Clinical Audit and Effectiveness Report 2014

Clinical Audit and Effectiveness Report Vicky Hill Clinical Audit and Effectiveness Facilitator

April 2013 to March 2014

St Columba’s Hospice Clinical Audit and Effectiveness Annual Report April 2013 –March 2014

Introduction

This report addresses audit and effectiveness activity at St Columba’s Hospice from April 2013 to March 2014. As previous years, some audit activity has centred on meeting the requirements set out by the National Care Standards for Hospice Care and NHS Quality Improvement Scotland Clinical Standards (NHS Quality Improvement Scotland, 2002).

The hospice is committed to meeting the requirements set out in the Quality Assessment Framework. A new Clinical Governance Structure was introduced in the autumn of 2012 and the embedding of this model into the hospice culture and practice has continued over the time period April 2013 to March 2014.

Clinical Governance Structure at St Columba’s Hospice St Columba’s Hospice made the decision to review and develop their Clinical Governance Structure in April 2012 and a new structure was introduced in autumn 2012 (see Appendix 1).

The Clinical Governance Structure aims to: o Provide safe and effective patient care o To further develop patient care in all services o Enhance lines of communication and responsibility o Increase the effectiveness of working across departments o Reduce risk by proactively identifying risk and taking action to mitigate against risk o Support the transition between Kirklands House and the new building at Boswall Road

To support all staff in working within the new Clinical Governance Structure, an education initiative looking at this new development and risk was rolled out in autumn 2012. All clinical and non-clinical staff attended study days that were designed specifically for their needs.

New staff members will be given information regarding Clinical Governance as part of their departmental induction. Further information, if appropriate to the role, is available from the Clinical Audit and Effectiveness Facilitator.

The membership of all groups was reviewed to ensure that all relevant departments have representation and to encourage working across departments. Each group now has a remit which encompasses relevant standards for which they are responsible. In addition, Audit, Risk and New Build are now part of the remit of all groups.

Audit and effectiveness priorities are identified by the Clinical Risk Group or other groups within the Clinical Governance Structure (e.g. Information group). These projects will be reported to Clinical Risk Group by the chairs of the groups within the structure. Audit and Effectiveness projects will be the responsibility of clinicians. The Clinical Audit and Effectiveness Facilitator will provide, where necessary, support for staff in planning, developing and delivering audit projects and their results.

Progress on Priorities The priority for April 2013- March 2014 was to continue to develop the Clinical Governance Structure and embed this model within all hospice services, departments and practice. Full audit reports and minutes of meetings are held in the shared drive and are accessible to all hospice staff. A summary of audit and effectiveness activity can be found in appendix 2. Using the aims of the Clinical Governance Structure, the following examples demonstrate some of the developments undertaken by groups within the Clinical Governance Structure to improve patient care.

Provide safe and effective patient care

Patient centred care is at the centre of all work within the Clinical Governance Structure.

There has been a wide range of work carried out by the membership of many of the groups within the hospice. These include:

SIGN 106 (Control of pain in adults with cancer): Following audit results in February 2013, the SIGN 106 group developed documentation, and following education sessions introduced this in July 2013. Further audit has been carried out by the group in October 2013 and March/April 2014. This audit is reported to the Care Delivery Group by the SIGN 106 subgroup.

Hand Hygiene Audits: Cleanliness Champions within the hospice have been trialling a locally developed Hand Hygiene Audit Tool. The aim is to introduce monthly Hand Hygiene Audits. This work is the responsibility of the Infection Control Group.

Dementia Project: A multidisciplinary subgroup has formed to take this project forward meeting a recommendation from Healthcare Improvement Scotland. This ongoing development of practice is reported to the Care Delivery Group.

Diabetes Guideline: A guideline for Managing Diabetes has been developed following a need identified by clinical staff.

To further develop patient care in all services

The hospice is committed to developing patient care in all services and examples of this include:

Complementary Therapy Audit: This work involved feedback from patients and carers regarding their experiences of Complementary Therapy within the hospice. A journal club session was arranged to disseminate the findings of this work and to promote the role of the service to the wider hospice team. This audit was carried out by the Complementary Therapy Service and reported to the Care Delivery Group.

Preferred Place of Death Audit: The hospice was asked by the Lothian Managed Clinical Network to audit practice of identification and achievement of Preferred Place of Death for patients who had died in all care services provided by the hospice. Monthly audits were carried out and reported to the End of Life Care Group. A journal club session has been delivered to inform staff of the results and changes to our documentation practice as a result of the audit.

Infection Control Audit: The Infection Control Group audit practice throughout services and departments three times a year using the Healthcare Associated Infection (HAI) Inspection Audit Tool (Healthcare Improvement Scotland).

Bereavement Risk Assessment: This document has been reviewed and developed to support effective recording and communication and further enhance care for bereaved relatives. This work has involved the End of Life Care Group and the Documentation Group.

Enhance lines of communication and responsibility

The Clinical Governance Structure identifies the responsibilities of all the groups within individual remits and identified standards. All minutes of meetings are reviewed by the Directors. All groups have considered the areas of audit, risk and new build within their work.

Effective communication is vital in delivering a high standard of care for the patients and families who use St Columba’s Hospice services. The Inpatient questionnaire has been reviewed with plans to review practice around Patient and Relative feedback organisation wide in the near future as part of the development of a Patient Engagement Strategy.

Communication with staff regarding developments have been enhanced by the introduction of electronic storage of minutes from meetings. This system has been developed and will be monitored by the Information Group.

Increase the effectiveness of working across departments

All audit and effectiveness projects promote multi-disciplinary and cross departmental working where appropriate. This is supported by the careful consideration of representation of departments (both non clinical and clinical) and disciplines within all groups within the Clinical Governance Structure. A number of audits have demonstrated multi-disciplinary, cross departmental working and examples of this are:

o Infection Control Audits (Catering, Domestic, Day Hospice, Inpatient Unit and Audit departments) o Minutes Audit (Volunteer, Inpatient and Audit Departments) o SIGN 106 (Nursing, Medical and Audit Departments) o Preferred Place of Death Audits (Medical, Nursing, Education, Practice Development and Audit Departments)

Reduce risk by proactively identifying risk and taking action to mitigate against risk

All groups have the responsibility to identify and mitigate against risk within the remits of their groups and this is supported by a hospice wide Risk Policy. The Governance Structure has a Risk Group (responsible for non-clinical risk) and a Clinical Risk Group (responsible for Clinical Risk). The following are examples of the risk work carried out by the hospice:

Policies and Procedures: There is a system in place for review of clinical policies and this is reported to the Clinical Risk Group. Following feedback from the recent Healthcare Improvement Scotland Inspection, a Bed Rails Policy and an Adult Support and Protection Policy have been developed. Further work on policies has been undertaken with the development of a hospice wide Staff Directory.

Reducing the Risk of Falls: Following audit activity highlighted in the previous audit report, a new falls incident form has been developed and is in use. All incidents and accidents, including falls, are reviewed as soon as possible after the event. In addition, this information is collated and reported to the Clinical Risk Group as a surveillance measure and to support the identification of trends at an early stage.

Safe and Effective Management of Patient Information: The Information Group have a key role in the management of written information for patients and carers. The group have developed and manage a system that ensures that current, up to date information is available.

Using Evidence base to support and develop learning and safe practice: All members of the End of Life Care group, following an education session on setting up electronic alerts, now receive regular emails identifying new literature published in the following areas: o End of Life Care Planning o Preferred Place of Death o Do Not Attempt to Cardiopulmonary Resuscitation (DNACPR) o Hospice Staff Support, Feelings and Attitudes o End of Life care Quality Indicators o End of Life Care- Last few hours and days of life o Care after Death o Bereavement Risk assessment

Relevant literature and evidence is then reported back to the End of Life Care Group.

Management of Medicines: Drug incident report is discussed at the Clinical Risk Group.

The Medicines Management Group have carried out audit activity reviewing drug omissions which has resulted in a change of practice. This audit is now on its 3rd cycle to ascertain if the change in practice has benefited patient care and if the change in practice has been effective and sustained.

Safe and Effective Management of Clinical Documentation: Risk was highlighted regarding the potential of out of date documentation being accessed by staff. A system is now in place where all clinical documentation is stored on the shared drive and staff print directly from there. There is also a process and guidelines for staff wishing to make changes to documentation. This area of work is within the remit of the Documentation Group.

Support the transition between Kirklands House and the new building at Boswall Road

All groups within the Clinical Governance Structure have identified issues related to their group’s remit in relation to the new build. The Heads of Department Working Group for the new build have supported the reorganisation and development of all hospice policies.

Clinical policies, Operational Policies and Human Resource Policies are now accessed via the shared drive. A Staff Directory has been developed to support staff and disseminate

information in our move between Kirklands House and Boswall Road initially. The future use of this resource is currently under review.

Clinical Audits Carried Out Between April 2013- March 2014 A wide range of audit topics have been addressed during this period (see appendix 2).

The projects continue to have a multidisciplinary approach, with clinicians from groups within the governance structure being encouraged to undertake related projects with support from the Clinical Audit and Effectiveness Facilitator. Many of the audit projects are evidence based and have either new audits or planned re-audits to be carried out in the near future, thus completing the audit cycle.

Priorities for April 2014- March 2015 The Clinical Risk Group have agreed to take forward audit priorities. This plan will outline the proposed audit and effectiveness project activity and will be reviewed at every Clinical Risk Group meeting.

Conclusion The Clinical Governance Structure continues to be embedded into practice giving guidance and support regarding communications and responsibilities in order to reduce risk, develop practice and continue to improve patient care throughout the hospice.

This year St Columba’s Hospice has continued to undertake a large number of multidisciplinary clinical audits and effectiveness projects. Again, as in previous years, these have included a mixture of new audit and effectiveness topics and re-audits of previous projects. It is hoped that the outcomes of the audits will facilitate the hospice in developing and evidencing the standard of care which patients experience throughout their involvement with hospice services. The Clinical Governance Structure has been designed to support this. This report illustrates the key role that the whole Hospice team

have in positively enhancing care delivery and demonstrates the importance that clinical audit and effectiveness has in the Hospice’s commitment to enhancing patient care.

Central to the success of continuing to develop safe and effective patient centred care lies the continuing development of the working between departments, disciplines and groups working within the Clinical Governance Structure.

References National Care Standards for Hospices- Scottish Executive Clinical Standards Board for Scotland (NHS Quality Improvement Scotland) (2002) Clinical Standards Specialist Palliative Care

Board of Governors New Build Committee

Audit Committee Management Committee Directors

NB Steering Group

HoDs Working Group

Staff Development Group

Risk Group

H&S Committee Operational Risk Group

Heads of Departments

End of Life

Care Delivery Group

Clinical Risk Group

Information Group

Documentation

Infection Control

Medicines Management

Appendix 2

Audit and Effectiveness Projects April 2013-May 2014 Preferred Place of Death

Hand Hygiene

Infection Control

Medicines Omissions

SIGN 106

Complementary Therapies

Referrals Audit

Pause for Thought

Patient Feedback

April 2013

March 2014

2013

August 2013

March 2013

April 2013

May 2013

May 2013

May 2013

October 2013

May 2013

June 2013

Aug 2013

September 2013

August 2013

March/April 2014

July 2013

Aug-Oct 2013

September 2013

January 2014

December 2013

Nov- Feb 2013/14

January 2014

Minutes Audit

December 2013