Annex - Northern Devon Healthcare NHS Trust NDHT

End of year Review 2010-11
Clinical Audit and Effectiveness Department
Number of projects
120
110
100
90
80
70
60
50
40
30
20
10
69
99
32
13
Implementation/Completed
Work in progress
Ongoing/monitoring
Not started
53
19
15
12
38
30
7
5
There were 359 projects active during the year.
These are shown in the chart by prioritisation
category. The category is allocated using the tool
designed by the Healthcare Quality Improvement
Partnership and further developed locally.
The outcomes of the 69 completed Category 1
projects as of 31/03/2011, together with their national
or local drivers, are shown in the table below and
overleaf
0
Cat1 Cat 2 Cat3
Prioritisation Category
Project driver Project title Outcome(s)
Assurance, high
cost
Assurance, high
risk
Assurance, NICE
guidance
Cancer
accreditation
Child protection,
corporate
requirement
CQC feedback
requirement
Two week wait referrals: Review against
national guidance
Neutropenic sepsis
DVT prophylaxis in orthopaedic surgery
CG40 Long Acting Contraception
CG47 Feverish illness in children
CG54 Urinary tract infection in children
Notification of skin cancer diagnosis to GP
within 24h (2009)
Malignant melanoma pathway
Notification of skin cancer diagnosis to
GPs within 24h (2010)
Lung cancer patient survey
Breast cancer patient survey
Gynae-oncology patients survey
Urology Patient Survey
Lung cancer: Peninsula-wide patient
survey
DSCB Multiagency child protection audit
Pain Team: Patient survey of pain
management
Respiratory Specialist Nursing Service:
Patient survey
Radiology: liver biopsy patients survey
Orthoptics patient survey
Radiology: breast biopsy patients survey
Radiology: Imaging-guided biopsy
patients survey
Radiology: lung biopsy patients survey
Orthoptics patient survey - Part 2 Children
and parents
Bideford Radiology Customer Service:
Patient survey
95.4% compliant with NICE referral guidance. Publicise to GPs for
education and to celebrate good practice
Poor compliance in small sample. Roll-out of new guidance and
continuous monitoring
Compliant with standard for DVT prophylaxis. No action required
No actions required
E learning module and diagnosis and treatment algorithm
implemented to assist with acute management
An algorithm for management of paediatric UTI has been
developed jointly by A&E and Paediatrics and implemented
Compliant, No action required
Compliant. No action required.
Compliant, No action required
Improvements to provision of patient information, new leaflet
written
90% satisfaction with the service. New information leaflet
regarding the help and support offered by the Breast Care Nurses
included in patient information packs.
Recommended nurse-led follow up clinic.
Wrote information leaflet about Key Worker role. Increased CNS
time to improve patient access
New patient information leaflet written and implemented.
Recommended improvements to record keeping and sharing of
information. Action agreed: Consultant Paediatrician to submit a
written report if unable to attend case conference
Improved patient information and communication
Improved patient information. Set up "telephone clinic" to enable
better patient access
Identified need for better explanation of risks, how to get results.
Re-wrote patient appointment letter. Re-addressed staff education
to improve customer care
Identified need for better explanation of risks, how to get results.
Identified need for better explanation of risks, how to get results.
Identified need for better explanation of risks, how to get results.
Re-wrote the appointments letters to improve patient information
and addressed communication skills of team with child patients.
Improved facilities
96% satisfaction with the service. No action required.
Clinical Audit and Effectiveness Department/KM/9.6.2011 Page 1 of 4

CQC feedback,
clinician priority
CQC feedback &
cancer
accreditation
CQC feedback
requirement new
service
CQC - quality
improvement:
Staffing
CQC-quality
improvement:
Respecting &
involving
(EOC)
CQC-quality
improvement:
Care and Welfare
(EOC)
Local, high risk
Surgical in-patients and out-patients
survey
Splints: Survey of patients using splints
fitted by OT Rheumatology Team
Radiology: ERCP patients survey
Radiology: General patients survey
Ponseti technique in the management of
club foot: Outcomes of treatment
Chemotherapy patient survey
Age-related macular degeneration clinic:
Patient survey
Cataract one-stop clinic: Patient survey
Ward Workload Assessment (Re-audit on
NDDH wards)
Ward Workload Assessment (Community
hospital wards)
Psychiatric Link Nurse Practitioner Role
Evaluation
Communication – patient feedback
Personal Hygiene
Pressure ulcers – patient feedback
Continence – patient feedback
Falls - inpatient assessment
ICP for the care of the dying: Re-audit of
variance
Paediatric asthma
Management of pregnant women with
raised BMI (National and local project)
Deaths in Acute Hospitals (NCEPOD)
National COPD Audit
Acute kidney injuries (NCEPOD)
Introduction of a one-stop clinic for cholecystectomy patients
including information DVD, consultation and booking for surgery.
More flexible use of types of material for splints in response to
patient feedback
Improved access to written information for fast-track patients
Recommended improvement to privacy and confidentiality for
patients having plain film examination
Patients reported satisfactory outcomes of treatment. No action
required.
Assisted with reduction of overcrowding and waiting times by
improved scheduling of appointments. Improved privacy for
discussion by introducing triage nursing role
New information leaflet about treatment designed and given to all
patients .Contact details given to patients for post-treatment advice
if required.
Improvements made to clinical and appointment information giving
for patients. Staff education about keeping patients informed if
they have to wait.
Improvements shown. Roll out plan for electronic version of
WWAT; develop monthly reporting system; improve recording of
Clinical Site Managers’ actions
Staff training; community hospitals to be covered by new electronic
system
New Psychiatric Liaison Service introduced at NDDH
Identified patient communication priorities for future Trust
monitoring. Various new patien information guides/leaflets
produced + new staff documentation & training introduced.
Benchmark lead to increase staff awareness of the need to involve
patients and carers, and to document their involvement; improve
format of care planning paperwork; tell staff to improve adherence
to review intervals
Benchmark lead to focus improvement work on ensuring that
patients have individualised care plans
Benchmark lead to focus improvement work on assessment,
individualised care plans and patient information
Findings fed into the Falls Group risk assessment improvement
process
Compliance has improved by 3% overall and individual standards
show 97-100%. No action required.
Patient information leaflet; template for individualised care plans;
staff told to check inhaler technique
New guideline; use of checklist; recalculation of BMI at 36 weeks;
assessments of women with BMI >= 40 weeks during third
trimester; distribution of information to primary health services;
Compliant with national benchmarks regarding avoidable deaths
No action required.
Compliant with national benchmarks for COPD treatment. Action:
Aim to improve measurement and documentation of patients'
height, weight and BMI.
No action required
National project
National Care of the Dying Audit Round 2
National Inflammatory Bowel Disease
Audit
Fractured neck of femur. College of
Ermergency Medicine
Pain in children. College of Emergency
Medicine
Asthma. College of Emergency Medicine
Cascade ICP to all clinical areas. 92-100% compliant
Most standards compliant. Action: IBD cases to be discussed at
MDT meetings.
Compliant with standards apart from 2h fast track. Staff education
addressed.
Post-analgesia pain scoring improved.
Post-nebuliser peak flow measurement improved.
MINAP: How the NHS manages heart No action required
attacks
National Carotid Endarterectomy Round 3 Recommended carotid patients are fast tracked for investigations
and surgery
National Maternity Survey 2010
Identified need for Improvements to patient information and choice,
continuity of care and privacy and dignity
NSF compliance Regional Falls and Bone Health Review Compliant, No action required
NPSA
Patient Safety First - Insulin prescription New insulin prescription chart introduced and guide to completion
on intranet
Clinical Audit and Effectiveness Department/KM/9.6.2011 Page 2 of 4

NPSA
Oral anticogulation
Trust compliant. No action required. Ongoing monitoring by
Patient Safety Initiative
Controlled drug records in Theatres Processes for handling controlled drugs in theatres changed
Patient safety Medicines management policy re-audit Informed changes to the Medicines Management policy made by
the Drugs and Therapeutics Group
Sexual history documentation
New Risk Assessment Form introduced
Patient safety,
corporate
requirement
Re-audit
Commissioner
request
Improving documentation for clinical
decision making and clinical coding
(Paediatrics)
Children’s consent
Consent information for vaginal
hysterectomy and pelvic floor repair
Documentation paediatric inpatients initial
assessment
Consent and documentation caesarean
section
Consent to acupuncture - Physiotherapy
Consent to Occupational Therapy
IV Fluid administration in Paediatrics (reaudit)
Antenatal Care Pathway
Formal Trust project put in place to improve capture and correct
coding of all outpatient and inpatient activity.
Staff training; coding department feedback process; electronic
audit tool
Patient information leaflet, changes to admission paperwork; pilot
change to Trust continuation sheets; staff training.
RCOG consent forms to be adopted with copies to patients.
Improved process for gaining consent
Revised admissions proforma to be developed in line with other
clinical areas
All patients are seen by surgeon before surgery and new RCOG
consent forms to be adopted
Consent form re-designed and implemented
Consent continues to be monitored/audited as part of monthly
documentation audits
Implementation of re-designed documentation of fluid balance in
children
Small project. Clinical requirements met. Review Nuchal
Translucency screening process
Clinical Audit and Effectiveness Department/KM/9.6.2011 Page 3 of 4

DIVISION SPECIALTY REASON WHY
CATEGORY 1
ANAESTHE
SIA/THEAT
RES/CRITI
CAL CARE
MEDICINE
and A&E
CATEGORY 1 PROJECTS NOT STARTED BY 31/3/11
PROJECT TITLE
COMMENTS
Cancer NHSLA NICE CG58: Prostate Cancer One of 11 NICE CGs pinpointed by the NHSLA for possible scrutiny to meet one of their 2010-11
Risk Management Standards. Reason given - workload pressures within Urology. On 2011-12
programme – starting January 2012 – Category 2 project now that the Trust is aiming for
Level 1 in 2011-12.
ITU
ITU
Acute
Medicine
Acute
Medicine
Cardiology
QUALITY
ACCOUNTS
NATIONAL
CONFIDENTIAL
ENQUIRY
QUALITY
ACCOUNTS
QUALITY
ACCOUNTS
QUALITY
ACCOUNTS
ICNARC: Cardiac Arrests
Prescribing and Delivering TPN on ITU
Adult Pneumonia (British Thoracic
Society)
Emergency Oxygen (British Thoracic
Society)
MINAP Report 2007: Thrombolytic
Treatment
Ophthalmology NHSLA External Dacrocystorhinostomy: Patient
Reported Outcomes
Lengthy discussion took place about local resources for this i.e. who would do the data entry and
submit this to the national organisers. Eventually Carolyn Mills decided it would be resourced from
1/4/11 onwards. Data collection/submission began 1/4/11
Arose from recommendations following a national NCEPOD project. .Reason given – lack of
permanent Anaesthetics Middle Grades to undertake audits. On 2011-12 programme – starting
August 2011.
There were 9 BTS audits during the year. This was one of three that were not taken part in as they
weren’t considered useful from a local clinical viewpoint. Annual projects – on 2011-12
programme.
There were 9 BTS audits during the year. This was one of three that were not taken part in as they
weren’t considered useful from a local clinical viewpoint. - local oxygen audit undertaken. Not
taking part in 2011-12 audit for same reasons.
Arose out of the local results of a stand alone MINAP national audit. Flagged up on quarterly
exception reports during the year and raised by CAED Audit Link with senior Divisional staff and
Consultant Cardiologists - no reason given why project not done Medicine Division decided not
to add to 2011-12 programme as they felt existing MINAP processes sufficient to address
possible areas of improvement.
NICE CG85 - one of 11 NICE CGs pinpointed by the NHSLA for possible scrutiny. Raised by
CAED Audit Link with senior Divisional staff - no reason given why project not done Category 2
project now that the Trust aiming for Level 1 in 2011-12.
NHSLA Eyelid Tumours and Lesions CSG NICE CG85 - one of 11 NICE CGs pinpointed by the NHSLA for possible scrutiny. Raised by
CAED Audit Link with senior Divisional staff - no reason given why project not done Category 2
project now that the Trust is aiming for Level 1 in 2011-12.
NHSLA
Glaucoma: The Diagnosis and
Management of Open Angle Glaucoma
and Ocular Hypertension – Treatment
and Outcomes NICE CG85 and Fast
Track Glaucoma Clinic Re-audit
NICE CG85 - one of 11 NICE CGs pinpointed by the NHSLA for possible scrutiny. Raised by
CAED Audit Link with senior Divisional staff - no reason given why project not done Category 2
project now that the Trust is aiming for Level 1 in 2011-12.
WOMENS
AND
CHILDREN
S
CORPORA
TE
PROJECTS
Paediatrics &
SCBU
NHSLA
CNST
EOC
EOC
Proliferative Diabetic Retinopathy:
Retinopathy Screening Guidelines
NICE CG86. DOH NSF Diabetes
Neonatal resuscitation – develop and
audit guideline [Neonatal Taskforce
evidence for Principle 7; NPSA signal)
(2011-12) [FT & DavinaP]
Ensuring Compliance with SOP for Last
Offices
Safety of Mental Health Clients in
General Health Settings – Development
and Use of New Safety Checklist
NICE CG85 - one of 11 NICE CGs pinpointed by the NHSLA for possible scrutiny. Raised by
CAED Audit Link with senior Divisional staff - no reason given why project not done On 2011-12
programme (April-July 2011) but now Category 2 project as the Trust is aiming for Level 1
in 2011-12.
Audit delayed pending development and implementation of guideline. Now Category 2 project on
2011-12 programme, starting March 2012.
Due to follow completion of Hygiene audit which was delayed due to change of lead. Now
Category 2 project on 2011-12 programme, September-November 2012.
Due for audit following roll out of checklist, but checklist not yet in use. Now Category 2 project
on 2011-12 programme, November 2011 – January 2012.
Clinical Audit and Effectiveness Department/KM/9.6.2011 Page 4 of 4