements in areas of need James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 25 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 24 and 25: (NHSBT UK Transplant Registry) Audi
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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