Quality Account 2010/11 - James Paget University Hospitals

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Monthly CVC BSI Rates 14 12 Rate of CVC BSI 1000 Catheter days 10 8 6 4 Series1 2 0 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Surviving Sepsis is a campaign that has been introduced to reduce mortality and morbidity associated with delays in recognition and treatment of sepsis. If not treated in a timely way, sepsis can become a medical emergency. Evidence suggests that a specific bundle of care interventions, initiated at point of diagnosis improve patient outcomes. The Trust focus at the current time is to improve sepsis recognition. Initiation treatment is being focussed on A&E and EADU. Plans are in place to roll out the ‘sepsis bundle’ throughout the Trust this year. Surgical Site Infection Surveillance is mandatory, with periodic surgical site surveillance undertaken following hip and knee joint replacement surgery. Results issued last year report that over the preceding five year period the following infection rates were seen: • national average for hip replacement 1.1% (JPUH = 1.2%) • national average for knee replacement 1.1% (JPUH = 1.3%) Some changes to practice have been implemented that should further improve wound care in the orthopaedic areas. World Health Organisation (WHO) Surgical Safety Checklist - In England and Wales, 129,419 incidents relating to surgical specialities were reported to the NPSA from 1 st January – 31 st December 2007. The WHO Surgical Checklist is designed to reduce the number of errors and complications resulting from surgical procedures. There are ten core standards that WHO recommend should remain, even if local adaptation to the checklist is made. At the James Paget we have integrated the checklist into our electronic theatre information system and have introduced a visual prompt in each. Audit results from October 2010 to March 2011 demonstrate that more than 99% of the checklist has been appropriately completed. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 36 of 62
Metric 6 – Mortality and Case Note Reviews (using Global Trigger Tool) 50% of harm events are thought to be avoidable (NPSA 2007). The use of triggers to identify adverse events during a manual record review has been used extensively to measure the overall level of harm in health care organisations. Local Improvement Aims: 1. 100 baseline random mortality reviews to be completed by end March 2010. 2. 40 baseline random case note reviews (harm events) to be completed by end March 2010. 3. 20 random mortality reviews to be completed every month from April 2010 onwards. 4. 20 random non mortality case note reviews to be completed every month from April 2010 onwards. Successes: • Excellent learning opportunities identified • Highlighted trends that are being incorporated into improvement projects e.g. delays in appropriate escalation of concerning patients, poor fluid management and completion of fluid charts, poor clinical record keeping Concerns: • Medical capacity to commit to review process • Overlap with existing mortality review groups • Timely administrative process to arrange reviews. Metric 7 – Medicines Management Between September 2006 and June 2009 27 deaths, 68 severe harms and 21,383 other patient safety medicines incidents were reported to the NPSA nationally. Local Improvement Aim: 1. Ensure reasons for drug admissions are appropriately documented on the drug chart 2. Improve pain management processes and patient outcomes 3. To evidence other medicines management actions required from adverse event trends. Successes: • Multidisciplinary focus • Working on the principle of 7 key responsibilities for medicines management • Working directly with Medicines Management Action Group. Concerns: Although progress has been made there is room for further improvements. As a result medicines management will have a more targeted focus in the forthcoming year to identify ideas and innovations and how we can make more of a difference. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 37 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 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 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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