CET Newsletter Issue 1

Clinical Effectiveness Team Issue 1 / July 2019 Newsletter Welcome to the first edition of the Clinical Effectiveness Team (CET) Newsletter Welcome to the first edition of our quarterly newsletter! Our aim is to spread the word regarding NICE, Clinical Audits, Service Evaluation projects.

Our newsletter is here to provide you with: • Up-to-date information about current projects • Results from recently completed projects • Tips and guidance from our Team to help you with your project

This Edition: Page 2

Clinical Audit – Introduction

Page 3

Service Evaluation – Introduction

Page 4

NICE – Introduction

Pages 5 Completed projects and summaries Page 11 Meet the Team

Next Edition (October ‘19): Also, if you have any specific questions, please get in touch and in the next issue our heroes will answer your questions in the upcoming Q&A section.

Designing a Service Evaluation

To get in touch email either Ricardo or Nina: Cet.lypft@nhs.net

Data Analysis

Designing an Audit Proforma

Q & A Section

Training Opportunity!

Want to know more and build your confidence in Clinical Audit, NICE, and Service Evaluation?

Come along to our Brand New Clinical Effectiveness Training:  3rd September 2019 @ The Mount, 9:30am – 12pm

If you have any suggestions for future articles, or would like your audit or service evaluation project featured in a future edition, please contact the team via: Email: cet.lypft@nhs.net Phone: 0113 85 59 331

Complete our booking form in order to attend: https://www.smartsurvey.co.uk/s/CETraining/

Tweet: @Lypft_CET

Clinical Audit– Introduction What is Clinical Audit?

Clinical Audits assess your service against a set of pre-existing national or local standards.

Why should I carry out a Clinical Audit?

Improving the quality of care for service users is at the heart of all Clinical Audits.

Clinical Audits can help to bring to light risks, allowing them to be addressed.

What help can the CET provide with Clinical Audit projects?

Our team are able to assist in a variety of ways:

    

Identify topics for local audits Support to develop audit tools, register audit, project data analysis, and report writing Provide copies of reports / action plans Advise on sampling, method, and support you through each stage of the cycle Provide regular reports for Clinical Governance Groups

Where do I begin?

So, you’ve decided to do a Clinical Audit, but you’re not sure where to begin or what steps are involved.

To the left is a brief overview of the 4 Stages in conducting a Clinical Audit.

For more information contact the Clinical Effectiveness Team or attend one of our Training Courses (pages 1 & 2).

Message from Ricardo: “Don’t forget! The CET are here to help; you must register all audit activity, including re-audits, before you begin.”

Service Evaluation– Introduction What is Service Evaluation?

A critical evaluation of how well your service is doing in terms of its desired goals.

This information can be captured from staff, service users and carers, and/or data repositories, such as PARIS and Datix.

Why should I carry out a Service Evaluation?

Service Evaluations help you answer questions such as: • Are we meeting the needs of our service users?

• How are service users responding to treatment?

• What happens to our patients after completing treatment?

• What do patients think about the service?

• Are we making the best use of our resources?

• How can we improve the service for staff, other organisations, patients and carers?

What help can the CET provide with Service Evaluation projects?

Our team are able to assist in a variety of ways:  Identify topics and clarify your aims for the project  Help design the project so it meets your aims  Advise on methods, participant sampling, method  Support you with data collection and data analysis

Where do I begin?

The basic steps in a Service Evaluation are shown to the left.

If you’d like to discuss your project idea further, get in touch with Vishal Sharma or visit our Staffnet page.

Message from Ricardo: “Get in touch with the Team once you have an idea, and we can help you design the right project to meet your aim.”

NICE– Introduction

NICE guidance, standards, and other resources help you to deliver the best possible care within the resources available.

NICE guidelines are evidence-based recommendations for health and social care in England; these set out the care and services suitable for most people with a specific condition or need, and people in particular circumstances or settings

NICE guidelines help health and social care professionals to:    

Prevent ill health Promote and protect good health Improve the quality of care and services Adapt in order to improve health and social care services What support can the CET provide?

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NICE’s aim is to drive and enable excellence across the health and social care system

 

Support the NICE Leads with completion of baseline assessments List outstanding work Monitor implementation of the action plan We also…

Our Team (CET) manage NICE guidance throughout the Trust!

We support the NICE leads in ensuring compliance with NICE recommendations via the Clinical Audit Process!

 

  

Organise NICE guidance across the Trust We disseminate the lists to the relevant NICE lead(s) and send out reminders We can provide the Service with information about relevant guidelines We will escalate any issues to the relevant Service or CG Groups Provide advice where to find useful information i.e. NICE website: www.nice.org.uk

For further information: Search via Staffnet ‘NICE Guidelines Implementation Procedure’ (C-0052)

Completed Projects– Clinical Audit See below list of completed Clinical Audit Projects from 1 st March 2019 – 31st May 2019.

Please contact the CET team if you would like any further information.

Title

Registered Current stage

Action plan Prioritisation implemented

Service

Project

Forensic Services

305

Audit On Healthy Living Education For Service Users High 18/05/18 Cycle complete Risk Of Developing Diabetes and Cerebrovascular Diseases

01-Mar-19

Local

Acute (Older People)

264

Nutritional screening, interventions and care plan in OPS 23/05/17 Cycle complete (dementia and mental health units)

22-Mar-19

Local

All services

259

Data sharing CG136

01/04/18 Cycle complete

31-Mar-19

Trust

Community (Learning disabilities)

288

Audit of the “in team” joint working request referral protocol for Occupational Therapy

20/12/17 Cycle complete

03-Apr-19

Local

Assertive Outreach Team

101

Community Treatment Order 11 and 12 consent to treatment and CPA audit

04/10/16 Cycle complete

05-Apr-19

Local

Acute (Older People)

12

Timely completion of discharge summaries at the Mount 07/09/18 Cycle complete

10-Apr-19

Local

Inpatients (Learning disabilities)

279

The monitoring and use of PRN psychotropic medication 12/07/17 Cycle complete for people with learning disabilities on an inpatient ward

11-Apr-19

Local

All services

0111-16

Rapid tranquillisation in the context of the pharmacological management of acutely-disturbed behaviour

02/03/18 Cycle complete

30-Apr-19

Trust

Forensic Services

307

MEWS at Clifton House

15/06/18 Cycle complete

03-May-19

Local

Rehab Ward 5 NC

75

Completeness of MDT meeting report

11/09/18 Cycle complete

24-May-19

Local

CMHT OPS

116

The Assessment of Cardiac Status Before Prescribing Acetyl Cholinesterase Inhibitors for Dementia

09/05/18

Closed Complete

24-May-19

Local

Learning disabilities (all services)

210

Learning Disabilities Review Programme (LeDeR)

01/04/17

Closed Complete

28-May-19

Trust

Community (Learning disabilities)

263

Management of challenging behaviour in LD

29-May-19

Local

11/01/18 Cycle complete

Completed Projects– Service Evaluation See below list of completed Service Evaluations from 1 st March 2019 – 31st May 2019.

Please contact the CET team if you would like any further information.

Service

Project

Title

Registered

Close Date

Leeds Mental Health CG

004

PICU Referral Criteria

20/09/18

17/05/19

Trust-wide

008

A Service Evaluation to Explore Understanding of Consent and Barriers to consent

09/10/18

29/05/19

Specialist & Learning Disabilities Services CG

009

Prevalence, typology and appropriateness of calls for physical health disorders on Leeds mental health

01/10/18

30/05/19

Trust-wide

011

Evaluation of the Hand Hygiene monitoring process

15/08/18

01/04/19

Specialist & Learning Disabilities Services CG

017

Evaluation of Liaison Psychiatry Training with LTHT

13/02/19

31/05/19

Trust-wide

036

Review of Subject Access Requests

01/03/19

25/05/19

Trust-wide

033

IHI Data Analysis

15/05/19

10/05/19

Trust-wide

034

IHI Post-Visit Evaluation

29/04/19

23/05/19

Completed Service Evaluations and Clinical Audit Reports are available on the QI Bookcase on Staffnet - see below for further details: Step 1: On Staffnet, select “Knowledge Centre”

Step 2: Then click on “Library and Knowledge Services” Step 3: Scroll down and on the left-hand side click on “Quality Improvement Bookcase” Step 4: Select either “Service Evaluation” or “Clinical Audit” Message from Nina: “As well as sharing the reports on Staffnet, infographics of recent projects are enclosed in the next few pages..”

Project 188: National Mental Health CQUIN Indicator 3b: Communication with general practitioners Patient Notes

Ensure necessary information is shared with primary care professionals.

Enable safe and effective care of patients seen by secondary care mental health services

100%

21%

72%

NHS Number recorded

Primary and secondary mental and physical health diagnoses

74% Medications prescribed and recommendations recorded

The Physical Health Team to develop prompts for staff in the new CPA care plan To develop a set of standards which will be used for community and inpatient discharge letter templates

GPs provided with a discharge summary/CPA within 48 hrs or 2 weeks’ time

49% Ongoing monitoring and/or treatment needs for cardiometabolic risk factors identified

Test the functionality of the electronic communication system which should automatically send CPA care plans and inpatient discharge summaries to GPs within 48 hours

Teaching sessions

Prompts to be included in the new CPA care plan (they are already in the current care plan and discharge summary templates)

Project 215: Documentation of Medicines Reconciliation on Admission

Assess the effectiveness of actions from previous cycles to reduce the incidence of medication errors for patients transferred from community to hospital.

66% of forms were fully completed. In 2016 there were no fully completed forms

Two areas of improvement: 1) self/carer (15%); 2) using patient as source of information (36%)

Reinforce knowledge of national and trust guidance regarding medicines reconciliation Review and update reconciliation Standard Operating Policy (SOP) Improve recording of the medicines reconciliation tabs

Clinical Audit of monitoring of clerking in and physical health evaluation on admission into the Clinical Assessment Unit (CAU)

The 2017 admission protocol for the CAU out of hours pathway and the LYPFT Physical Health on Admission procedural document (C-0005)

Service users had an ECG

94%

Service users had blood tests

94%

Service users had a GATE assessment

94%

Service users offered a physical examination

100%

 Educate all new medics on best practise in CAU  The audit findings and above recommendation have also been shared with: • The CAU Clinical Improvement Forum (CIF) • All staff at an CAU away day Project 076 For more information contact the CET via email: cet.lypft@nhs.net

Clinical Audit of the documentation and implementation of ECG and Haematological investigations at South ICS

Less than 1 in 3 service users audited had the required routine haematological investigations

8/25 patients (32%) had routine blood tests and only 2/25 (8%) had documented and actioned results ECG Taken 15% Documented

Re- audit of adherence to the Maudesley Guidelines for performing ECGs and blood tests on prescribing antipsychotics

15% Creatine Kinase Taken 31% Documented

Routine+

15%

Prolactin Taken 15%

 Increase the number of staff members trained In blood and ECG taking within South ICS

Documented

8%

 Increase access to Leeds Care Record (LCR), so that more people have ownership of whether bloods have been done  Present the findings and proposed actions locally to increase awareness  Create a method of recording and updating results Project 081 For more information contact the CET via email: cet.lypft@nhs.net

Meet the Clinical Effectiveness Team Dr Saeideh Saeidi Head of Clinical Effectiveness

Yasaman Bagheri Clinical Audit Facilitator

S.saeidi@nhs.net 0113 85 59334

Yasaman.bagheri@nhs.net 0113 85 59332

Fabrizio Girolomini Senior Clinical Audit Facilitator

Fiona Lacey Clinical Audit Facilitator

F.girolomini@nhs.net 0113 85 59337 Fiona.lacey@nhs.net 0113 85 59336

Dr Vishal Sharma Evaluation Advisor

Tesfya Sheti Clinical Audit Assistant

Vishal.sharma2@nhs.net 0113 85 59334

Tesfya.sheti@nhs.net 0113 85 59331

Helen Turner Clinical Audit Facilitator

Helen.turner39@nhs.net 0113 85 59335

Nina & Ricardo Clinical Effectiveness Heroes Based at The Mount along with the rest of the CET

Message from Nina: “Hope you enjoyed the first edition of our CET Newsletter!

Keep a look out on Trustwide around the 1st October 2019 for the next quarters edition.�