Minutes of the St George’s Clinical Quality Review Meeting Attach 12 Wednesday 17th July 2013, 09:00-10:45am ENT Seminar Room, 1st Floor, Lanesborough Wing St George’s NHS Healthcare Trust Present: Tom Coffey (TC) - Chair Ravi Balakrishnan (RB) Tim Hodgson (TH) Iain Rickard (IR) Theresa Douglas (TD) Deirdre Baker (DB) Alison Robertson (AR) Kaye Glover (KG) Amelia Whittaker (AW) Leo Whittaker (LW) Lulu Awori (LA) - Minutes Kim Scott (KS) Rosalind Given-Wilson (RGW) Vikki Carruth (VC) Nigel Kennea (NK) Mike Lane (ML) Maureen Ross (MR) Angelique Edwards (AE) Amanda Bland (ABl) Elizabeth Rhodes (ER) Laura Badley (LB) Wendy Brewer (WB) Wandsworth CCG (WCCG) – General Practitioner London Borough Wandsworth - Consultant Public Health Medicine Merton CCG (MCCG) – General Practitioner WCCG – Performance Manager SGH – Head of Contracts SGH – Assistant Director Finance - Resources SGH – Chief Nurse and Director of Operations SGH – Performance Development Manager SL CSU – Associate Director of Commissioning SL CSU – Acute Contract Manager SL CSU – Acute Contract Management Support SL CSU – Acute Contract Management Support SGH – Medical Director SGH – Deputy Chief Nurse SGH – Associate Medical Director WCCG– General Practitioner NHS England – Deputy Head of Supplier Management (London Region) WCCG–Community Services Wandsworth CQR Chair & WCCG 111 Clinical Lead WCCG– Quality & Patient Safety Manager SGH – Consultant Haematologist SGH – General Manager SGH – Joint Director of HR and Organisational Development Apologies: Kevin Sanders (KS) Lucie Waters (LWa) Carmel Harrington (CH) Evonne Harding (EH) SGH – Deputy Director of Corporate Affairs WCCG– Director of Commissioning SL CSU – Head of Contracting WCCG– Head of Clinical Governance and Lead Nurse Page 1 of 10 Minutes of the St George’s Clinical Quality Review Meeting 1. Attach 12 Introductions & Apologies As above. 2. Notes of the last meeting The previous minutes were agreed as accurate. 3. Matters Arising – Actions from the last meeting. 1. DB to confirm start date for the Saturday Morning Subarachnoid Service with KCH. UPDATE: Start date still under discussion with KCH. ACTION1: DB to update on Saturday morning subarachnoid service provided jointly with KCH. 2. AW and LW to circulate Accelerated Recovery Programme (ARP) leaflets to local GPs. UPDATE: Complete. 3. AW/KS to provide SI Assurance Process update. UPDATE: Complete. 4. KS to share the Standard Operating Procedure (SOP) for the Day Assessment Unit. UPDATE: Complete. 5. AB to progress advertising geriatric outpatients to Wandsworth and Merton GPs.UPDATE: To be discussed in October CQRM. 6. VC to share FFT results by ward. UPDATE: Complete. Agenda item 5.2. TC and RB to discuss the acute coronary pathway review proposal with SGH cardiologists. UPDATE: Complete. TC shared that the cardiologists will be having an internal review and the outcome of this will be brought back to CQRM. As coronary bypass grafting, angioplasty and stent insertion are specialised services, AW is to identify the leads at NHS England. 7. 8. ACTION2: RB to brief MR on reasoning behind review of coronary pathway. ACTION3: AW and MR to coordinate inviting the NHS England lead London personnel for the specialised coronary pathways to attend a future CQRM. Page 2 of 10 Minutes of the St George’s Clinical Quality Review Meeting 9. 10. 11. 12. 13. 14. 15. 16. 17. 4. Attach 12 AR/EH to send RB the membership of the local adults safeguarding board and identify who attends on behalf of Public Health. UPDATE: Complete. DB to discuss capacity and workload of MDT cancer coordinators with the Cancer Directorate and share the coordinator process and capacity issues if any with AW. UPDATE: DB confirmed that there are no capacity issues, but that the department is hoping to implement IT solutions to streamline the tracking process for the cancer pathway coordinators. RGW to confirm if there are pathway coordinators for patients on the acute cardiac pathway.UPDATE: RGW shared that there is no cardiac pathway coordinator. KS to submit Pressure Ulcer SI (7654) closure report to CSU for distribution and discussion at the July meeting. UPDATE: Complete. CSU to support EH in progressing Quality Alert system for Wandsworth and Merton CCGs. UPDATE: TC shared that the Make A Difference (MAD) button is now operational in Wandsworth and TH added that Jenny Kay, Merton CCG Director of Quality, is reviewing a Quality Alert System for Merton CCG. AW/AR to finalise C.Diff definition and ensure consistency with Department of Health guidelines. UPDATE: TC shared that a Wandsworth CCG management team meeting was held last week and there was no agreement for a local reporting mechanism. For national reporting, the suggestion was that the review can only be done with pre-testing with microbiologists review all C.Diff requests against national guidelines to ensure requests are undertaken for appropriate patients and are clinically symptomatic of C.Diff. AR responded that it was not possible to ask this of microbiologists, and TC and AR are to pick up outside of the meeting. KS to bring internal MRSA SI cases to future CQRM, and share investigation of MRSA cases with EH/Wandsworth CCG via the SI email address. UPDATE: Complete. Agenda item 7.3; one case presented as the second case had been de-escalated AR/VC to produce a summary report on MRSA figures for the past 12 months. UPDATE: AR shared that currently it is not possible to indicate if patients are MRSA positive on admission as lab data and admissions data are not yet connected; there are discussions with IT to amend this within the next few months. ACTION4: AR/VC to produce a summary report on MRSA figures for the past 12 months. RGW to feedback CQC response on MI mortality at July meeting. UPDATE: Complete. Agenda item 6. Sickle Cell Elizabeth Rhodes, SGH Consultant Haematologist, gave a presentation on the Haemoglobinopathy service peer review, which took place in October 2012.The self-assessment was constructed using around 60 quality standards, of which around 70% were met. ER shared that the document has been made public. Page 3 of 10 Minutes of the St George’s Clinical Quality Review Meeting Attach 12 ACTION5: ER to share Sickle Cell/haematology self-assessment with DB, for wider circulation with CQRM group. Although there were no immediate risks identified, ER stated there are a number of concerns around the service including insufficient staffing levels and the lack of an of hours transfusion service. ER also noted that Merton CCG were not as engaged with service development and integration as Wandsworth CCG. ER confirmed that although Wandsworth commission the pain service, it is still available for use by Sutton and Merton patients and added that the Wandsworth funded clinic nurses are pain trained, not sickle cell trained. ER shared that next steps for the service include some quick remedies, such as leaflets to improve patient information and the development of the service website. Regular meetings will be held to implement what is needed and longer term solutions to service improvement include increasing staff numbers, increasing the size of the day unit, providing a Saturday and evening transfusion service and the provision of more dedicated beds. DB noted that an overall bed capacity plan encompassing these needs is currently in development. It was confirmed by ER that everything from admission onwards is under specialised commissioning. TC asked about the involvement of Sutton, Croydon and Merton CCGs for the community based commissioning group meetings, and ER responded that at present there is only attendances from Wandsworth CCG but that other CCG colleagues would be welcome to attend the meeting, which is chaired by Wandsworth GP Simon Begg. ACTION6:TH to identify a Merton GP to attend the community-based commissioning group meeting chaired by Simon Begg. ACTION7: ER and MR to send report for discussion in September CQR on how to address gaps in Sickle Cell service. 5. Francis Report 5.1 – Workforce Programme Wendy Brewer, SGH Joint Director of HR and Organisational Development, gave narrative and outlined that it is not necessarily that a happier workforce equals happier patients and that there are complexities around the issue. WB shared that the staff survey has improved since last year and engagement levels have increased, although reports on bullying, harassment, abuse and stress are still relatively high in comparison to other trusts. WB noted that there is an over-arching action plan around staff engagement which will include a Wellbeing Strategy, undertaking a formal Page 4 of 10 Minutes of the St George’s Clinical Quality Review Meeting Attach 12 engagement programme called Listening into Action and there are other actions responding to bullying allegations. There are elements in the action plan relating to leadership and ensuring the Trust has a structured approach to what is expected from those who lead as well as developing the support given to them by the development of a leadership framework. WB added that the action plan is linked to the values the Trust has had in place for the past 4 to 5 years, noting that embedding the values into behaviours and leadership will be key. In terms of workforce planning, WB shared that one of the key outcomes of the review is the need to have enough clinical staff cover, whilst trying to be efficient and achieve financial balance simultaneously. WB added that a process of planning has been developed taking into consideration how many staff members are needed for service delivery versus the productivity of the given service, with diagrams to illustrate the process. WB confirmed that the Trust has seen a net increase in consultant and nursing staff. WB shared that efficiency measures are largely around reducing agency expenditure.Additionally, WB noted that the Trust has not previously had a structured approach to engaging agency staff and that the re-rostering for nursing is being linked to that for bank booking, and bookings for medical locums will be pulled into one place. WB highlighted that, since merging in 2010, community staff continue to feel separate from acute staff and that measures will need to be put into place to ensure both staff groups work in an integrated manner. AW asked if community staff have access to hand washing facilities and AR responded that portable hand cleansing kits have been provided, and also that the facilities for back office staff areas need to improve. 5.2 – Friends and Family Test VC gave narrative on charts showing patient responses by ward and informed the group that the charts will be presented at the Trust Board meeting next week. VC stated that as yet there are still no national average figures available, and that the response rate from A&E remains difficult. VC shared that colleagues on wards print the charts and place them on their information boards, using them to undertake actions based on the responses or aim to attain more responses from patients on their wards .AR confirmed that the response rate target for eligibility was just missed in month 2 at 14.9%. *POST MEETING NOTE*further guidance on this CQUIN was published in July to clarify the payment mechanism for part 2 of the FFT CQUIN. The 40% allocated to this indicator will be split across 2 goals: 1. Achieving a response rate of 15% for Q1 2. Achieving a response rate of 20% for Q4 and where the response rate in Q4 is higher than in Q1. ACTION8: VC to bring FFT data by ward for discussion at next CQRM after it has been discussed at the Trust Board meeting. 6. CQC: Myocardial Infarction (MI) Mortality Alert Page 5 of 10 Minutes of the St George’s Clinical Quality Review Meeting Attach 12 NK gave narrative about the alert which identified 38 deaths that had occurred between October 2011 and September 2012 within the myocardial infarction patient group. NK shared that a detailed multi-professional review audit was undertaken in response to the alert but highlighted that existing processes within the Trust had already identified issues which were in discussion at the Mortality Monitoring Group (MMG) and so the Trust had been aware of the patients flagged by the CQC mortality alert. NK also shared that the number of deaths per month had not changed substantially compared to the months before or after the alert, highlighting an issue in denominator data. NK stated that the case mix was not atypical of the cardiac arrest centre. A detailed triangulation was undertaken, reviewing adverse events, Serious Incidents (SIs) and legal complaints and it was found that there were no adverse events unreported. NK shared that RB assisted in providing an independent sense check by reviewing case notes, pro-formas completed by the auditors and the case summary. NK noted that the essential issue was coding, with the denominator being the principal problem. NK noted that this problem has been identified nationally in that the national audit for acute coronary interventions for MI and the HES data as a primary diagnosis do not correspond with each other. NK asserted that the Trust should strive for sensible and consistent coding, ensuring that two patients with a relatively similar course are coded in the same way. Since the review, NK yesterday received closure of the issue, CQC wanted further details of what initiatives are going forwards as a result and what the timelines for these will be. NK stated that initiatives related to infection control and falls have been included as patients had been identified related to these issues. However, NK highlighted that the major issue was to increase interaction between clinical and coding colleagues. The information team has now strengthened considerably through substantial investment into information and coding individuals. NK added that the Head of Information attends the Mortality Monitoring Group and that the Head of Coding has also been invited. There was disappointment in learning that coding issues picked up in the MMG and flagged to the coding team had not been acted upon until the internal PbR Audit had taken place. There has been a commitment from both information and coding colleagues to work on checklists and ideas around for coding for specific clinical areas and the coding team have committed to holding three monthly meetings around each service. NK highlighted that the MMG independently reviews all deaths taking place following an elective admission as well as all deaths occurring included in alerts highlighted in monthly Dr Foster data. A Record of Death form has been introduced, which NK stated may have been shared in the SGH CQRM before, which includes a judgement about whether the death had any potential avoidable factors. NK shared that this week he had circulated a survey to all care groups around their processes for mortality and morbidity monitoring, aiming for a proportionate review of all deaths in the Trust. ML queried who gives the opinion on whether the deaths have avoidable factors, and NK responded that this is dependent on divisional structures. ACTION9 :NK to share timelines for initiatives underway as a result of the CQC Myocardial Infarction Mortality Alert with AW for wider distribution to CQRM group ACTION10 : NK, AW and BW to discuss Hospital Standardised Mortality Ratios (HSMR) rates in low-risk HRG groups further and establish if it is a Page 6 of 10 Minutes of the St George’s Clinical Quality Review Meeting Attach 12 distinct concern. 7. Serious Incidents 7.1 – SI Tracker Recent additions to SI Tracker Report Log for discussion at September CQRM include: - 17084: Delayed diagnosis 17088: Medication omission, for which there was a delay in declaring the incident as an SI as the patient presented at Croydon University Hospital (CUH) 7.2 – Closure Reports 7654 - Deep Pressure Ulcer VC noted that there were several compounding factors to the deterioration of the patient’s pressure ulcer, as identified by the root cause analysis. The patient presented with two Grade 2 pressure ulcers, was nutritionally compromised with abnormal swallowing, constipation and weight loss. The patient also had a significant deterioration in mobility, became incontinent and developed a chest infection. Over several months the ulcer then deteriorated to a Grade 3 and the patient remained very unwell, developing a Pseudomonas infection and eventually the ulcer further deteriorated to Grade 4 over time. The patient died from complications associated with chronic renal disease. VC shared that there is a monthly Pressure Ulcer Strategy Group, which she chairs. There is attendance from all divisions, including both community and acute colleagues. Outcomes from this group are fed back through the monthly Nursing Group and a variety of reports are developed for different audiences such as the Patient Safety Committee and the Trust Board. There is work ongoing focusing on education on the grading of pressure ulcers, and there are currently two registered nurses grading all pressure ulcers and funding has been successfully granted for the recruitment of a second Tissue Viability Nurse (TVN). VC added that there was a spike in pressure ulcer numbers in April, but that cases have since reduced. TC queried how quickly pressure ulcers are acted upon once scored. VC responded that there is on-going education around the grading of pressure ulcers, but emphasised that it is used as a guide and that other factors should be considered in conjunction. Additionally, the score/grade of the ulcers are reassessed regularly particularly in the event of a change in leadership of care of the patient. TC also queried if resources to manage pressure ulcers, such as specialised mattresses are stored in bulk on site or ordered when needed, and VC responded that recently there have been challenges in equipment needs. VC added that a significant number is agreed and any additional are ordered, with more staff pulled into patient care Page 7 of 10 Minutes of the St George’s Clinical Quality Review Meeting Attach 12 when needed and cited that demand for the equipment comes in spikes of pressure ulcer cases. Equipment request data is now being monitored closely, with time requested and time delivered being noted. AB commented on delays to referral to a TVN, and questioned if the severity of the ulcer could have been reduced if it had been assessed earlier. Additionally, AB commented that the action plan did not pick up on the equipment used. AR responded that the outcomes of the action plan represent a thematic analysis to encourage systematic change that can improve the management of care for similar cases. TC queried whether there is a Standard Operating Procedure (SOP) or internal processes for a dietician assessment ACTION11: VC to establish if there is an internal process to orchestrate a dietician assessment if a Tissue Viability Nurse is in care of a patient with abnormal swallowing (such as in STEIS: 2013/7654), and report back to AW to share with CQRM group. 7.3 – Internal MRSA SIs RGW shared that the case was complicated, and the review was circulated as an attachment (Attachment 7a) AR shared that the second case will be reviewed at the next CQR meeting. 8. Final 2013/14 CQUINs VTE Assessment RGW shared that the Trust is changing to electronic systems for monitoring VTE and is expecting it to impact on the CQUIN. End of Life Care ACTION12: TD to pick up with AW regarding End of Life CQUIN 9. Performance Reports ACTION13: Performance to be placed higher up in the agenda KG shared that Tuberculosis stands out as a concern. Page 8 of 10 Minutes of the St George’s Clinical Quality Review Meeting Attach 12 ACTION14: Invite TB clinical team to give narrative on issues flagging in performance scorecard in September CQRM. DB shared that there have been a record number of attendances at A&E. IR queried the delays in LAS 15 minute turnaround times. ACTION15: KG to present more detailed discussion on LAS at August CQRM. 14. GP Quality Alerts For information. ACTION16: ‘Make A Difference’ (MAD) Button to be standing agenda item. 15. Quality Risk Profile For information. 16. External/Internal Audits For information. 17. Any Other Business None. 18. Next Meeting: 21st August 2013, 0900 – 1045, Hyde Park Room, 1st Floor, Lanesborough Wing Future Agenda Items September - Outcome of internal coronary pathway review - Tuberculosis Monthly Rolling Agenda Items - Sickle Cell - Friends & Family Test - GP Quality Alerts - Make A Difference (MAD) Button October CQRM August - Geriatric Outpatients - Internal MRSA SI December CQRM - Post-Natal Clinic Audit (update on risk assessed patients and those who DNA) Page 9 of 10 Minutes of the St George’s Clinical Quality Review Meeting Attach 12 ACTION SUMMARY – CQR Meeting of 17th July 2013, 09:00-10:45am Minutes ref Action Description Lead 3) Matters Arising 1. DB to update on Saturday morning subarachnoid service provided jointly with KCH. DB RB to brief MR on reasoning behind review of coronary pathway. RB 2. AW and MR to coordinate inviting the NHS England lead London personnel for the specialised 3. AW/MR coronary pathways to attend a future CQRM. 4. AR/VC to produce a summary report on MRSA figures for the past 12 months. AR/VC ER to share Sickle Cell/haematology self-assessment with DB, for wider circulation with CQRM 4) Sickle Cell 5. ER group. TH to identify a Merton GP to attend the community-based commissioning group meeting 6. TH chaired by Simon Begg. ER and MR to send report for discussion in September CQR on how to address gaps in Sickle 7. ER/MR Cell service. VC to bring FFT data by ward for discussion at next CQRM after it has been discussed at the 5) Francis Report 8. VC Trust Board meeting. 6) CQC: Myocardial Infarction NK to share timelines for initiatives underway as a result of the CQC Myocardial Infarction 9. NK (MI) Mortality Alert Mortality Alert with Amelia for wider distribution to CQRM group NK, AW and BW to discuss Hospital Standardised Mortality Ratios (HSMR) rates in low-risk HRG 10. NK/AW/BW groups further and establish if it is a distinct concern. VC to establish if there is an internal process to orchestrate a dietician assessment if a Tissue 7) Serious Incidents 11. Viability Nurse is in care of a patient with abnormal swallowing (such as in STEIS: 2013/7654), VC and report back to AW to share with CQRM group. 8) Final 2013/14 CQUINs 12. TD to pick up with AW regarding End of Life CQUIN TD/AW 9) Performance Reports 13. Performance to be placed higher up in the agenda LA Invite TB clinical team to give narrative on issues flagging in performance scorecard in 14. DB September CQRM. 15. KG to present more detailed discussion on LAS at August CQRM. KG 10) GP Quality Alerts 16. ‘Make A Difference’ (MAD) Button to be standing agenda item. LA Page 10 of 10