Agenda item 2.3 Sp Services Q&S report

FOR INFORMATION

Specialist Services Division Page 1 of 21 Quality and Safety Committee Quality and Safety Report 18 October 2011

AGENDA ITEM 2.3

18 October 2011

SPECIALIST SERVICES DIVISION QUALITY AND SAFETY REPORT Report of

Divisional Director Specialist Services

Paper prepared by

Divisional Nurse Specialist Services

Executive Summary

This report provides the Cardiff and Vale UHB Quality and Safety Committee with assurance on the progress being made with the Specialist Services Division Quality and Safety Group priorities and arrangements, with regards compliance with and implementation of:

• Integrated Governance and the Standards for Health Services in Wales;

• Infection Prevention and Control • Patient experience • Financial and information governance • Policies and procedures • Complaints, compliments and claims • Clinical Audit and Effectiveness • Clinical and non clinical risk

management • Research and Development • Audit requirements • Personal development, review, training

and education Action/Decision required

The Quality and Safety Committee is asked to NOTE the report.

FOR INFORMATION


Link to other Board Committee (s) and sub-committees

Health and Safety Committee Infection Prevention and Control Group

Link to Standards for Health Services in Wales

Standard 1, Governance and Accountability

Link to Public Health Agenda

The report demonstrates that the UHB is a Public Health facing organisation, and references key projects and work priorities linked to the public health agenda.

Link to UHB Strategic Direction and Corporate Objectives / Legislative and Regulatory Framework

This report presents progress with the Specialist Services Division Quality and Safety priorities and the links with the operational / 5 Year Plan / core objectives/ legal requirements and regulatory bodies

Link to relevant evidence base

The Quality and Safety priorities link to the 1000 lives plus evidence base and best practice for infection prevention and control

FOR INFORMATION


SPECIALIST SERVICES DIVISION QUALITY AND SAFETY REPORT INTRODUCTION This report provides assurance to the Cardiff and Vale University Health Board Quality and Safety Committee with regards to the progress made with implementation of Specialist Services Division Quality and Safety priorities and arrangements. The Specialist Services Division has made progress with the implementation and monitoring of the Quality and Safety agenda in line with the Annual Quality Framework, Operational Plan, Infection Prevention and Control Annual Programme and Doing Well, Doing Better – Standards for Health Services in Wales SPECIALIST SERVICES DIVISION Divisional Objective

To provide high quality efficient specialist services being recognised as leading the delivery of highly specialised care in Wales. Leverage these areas of expertise to improve support to local services, improving safety and integration, and working in partnership to enable patient care to transition smoothly between primary, secondary and tertiary services.

The Specialist Services Division comprises seven clinical directorates with associated clinical services and sub-specialties. The Division has a budget of £94.205m and a current workforce of ~1,400. The high level profile of the Directorates and major associated clinical specialties are detailed below and include a number of highly specialised areas serving both the South East region and wider all Wales population. The services also generally provide secondary care services to the local Cardiff and Vale population. Clinical Directorate Specialty Population Coverage

General Cardiology Cardiff and Vale Cardiac Rehabilitation Cardiff and Vale Diagnostic and Interventional Cardiology South East Wales

Electrophysiology and Ablation South East Wales

Complex Ablation Services South and Mid Wales

Cardiothoracic Services

Specialist Heart Failure South East Wales

FOR INFORMATION


Thoracic Surgery South East Wales Cardiac Surgery South East Wales Clinical Perfusion South East Wales Myocardial Perfusion Imaging South East Wales Specialist Cardiac Diagnostics South East Wales

Specialist Device Implantation South East Wales Adult Critical Care UHW Cardiff and Vale Adult Critical Care UHL Cardiff and Vale Critical Care

Services Specialised Adult Respiratory Intensive Care South East Wales

Nephrology South East Wales Regional Dialysis Units South East Wales Renal Surgery South East Wales

Nephrology and Transplant Services

Transplantation South East Wales General Haematology Cardiff and Vale Malignant Haematology South East Wales Haemophilia Services South East Wales Sickle Cell and Thalassemia Cardiff and Vale Stem and Bone Marrow Transplantation South East Wales

Gene Mutation Analysis Cardiff and Vale Aphaeresis Service South East Wales Adult Immunology South and Mid Wales Adult Immunotherapy South and Mid Wales Specialist Allergy South East Wales

Clinical Haematology and Clinical Immunology

Paediatric Immunology South and Mid Wales

General Neurology Cardiff and Vale / Cwm Taff

Multiple Sclerosis Services South East Wales Specialist Epilepsy South East Wales Specialist Neurology South East Wales Adult Neurosurgery South and Mid Wales Paediatric Neurosurgery South and Mid Wales Neurophysiology South East Wales Neuropsychology Cardiff and Vale Spinal Rehabilitation South and Mid Wales

Neurosciences Services

Neuro Rehabilitation South East Wales Clinical Genetics All Wales Medical Genetics

Services FH services All Wales

FOR INFORMATION


Integrated Governance Framework The Specialist Services Division Quality and Safety Group was formally established in May 2010. Meetings are chaired by the Divisional Nurse, supported by the Q&S Medical Lead, Dr Richard Anderson, Consultant Cardiologist, and Maria Roberts, Patient Safety Manager, with membership from each of the Directorates as well as the Divisional Pharmacist, Divisional Therapist, IP&C team, staff side representatives, Clinical Audit, Health and Safety, Corporate Risk Management and the resuscitation team. Meetings occur six weekly with a standard agenda reflecting the corporate agenda, which is supplemented by key clinical governance topics. The Division has delivered improvements in provision of safe and quality services in the last year including

• Neurosurgery – significant progress has been made to consolidate and improve the provision of Neurosurgical Services at the University Hospital of Wales. Two new operating theatres dedicated to Neurosurgery were opened in December 2010, and a new eighteen bedded Neurosurgical High Care Ward opened in February 2011. In addition, two Consultant Neurosurgeons have been appointed and both are now in post.

• HTA Inspection of stem cell transplant processes in Haematology during February 2011.The report was positive particularly regarding quality management and the structure and communication within Haematology

• C.diff – Continued reductions in cases plus improved isolation and less cross infection

• Introduction of falls risk indicator tools across the Division and in July an audit of their use was completed with Senior Nurses auditing each others areas

• Bundles of care - Skin bundle has been successfully introduced in many areas and will be fully rolled out by December 2011. Haematology has piloted the PVC bundle and it is being introduced in N&T and CC. Critical Care continues to have excellent results in line with the CVC bundle and it is being rolled out to N&T. Critical Care also utilises the ventilator care bundle and the urinary catheter care bundle.

• Transforming care roll out • Initial self assessment for HCS was completed by a multiprofessional

group in March 2011. The feedback reports from the Directorate Q&S meetings support the compilation of ongoing evidence.

FOR INFORMATION


• A full Fundamentals of Care audit was undertaken in March and another is currently underway. Action planning based on the results has been undertaken and a Divisional approach taken to common issues.

• Improved compliance with complaints responses (see below). • Agreement of appropriate nurse establishments in all areas resulting in

the correct number of suitably trained and competent staff. • A variety of patient stories and concerns are built into the Divisional Q&S

meetings. Patient stories are utilised in Critical Care to identify patient experience and have been used in Neurosciences and Nephrology to evaluate new and redesigned services.

• In response to an increasing number of complaints from patients unable to access in-patient beds for treatment due to increased neurosurgical patients, a 23.59 Day Unit (PIB) has been developed in Neurology. As a result the elective waiting list has reduced from 109 pts to 30 pts with no complaints about cancelled treatments for over 12 months

• Creation of a 9 bedded ACS service to support the smooth flow of regional ACS patients in and out of UHW

• The model of care for both spinal and neuro rehabilitation patients has been redesigned with in-reach support to UHW acute services resulting in reduced lengths of stay.

• Rapid Access Chest Pain Service has been commenced in the last 4 weeks

• Developed Transplantation Services by opening the new Transplant Unit and delivering the increased target of 140 transplants

• Critical Care has held the first IP&C awareness week with the aim of improving hand washing compliance and reducing infection rates. The event is being evaluated with the lessons learned, impact, and sustainable change as a result being audited. The Division is planning that each Directorate within the Division will host an awareness/improvement week in turn throughout the year.

• Nurses in the Division are collaborating with the Senior Nurse for Standards and Professional Regulation in developing a model whereby complaints and clinical incidents are mapped to FoC standards and plans developed to address them via a quality drive. This is aimed at getting the basics of care right allowing a foundation on which to develop and enhance services.

Through an active Divisional Quality and Safety Group, priorities for 2011/12 include:

FOR INFORMATION


• Q&S processes need to mature with increased ownership from the Directorates

• Specifically target and improve MSSA rates in Nephrology & Transplant

• Implement SKIN bundle to all appropriate clinical areas within the Division by Dec 2011

• Continue improvement in C. Diff rates and monitor compliance through Divisional Q&S and audit.

• Implement protected mealtimes and red trays in all areas within the Division

• Implement a quality drive on basic standards of care through the roll out of Awareness Weeks in all Directorates

• Deliver safe and quality services with the correct and competent workforce (nursing establishment review, recruitment into medical posts)

• Achieve financial sustainability (eliminate agency, reduce overtime and bank).

• Reduce delayed transfers of care • Improve complaints management performance to achieve 30 day

target and focus on corrective action and learning resulting from complaints.

• Continued reduction of Healthcare associated infections • Reduction of hospital acquired Pressure Ulcers – Critical Care

particularly. • Reduction of Patient Falls (associated with harm) • Improve compliance with Thromboprophylaxis risk assessments • Implementation of the Critical Care Outreach Team • Achieve waiting times targets and efficiencies • Roll out of Transforming Care programme by December 2011 • Increase the compliance with staff Personal Development Planning,

mandatory/statutory training • Development of performance Dashboard • Increase the use of RCA investigations for concerns, incidents and

HCAIs

FOR INFORMATION


SPECIALIST SERVICES DIVISION QUALITY AND SAFETY GROUP ACHIEVEMENTS AND WORK IN PROGRESS: Integrated Governance and the Standards for Health Services in Wales: Robust Divisional and Directorate structure for Quality and Safety with aligned agendas, terms of reference and feedback mechanism. Standard agenda items include risk management, IP&C, safeguarding, Health and Safety and Directorate risks. The initial self assessment for The Standards for Health Services in Wales was undertaken by a multidisciplinary group so that all aspects were captured. The results were presented at the May 2011 Divisional Quality and Safety meeting and a plan developed for future self assessments. The feedback form from Directorate Q&S meetings assist with the gathering of pertinent information and evidence. Infection Prevention and Control (IP&C): The tables below (up to 31st July 2011) demonstrate the year on year improvements made in the number of C Difficile cases in the Division. Recognition and immediate isolation of symptomatic patients has significantly reduced cross infection. Every case is subject to an RCA process in order to highlight issues that may require a change in practice and to learn lessons to prevent further cases. YEAR Reduction targets compared to

previous year ACTUAL TOTAL

20% reduction

40% reduction

08-09

- - 161

09-10

129 97 106 (20% achieved)

10-11

85 64 83 (20% achieved)

Division

11-12

66 50 25 (31st July)

FOR INFORMATION


Specialist Services C difficile Reduction Target

0

10

20

30

40

50

60

70

80

90

Apr‐11

May‐11

Jun‐11

Jul‐11 Aug‐11

Sep‐11

Oct‐11

Nov‐11

Dec‐11

Jan‐12 Feb‐12

Mar‐12

Month

Num

ber

0% reduction 20% reduction 40% reduction Actual

FOR INFORMATION


The table below demonstrates the Division’s performance in reducing MRSA bacteraemia. YEAR Reduction targets compared to


20% reduction

40% reduction

08-09

- - 26

09-10

21 16 28

10-11

22 17 20 (20% achieved)

Division

11-12

16 12 5 (31st July)

The table below demonstrates the Division’s performance in relation to MSSA bacteraemia. It is clear that reducing the incidence will be a priority for the Division in the coming year. Actions to date include starting the roll out of the CVC bundle in N&T and changes in practice related to connection and disconnection to dialysis. Dr Eleri Davies has attended the regular N&T IP&C meeting to discuss the issues and work with the Directorate to develop an ongoing action plan. YEAR Reduction targets compared to


20% reduction

40% reduction

08-09

- - 59

09-10

47 35 65

10-11

52 39 76

Division

11-12

61 46 24 (31st July)

Progress in relation to the above and all HCAIs has been made across the Specialist Services Division with:

• Development and implementation of the Specialist Services Division Infection Prevention and Control Action Plan

• Nominated consultant Champions for IP&C and ward named link nurses • Implementation and improved compliance with antimicrobial policy and

promotion of antimicrobial prescribing stickers • Environmental cleanliness – Cleaning for Credits audits and results

reported; review of ward cleaning schedules, standards developed for hand hygiene pre meals and post toileting and for commode cleaning

• Patient isolation – defining wards and cubicles/bays for prompt isolation

FOR INFORMATION


• Training – ward based, promotion of e-learning Patient Experience Each Quality and Safety group commences with a patient story from a complaint, clinical incident, infection prevention and control issue, independent review, or lessons learnt from informal feedback from patients and relatives.

• Critical Care sends out questionnaires based on Fundamentals of Care to all patients discharged. Results are prominently displayed within the units and used as learning points for improvements and changes in practice.

• Nephrology & Transplant and Neurosciences have used patient stories to evaluate the provision of newly developed day services.

• Nurses in Rookwood have worked to develop a HIPO audit that is being distributed to inpatients on a monthly basis. As the patients have a long admission period, significant amounts of data will be achieved and the results will be used in the development of the new Rookwood facility in UHL.

• Critical Care undertakes patient stories, encourages relatives to keep a patient log to inform them of their experience when they recover and are in the process of commencing patient diaries which are kept by nurses for the patients.

• N&T have a pre dialysis support group to prepare patients and their families for the time when they will require dialysis. Patient and carer feedback demonstrates that this is a very well received service that all attendees benefit from greatly.

• Nephrology and Transplant patients and staff are on the Welsh Kidney Patients Board which has open question sessions.

• Suggestion boxes are used in Critical Care and Cardiac Services. • Cardiac Arrhythmia Nurses run two patient focus groups per year. • Heart failure services are currently undertaking a two year HIPO project.

Financial and information governance There are natural linkages between the quality and safety agenda within the Division and finance. Evidence suggests that reducing waste, avoidable harm and variation can have a positive impact on finance. All establishments have been agreed and implemented resulting in a decrease in the usage of temporary staff

FOR INFORMATION


Operational and finance plans for 2011/12 are being implemented. Operationally the Division remains at a break even financial position. A plan to deliver 6.64% (£6.225m) savings has been developed and is currently in line with planned savings profile. It should be noted that there are high risk elements to the savings plan which are intrinsically linked to the WHSSC agenda. Policies and procedures The Division has embraced the UHB Discharge protocol with improving compliance with PDD and morning discharges, in order to improve patient safety and flow. Neurosurgery consistently achieves a lower than peer group elective risk adjusted length of stay, 5.6 days compared to 6.9 days. The Division has played a key part in the review of the UHB Major Incident policy and the out of hours on call arrangements for senior staff. The Divisional Nurse and Divisional Manager are attending Hospital Major Incident Medical Management training in October. The hospital transfusion team has attended the Divisional Q&S meeting to advise on and discuss zero tolerance on blood transfusion, blood samples and new transfusion form procedures. A specific section of March’s Divisional Q&S meeting was devoted to raising awareness of the Policy for New Interventional Procedures. Denise Shanahan has attended the Divisional Q&S meeting to present on Procedural Guidelines for the Prevention and Management of Falls in Vulnerable Adults. The audit of the use of the falls risk indicator tools demonstrates that whilst there is some room for improvement, ward staff are utilising the risk assessments and responding appropriately. Concerns The Division has received 54 complaints between 1st April and end Sept 2011. Please see the below table for details of compliance.

FOR INFORMATION


On the inception of Putting Things Right, Angela Hughes attended the Divisional Nursing Board in order to develop pertinent knowledge and skills in the Lead Nurses who now lead on this agenda in the Directorates. She also attended the Divisional Quality and Safety meeting to ensure general awareness amongst medical staff and other staff groups. Trends from complaints include:

• Concerns about treatment • Lack of communication (excepting staff attitude and behaviour) • Standards of care • Waiting times • Discharge arrangements

Due to the nature of the services delivered within the Division the concerns tend to be very complex. Several actions have been taken in order to improve compliance with the standards including:

• Informal intervention at an early stage to resolve issues as close to the occurrence as possible.

• Offering an early meeting with relevant staff in order to resolve issues face to face in an open and honest manner.

• Implementation of a shared drive to facilitate concerns management and monitoring.

• Divisional Nurse meets with Concerns Manager and Concerns Coordinators every two weeks to review concerns and response performance. Lead Nurses meet with their respective Concerns coordinators regularly.

• Development and implementation of action plans to amend practice and learn lessons.

FOR INFORMATION


• Divisional Nurse and Lead Nurse meet with patients/carers who have raised complex or serious issues in order to inform them of the findings and share action plans.

• Directorate staff have been RCA trained so that they can undertake complex concerns investigations.

The Division has received many written letters and e mail compliments across wards and departments. In the first half of 2011/12 7 claims have been received within the Division Key themes arising from claims received into the Division include: ? avoidable complications of treatment/surgery Lack of recognition of deteriorating patient Inappropriate care The Division uses the Quality and Safety agenda to share lessons learnt and trends identified from concerns. Rule 43 HM Coroners inquests In the last 12 months the Division has received two Rule 43 letters from HM Coroner. One related to Cardiac Surgery and the failure to remove the aortic cross clamp prior to cessation of bypass which resulted in the patient suffering a significant period without cardiac output from which he later died. The second Rule 43 involving Critical Care, related to the delay in passing on deranged clotting results to medical staff. The patient subsequently died but not as a result of that failure, however, if repeated it could have significant implications for another patient. The Directorates have worked with the investigators and the Division to implement actions to prevent repeat incidents occurring. The Division is cognisant of Rule 43 letters received elsewhere in the UHB that have implications for the Division. These are discussed at Divisional and Directorate Q&S meetings. Serious Incidents reported to WAG Since the Division’s inception in April 2010 five serious adverse incidents have been reported to Welsh Government. All incidents were subject to an RCA investigation.

FOR INFORMATION


Clinical Audit and Effectiveness Fundamentals of care audits are undertaken every 6 months, the lowest 3 scoring standards were re audited and corrective action plans developed. The next audit is due for completion in September 2011. Infection prevention and control audits are monitored at the Quality and Safety meeting: Hand hygiene audits; Commode cleaning audits; Credits for cleaning audits and corrective action identified. Hypoglycaemic audit of insulin dependent diabetic inpatients in acute hospital beds confirmed a significant risk of patients developing hypoglycaemia due to changes of routine, diet, and time of insulin administration. New guidelines have been drafted by the Diabetes team for the management of hypoglycaemia and were presented at the January Q&S meeting by Dr Aled Roberts, Consultant Diabetologist The skin bundle patient assessment tool is currently being rolled out across the Division with progress reported via the Quality and Safety group. A weekly census audit takes place to discuss all patients in the Division that have been in acute hospital beds for more than 14 days. Clinical management plans, discharge arrangements, constraints to discharge etc are all discussed and escalated as required to improve care and patient flow. The Division has developed the annual audit programme for 2011/12 to include National, core and local audits generated from lessons learnt from incidents, complaints and claims.

Clinical and non clinical risk management The Directorate risk registers are updated and inform the Divisional risk register. Each is discussed at Q&S meetings and at regular meetings between the Divisional Nurse and the Corporate Risk and Governance Manager. Significant risks within the Division include

• Provision of Cardiac Surgery - including ability to meet 36 week RTT, ability to treat urgent patients, impact of staff shortages (theatre and CITU staff), impact of lack of access to inpatient beds.

• Sustainability of services provided at Rookwood Hospital due to poor condition of infrastructure.

• Incidents of violence and aggression.

FOR INFORMATION


• Lack of suitably trained staff/skill mix especially in light of the current vacancy freeze.

• Loss of income as restriction/closure of services in order to manage staff shortages will mean we will have to return money to WHSSC.

Clinical Incidents:

Cardiothoracic directorate Top 10 reported clinical incidents 01.01.2011:30.04.2011 by inc date

125 total

Lack of suitably trained/skilled staff 20 Medication Error 18 Pressure ulcer - not graded 5 Patient incorrectly identified 4 Failure to isolate patient in line with guidelines 4 Delay/difficulty in obtaining clinical assistance 4 Lack of/delayed availability of beds (general) 4 Communication failure - outside of immediate team 4 Communication failure - within team 4 Documentation - misfiled 4

Haematology directorate Top 10 reported clinical incidents 01.01.2011:30.04.2011 by inc date

44 total

Lack of/delayed availability of beds (general) 17 Blood satellite fridge incidents 5 Infusion injury (extravasation) 3 Transfusion docs e.g. traceability, fridges 3 Treatment/procedure - delay/failure 2 Scans/X-rays/specimens - mislabelled/unlabelled 2 Documentation - missing/inadequate/illegible healthcare record/card 2 Patient incorrectly identified 1 Test results/reports – mislabelled 1

Critical Care directorate Top 10 reported clinical incidents 01.01.2011:30.04.2011 by inc date

192 total

Pressure ulcer - grade 2 27 Medication Error 22 Pressure ulcer - grade 3 16 Pressure ulcer - not graded 15 Failure of device/equipment 13 Unplanned removal of medical device 12 Lack of suitably trained/skilled staff 12 Lack/unavailability of device/equipment 11 Pressure ulcer - grade 1 8 Treatment/procedure - inappropriate/wrong 4

FOR INFORMATION


Nephrology and Transplant Top 10 reported clinical incidents 01.01.2011:30.04.2011 by inc date

Total 75

Lack of suitably trained/skilled staff 17 Medication Error 6 Delay or failure to monitor 3 Treatment/procedure - delay/failure 3 Unexpected complications 3 Discharge – inappropriate 2 Failure/delay in collection/delivery systems 2 Unsafe/inappropriate clinical environment (inc. clinical waste) 2 Delay/difficulty in obtaining clinical assistance 2 Equipment user error 2 Neurosciences Top 10 reported clinical incidents / 01.01.2011:30.04.2011 by inc date

Total 84

Lack of suitably trained/skilled staff 30 Communication failure - within team 6 Challenging behaviour BY a patient 6 Transfusion docs e.g. traceability, fridges 2 Documentation – misfiled 2 Tests - failure/delay to undertake 2 Failure of device/equipment 2 Medication Error 2 Self-harm 2 Treatment/procedure - inappropriate/wrong 2

Personal injury/accidents – Patients and staff: A total of 132 accidents involving patients across the Division were reported from 1st April – 1st September 2011, the majority were reported by Neurosciences and Cardiac Services/Critical Care, within the category of slips, trips and falls. Out of 155 staff incidents over the same time period, 101 incidents were attributed to violence and aggression/inappropriate behaviour, again most of these incidents occurred in Neurosciences which reflects the complex nature of the patients. The UHB Case Manager has provided significant support to staff involved with violent incidents providing links with the Well Being Service, Occupational Health and the Counselling services.

FOR INFORMATION


Research and Development The Division’s R&D lead is Dhavendra Kumar, Consultant Medical Genetics, the October Q&S meeting will be used to discuss R&D arrangements and to ensure the Division and Directorates engage with the research agenda and link closely with the UHB Faculty for Improvement during 2011/12. The Division has a clinical audit framework for 2011/12; further work is required in terms of feedback from the Directorates to the Division via the Q&S meeting.

Audit requirements An internal audit review of Health and Safety arrangements in March 2011 evaluated the adequacy of the systems and controls in place to provide assurance to the UHB with regards to risks associated with objectives. Findings confirmed adequate assurance.

Personal development, review, training and education The Division is committed to the UHB plan to increase the number of staff having a PADR and PDP annual review. Each Directorate has a team of KSF champions to take the issue forward. The Divisional Nurse takes a lead support role and undertakes refresher KSF training. Quarterly champion forums have commenced and compliance is monitored via the Divisional Partnership forum. CONCLUSION The Specialist Services Division has made progress with establishing and progressing its Quality and Safety priorities and arrangements, communicating and sharing best practice and lessons learnt to improve the patient experience, patient safety, and developing evidence in relation to the UHB Operational Plan, Standards for Health Services in Wales and external requirements. RECOMMENDATION The Quality and Safety Committee is asked to receive and NOTE this progress report from the Specialist Services Division.

FOR INFORMATION


IMPACT ASSESSMENT

Health Improvement

The Specialist Services Division is delivering the quality and safety agenda with service and health improvement to provide assurance to the Board that governance arrangement are in place and corrective action is taken when things go wrong. This ensures a positive impact on health improvement.

Workforce

Ensuring the workforce skill mix is appropriate to meet the standards of care for patients with regards to case mix and dependency is a priority for the Division. Recruitment of staff or deployment of staff into key posts to maintain patient safety and quality of service is vital

Education and Training

Appropriately trained, skilled and competent staff able to undertake their roles is essential to providing high standards of safe care to patients The Division is prioritising PDPs for staff to inform the training needs analysis.

Financial

Failure to manage, reduce and mitigate against risk will result in a high financial risk. Ensuring good risk management systems that reduce waste, variation and avoidable harm will result in financial efficiencies. Service developments are aimed at improving quality and safety for patients whilst achieving cost savings.

Legal

Compliance with safeguarding arrangements, investigations as a result of claims and serious incidents are required to help to inform the external assurance processes of the UHB.

Equality

Ensuring compliance with the Standards for Health in Wales will help ensure the provision of safe and equitable services for all.

Environmental

Action plans arising from concerns, patient experience feedback, Rule 43 requirements and standards for single sex accommodation inform improvements in the environment.

RISK ASSESSMENT

FOR INFORMATION


Clinical/Service

Lessons learnt from concerns action plans and service improvement plans provide assurance that appropriate standards of care minimise clinical risk.

Financial

Compliance with the Standards for Health in Wales, effective complaints and claims investigations and demonstrating service improvements help support achievement of the UHBs aims and objectives and improve financial effectiveness.

Reputational

Developing an open culture of risk management and risk reduction through promoting the priorities of the quality and safety agenda help reduce the risks to organisational reputation and improve services to patients.

Acronyms and abbreviations

ACS – Acute Coronary Syndrome CC – Critical Care C.diff - Clostridium difficile CITU – Cardiac Intensive Care FoC – Fundamentals of Care HCAIs – Healthcare Associated Infections HIPO – Health Improvement Patient Outcome HTA – Human Tissue Authority KSF – Knowledge and Skills Framework IP&C – Infection, Prevention and Control MDT – Multidisciplinary Team MRSA - Methicillin-resistant Staphylococcus Aureus MSSA - Methicillin-Sensitive Staphylococcus Aureus N&T - Nephrology and Transplant PADR – Personal Appraisal Review Process PDD – Predicted Date of Discharge PDP – Personal Development Plan PIB – Programmed Investigation Beds PVC - Peripheral Venous Cannula bundle Q&S - Quality and Safety RCA – Root Cause Analysis R&D – Research and Development RTT – Referral to Treatment

FOR INFORMATION


UHB – University Health Board UHL – University Hospital Llandough UHW – University Hospital of Wales WHSSC – Welsh Health Specialist Services Committee

CONSULTATION AND ENGAGEMENT Directorate Quality and Safety Groups SOURCES OF INFORMATION Standards for Health Services in Wales

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Agenda item 2.3 Sp Services Q&S report

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