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Quality and Safety

Quality is a key governance priority for Greater Huddersfield, recognising the role of CCGs in creating a culture which supports continuous improvement. As a subcommittee of the Cluster Board the CCE has the responsibility for scrutinising and gaining assurance in relation to the three domains of quality; safety, effectiveness and experience and the role of the Quality Group is to provide this assurance to the CCE. The group receives regular reports which collate information about quality, safety and experience from various sources. The CCE Quality Group met on 10 July 2012 and 15 August 2012 where information on the following key quality metrics were reported:EMSA th

CHFT reported 2 clinically unjustified breaches in the Surgical Assessment Unit on 10 May 2012. These breaches were toilet/wash facilities breaches, therefore will not show on Unify report, and were due to capacity issues. These were rectified first thing in the morning rather than move patients during the night. CHFT have now put in place a process where the Head of Quality is informed as soon as breaches occur. At the June 2012 Quality Group it was reported that CHFT had recorded one clinically unjustified breach in April 2012. This occurred on the Calderdale Royal site on the Acute Stroke Unit (ASU) and involved toilet and washing facilities. Following discussion with CHFT’s EMSA lead the April data will be revised to remove this breach as the breach was clinically justified. The patient had been admitted to the acute stroke unit, with suspected stroke, but a diagnosis of non-stroke was made on the second day of admission and the patient was moved from the ASU. As ASUs are exempt from MSA requirements, a breach should not have been recorded. CHFT will be applying breach

EMSA No actions required

revisions policy and it is anticipated that in future reports these breaches will be removed VTE Risk Assessment

VTE Risk Assessment

VTE risk assessment at CHFT continues to be in line with the national average.

No actions required

National Patient Safety alerts CHFT have one alert open past the closure date of 2 April 2012 – Safer spinal (intrathecal), epidural and regional devices (NPSA/2011/PSA001). The Royal College of Anaesthetists, Association of Anaesthetists and the Obstetric Anaesthetic Association produced a joint statement last year saying that they felt there were risks associated with individual Trusts doing their own small trials and felt that there should a national trial of the new devices and then a decision made and the device chosen to be implemented nationally. The NPSA responded by saying that they didn’t agree and urged Trusts to continue trialling and then implement their chosen device. The Clinical Director for anasthetics is leading on this and has identified the risks to CHFT of trialling new devices with differing connectors with doctors who work across many sites. CHFT believe their risks of wrong spinal injection are extremely low as they are generally caused by wrong injection of chemotherapy agents into CSF, which they do not undertake as patients are referred to Leeds for intrathecal chemotherapy). Further advice is awaited from the College and there are other Trusts who have made the same decision on the back of the joint statement. CQC Compliance In March 2012 the Secretary of State asked the CQC, as the regulatory agency, to conduct an inspection of Termination of Pregnancy Services as a priority. Verbal feedback, given to CHFT on the day of inspection, indicated that they were compliant with the standards they were inspected against. The report has now been published and the following table provides an overview of the outcome:

NPSA – outstanding alert to be discussed at Clinical Quality Board and considered for inclusion on CHFT and NHS Kirklees/GHCCG Corporate risk registers.

Provider Date of review Outcome 21 - Records Link to report

Calderdale Royal Hospital 22 March 2012

Compliant Calderdale Royal Hospital Termination of Pregnancies

The follow up reports for SWYPFT Chantry View and Fox View in May 2012 have found the service to be fully compliant against the standards inspected against. A routine inspection has also been undertaken at The Poplars which was found to be compliant against the standards inspected against. A follow up visit for Locala at Holme Valley Memorial Hospital also took place 29 June 2012, following their initial inspection visit in November 2011. The standards inspected against were found fully compliant. CQC/Ofsted Inspection of Safeguarding Children Action Plan The CQC/Ofsted inspection of Safeguarding and Looked After Children’s Services began on 3 October 2011 and the joint inspection report published on 18 November 2011. The CQC report on the outcome of the Integrated Inspection of Safeguarding and Looked After Children’s Services in Kirklees was published on 21 December 2011. An action plan to address the recommendations in the CQC report has been developed and submitted to NHS North of England and the CQC on 3 January 2012. The action plan has been monitored through the Quality & Safety Sub Group and evidence collated accordingly.

MRSA From 1 April to 20 July 2012, six MRSA bacteraemia cases have been reported in Kirklees residents.


● ● ● ●

One post 48 hour case reported by MYHT – allocated to NHS North Kirklees CCG. Two post 48 hour MRSA cases reported by LTHT – one allocated to GHCCG One pre 48 hour MRSA case reported by LTHT – allocated to GHCCG One pre 48 hour MRSA case reported by MYHT – allocated to NHS North Kirklees

One post 48 hour MRSA reported by CHFT – allocated to GHCCG.

To address the learning identified from root cause analysis investigations patient held alert cards are to be issued in September following a communications campaign. Urinary catheter record has been developed for patients/professionals and carers as urinary catheters were the main risk identified from pre 48 hour MRSA bacteraemia cases in 2010/2011. Risk placed on corporate risk register.

C- difficle NHS Kirklees is over the planned trajectory to date with 32 cases reported 1 April – 30 June 2012, against a trajectory of 104 cases for the year, this includes all pre and post 72 hour cases in Kirklees residents. NHS Kirklees Deputy Director Infection Prevention and Control (DDIPC) has discussed the NHS Kirklees position with NHS North of England HCAI lead to see if all actions are being taken: Weekly data is reviewed and submitted to NHS North of England, HCAI lead. The team is progressing mapping tools to map patient postcode and GP on a weekly basis to identify trends. Enhanced surveillance continues to be undertaken by NHS Kirklees infection prevention and control team. Twenty-one CDI patients (community sampling) have been followed up by NHS Kirklees infection prevention and control team in quarter one. Five patients were in care homes, four patients had a previous history of CDI, twelve patients had been an inpatient within previous two

MRSA – Clinical Quality Board received CHFT Infection, prevention and control action plan. HCAI Group Meeting frequency has been increased to bi-monthly to acknowledge the risk affecting all health economy partners and reports to GHCCG Quality Group. A Root Cause Analysis is undertaken for all acute and community acquired bacteraemias and reported to Infection Prevention and Control Operational group, Director of Public Health, GHCCG and HCAI Health Economy Group with lessons learnt being shared across the Health Economy. C-Diff – Included within the HCAI Health Economy Group work. A health economy CDI management plan has been developed and agreed and is monitored by the HCAI Health Economy Group, this plan has also received SHA scrutiny. Root Cause Analysis undertaken for all Care Home CDI cases, CDI outbreaks and

months prior to diagnosis, seven patients were on PPIs and eight patients had antibiotics prescribed prior to isolation of CDI. The team is working with medicines management team to evaluate links between individual GP prescribing for antibiotic and PPI prescribing. CDI patient alert cards to be issued across the health economy to raise awareness and engagement.

Patient Experience Calderdale and Huddersfield NHS Foundation Trust (CHFT) National In-Patients Survey The Quality Group and CCE have received and reviewed the ninth national survey of inpatients, which involved 161 acute and specialist NHS trusts. Patients were eligible for the survey if they were aged 16 years or older and had at least one overnight stay during June, July or August 2011 and were not admitted to maternity units. The number of respondents taking part in the CHFT survey totalled 475 patients. The results are largely intended to be used by NHS trusts to help identify areas where performance can be improved and to be aware of what patients think about their care and treatment. The results will be used by the CQC to inform regulatory activities and will also include the data in their Quality and Risk Profiles to assess compliance with the essential standards set by the government. CHFT have identified Patient Experience in their Quality Improvement Strategy 2009 2012 and their goal for 2012 is to be in the top 20% of acute trusts in the NHS and for 90% of our patients to recommend their care to others. The Trust have committed to complete full In-patient Surveys on a twice-yearly basis and a full Out-patient Survey annually, together with localised monthly surveys, which will be conducted in all wards and departments. Overall, CHFT have demonstrated little real improvements compared to the 2010 survey. Building closer relationships and safe high quality and co-ordinated care have shown

CDI associated deaths. Outcomes are reported to the IP & C Operational Group as per MRSA reports. Antibiotic campaign planned for winter 2012 Continual work across the health economy and region on viral gastroenteritis outbreak management. Patient Experience – Inpatient and Out-patient surveys for CHFT The response to these surveys will be discussed with CHFT at the next Clinical Quality Board on 9 October 2012. Patient experience is a standing agenda item on the Clinical Quality Board. The Quality Group will monitor performance of the Patient Experience CQUINS indicators.

some improvement from the 2010 survey. Access and waiting domain has shown low improvements and better information, more choice is in the low improvement, low score quadrant. The following actions and next steps have been agreed and will be overseen by the Quality Group: i.


The 2012/13 CQuINs Scheme for CHFT Acute services includes two indicators for patient experience. The nationally set indicator and a local indicator which involves Real Time Patient Monitoring to:  Maintain of good practice  Improve performance in discharge questions  Improve performance in medication questions  Improve performance in hospital food question the national indicator the local Expected achievements for the local CQuINs indicators will be agreed following a quarter 1 baseline and taking into account the national survey results. The national CQuINs goal has been agreed. Patient experience is a standing item at CHFT Quality Board where actions and improvement work is agreed and monitored.

CQUINs The overview of the development of local CQUIN schemes including implementation, trajectories setting, improvement plans and recommending these to the relevant Contract Management Boards continues to be managed through the Clinical Quality Board arrangements. All providers submitted Quarter 1 returns by the specified deadline (31st July 2012). For Quarter 1, our main providers achieved the following performance in the indicators that required data submission in Q1







Q1 comments

Calderdale and Huddersfield Foundation Trust (CHFT) acute


Achieved VTE indicator All other indicators for 12/13 scheme required data submission for benchmarking and then agree trajectories

South West Yorkshire Partnership Foundation Trust (SWYPFT)


Did not achieve assessment for psychological therapies and partially achieved in patient survey.

Spire Elland Hospital


Yorkshire Ambulance Service (YAS)


CQUINS – All Q1 submissions are to be reviewed at the relevant Clinical Quality Board and agreement of Q1 performance. We are currently agreeing year end trajectories for indicators that relied on Q1 data submission for baseline.

To be agreed at the Clinical Quality Review Group on 4th September 2012. Partially achieved improving response rates for rural areas & raising public awareness indicators

Key performance concerns considered by F&P and escalated to CCE (additional items considered as part of quarterly, rather than monthly reporting): •

18 weeks. CHFT meeting aggregate performance standards, however pressures in certain specialities (ENT, Orthopaedics) mean the 90% by month, by specialty is not being achieved. CHFT project end of Q3 achievement of this standard.

Performance being monitored closely through contract management mechanisms.

YAS A8 performance in GHCCG area. Follow on previous action to establish task and finish group to consider YAS position and potential further action. CCE agreed that all reasonable actions have been considered and where appropriate implemented at the current time.

Continue to monitor, liaise closely with YAS and consider further actions/solutions as

these become available and known. No further specific action at this time. Mental Health: Proportion of people on CPA (Care Programme Approach) followed up within 7 days. 94% performance for Q1 against plan of 100% and national minimum standard of 95%. Caused by SWYPFT are co-ordinator and lead manager being on annual leave at the same time. High levels of activity for patients with ambulatory conditions. Potential impact for recurrent QIPP delivery.

SWYPFT has launched internal investigation

Smoking 4 week quitters: Performance significantly below target. Target not profiled and historically performance is poor early in year and significantly improves in Q4. Delayed reporting system makes current Q1 performance reporting artificially poor.

Audit of pharmacy LES and voucher scheme. Review of GP LES. Work to improve update of dental LES. Pilot project with voluntary/community organisations.

Coverage of NHS Healthchecks. Significant shortfall against national target resulting from previous commissioning decisions. Expecting improved performance from Q2.

New LES agreed July 2012, 33 GHCCG practices signed up.

High levels of non-elective/emergency/A&E activity. Financial impact factored into plans.

Close liaison with provider. Planned in-depth work at Clinical Strategy Group.

Ambulance journeys: Trading above plan.

Admission avoidance model in development. Considering additional dedicated resource in specific areas. Pilot work with GP practices on further use of predictive risk techniques.

Level of overtrade being clarified as appears inconsistent between data

sources. • Finance and QIPP

Choose and book utilization. Above regional and national performance but below 90% target.

Any Qualified Provider The procurement processes for prioritised Any Qualified Provider services are now drawing to a close. The CCE received an update and agreed recommendations covering the following key areas: AQP procurement for Adult Hearing Services (Cluster-wide), MRI (Cluster-wide), Non-Obstetric Ultrasound (Cluster-wide) and Psychological therapies (Calderdale only) has followed a nationallycoordinated process. Following national checks and regulatory assessment, service-specific review of providers has been carried out for CKW by assessment teams involving clinical, quality, service and contract/management leads from across the four CCGs. A standard national assessment framework has been used throughout, together with an electronic assessment tool that has ensured compliance and maintained an audit trail of the process. The overall process has been supported and monitored throughout by the relevant regional Qualification Centre of Excellence. Adult Hearing Services: Procurement process has concluded. Successful and Unsuccessful bidders have been notified. Successful bidders are being contacted to finalise contracts and agree mobilization. Diagnostics: IAPT:

NOUS and MRI: Advert window has closed. Assessment is at advanced stage.

Advert window has closed. Assessment is underway.

The expected contract value to each new supplier is likely to be less than ÂŁ100k for the contract period (to 31st March 2013). However because of the uncertainty associated with introducing new suppliers, a cautious assumption of value up to ÂŁ250k has been agreed with Ian Currell when considering appropriate governance routes and to ensure compliance with Standing Financial Instructions. This means that each new contract will be signed by a Designate Chief Officer and

Working with individual practices to improve utilization rates.

either Cluster Chief Executive or Cluster Director of Finance. The expectation is that CKW will meet the DH requirement for three AQP services to be operational by end September 2012.

Governance and Risk

Governance Further to the last update, the following items have progressed within governance arrangements for Greater Huddersfield; • Committee Structure has been prepared and is to be agreed by SMT before agreement by the governing body • A definitive list of policies and procedures is being collated and an action plan for progress will be published for decision at SMT • Draft Terms of Reference for sub-committees have been shared with Internal Audit Colleagues for review although will require update dependent upon finalisation of committee structure • Sessions have been arranged with the CCE to commence the population of the Assurance Framework, this will be led by Internal Audit colleagues Risk NHS GHCCG continues to pay close attention to developing and working with a robust risk management system. Each sub-group takes identifies risks as part of its core business and these are regularly reported to CCE. We are currently undertaking a focussed piece of work through our senior management team with the intention of fully embedding the risk management system in the CCG, ensuring that NHS Kirklees risk are mapped to GHCCG where required and updating the system of risk ownership to reflect the new CCG structure. At present, NHS GHCCG has 30 risks on its risk register, with two scoring over 15:

Risk to delivery of QIPP over the next 3 years. Risk being addressed through establishment of processes to agree and monitor QIPP delivery within the CCG, and working with partners in the strategic review to deliver transformational QIPP schemes across the health and social care economy. Risk that quality improvements associated with reduction in pressure ulcers will not be received. Risk scoring will be reviewed following consideration of providers’ Q2 CQUIN data.

In addition, the risk to the MRSA target has been placed on the risk register. This issue is covered in the quality section above. The risk is currently scored at 12, however this will be reviewed at the next Quality & Safety sub-group. Transition and Workforce

Workforce Since the last report, appointments have been made to the Designate Chief Officer and Designate Chief Financial Officer roles. The rest of the CCG management structure has now been finalised and we are working with HR and our teams to manage the process to appoint to this structure in the near future, in line with the national policy. Staff have been encouraged to respond to the draft structure of the CCGs in Kirklees and the CSS through our staff briefings. The CCG has also appointed its external nurse and consultant ,and interviews for lay members are scheduled for 18 September. Transition GHCCG’s wave 2 authorisation application was submitted on 3 September and our site visit is taking place on 19 October. Part of the submission was the 360 feedback report which contained helpful information to inform our development going forward. Our organisational development programme continues, with recent topics addressed including equality & diversity, local assurance frameworks, safeguarding and developing medium/longer term

strategic and financial plans. Our Memorandum of Understanding with Public Health was signed off by CCE in September. This MoU will operate in shadow form for the next few months, with a final review taking place in January in advance of full implementation on 1 April 2013. We are continuing to engage in regular, constructive dialogue with the CSS and recently held a joint meeting of our senior teams to take stock of progress on service costing and delivery models. In addition to the actions described in this report that focus on building the infrastructure of the CCG, we are also working well with external partners on other elements of transition, such as the development of the Health and Well Being Board. CCG representatives are involved in the drafting of the JHWS and the CCG Clinical Leader is Vice Chair of both the Health & Well Being Board and the Children’s Trust. Transformation

CAMHS Tier 3 Earlier this year, and following considerable discussion with partners, Greater Huddersfield CCE approved a proposal to tender the tier 3 CAMHS service currently provided by CHFT. Both North Kirklees and Calderdale CCEs also approved this proposal and a procurement programme board for this exercise is now underway. This group is made up of representatives from across the 3 CCGs, and is chaired by myself. The advert for Expressions of Interest was placed on the Supply to Health website on 10 August, with pre-qualification questionnaires to be submitted by 10 September. It is anticipated that a recommendation on contract award will be brought to the Cluster procurement sub-committee in late December/January. Calderdale and Huddersfield Health and Social Care Strategic Review A progress report on the Strategic Review has been prepared by Joe Gibson, Programme Director and is available later in the agenda.

GHCCG clinicians and managers are well represented on the programme’s care streams, as well as both the Steering Group and Programme Board.


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