HULL AND EAST YORKSHIRE HOSPITALS NHS … HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST Clinical Audit and Effectiveness Annual Report 2014 / 15 1. Introduction The Clinical Audit and

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HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST

Clinical Audit and Effectiveness Annual Report 2014 / 15

1. Introduction The Clinical Audit and Effectiveness Team sits within the Quality, Governance and Assurance Directorate and works closely with the Quality Facilitators and Quality and Safety Managers. The Clinical Audit and Effectiveness Team manages the clinical audit project approval process, monitors participation in national and local audits and the implementation of any resulting actions, provides support and training to staff undertaking clinical audit projects and monitors compliance with the NICE guidance. The central team also co-ordinate the NCEPOD studies including the gap analyses and monitoring of actions. The Clinical Audit and Effectiveness Team consists of 1 Clinical Audit and Effectiveness Manager (0.5 WTE), supported by 2.6 WTE Clinical Audit and Effectiveness Facilitators. In addition, the team is supported by an Audit Clerk (0.7 WTE), who is based at the Medical Records site. Between September 2014 and April 2015, the 1 WTE Clinical Audit and Facilitator post was vacant, due to a delay in appointing a suitable applicant. Professor McCollum is the Director of Clinical Effectiveness and acts as a professional lead, providing guidance to the Clinical Audit and Effectiveness Team. In April 2014, the Clinical Effectiveness, Policies and Practice Development Committee met for the first time. This new committee combined the Clinical Audit and Effectiveness Committee, Policies group and Clinical Practice Development Committee. The committee meets monthly and membership includes the Health Group Medical Directors, a Quality and Safety Manager from each Health Group, pharmacy, nursing and therapy representatives and the Clinical Audit and Effectiveness Manager. Professor McCollum chairs this committee, which reports to the Operational Quality Committee. This report summarises the clinical audit and effectiveness activity for 2014/15 within the Trust. 2. Clinical Audit Priorities and Plan One of the Clinical Audit and Effectiveness Team’s responsibilities is to facilitate clinical audits within the Trust. Each Clinical Audit and Effectiveness Facilitator is linked with at least one Health Group and is able to assist clinicians with many aspects of the clinical audit process. This assistance can range from suggesting clinical audit topics to project design, data entry, sample identification, data analysis, data collection form or survey design, presentation preparation, case note retrieval and support with report writing. The Trust has a prioritised programme that relates to both local and national priorities with the overall main aim of improving patient outcomes. The priorities reflect a combination of both local and national priorities and are listed in the table below:-

TYPE OF AUDIT PRIORITY Assurance Framework audits 1 CQuIN audits 1 NHS Commissioning Board Special Health Authority Audits (including Patient Safety Alert Notices, Rapid Response Alerts, Safer Practice Notices, Patient Safety Information)

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NSF Audits 1 Peer Review 1 NICE Guidance (including Technology Appraisals, Interventional Procedures and Guidelines)

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2

NCEPOD audits 1 National audits 1 Audits identified as a result of risk issues (including SIs, incidents, PALS/complaints)

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Peer review 1 Local policy audits 2 Trust-wide audits 2 Care pathway/local guideline audits 3

Key

Priority 1 External or local ‘must do’ audit Priority 2 External or local ‘should do’ audit Priority 3 Local interest audit

A programme of audit projects was developed by the Health Groups based on the Trust audit priorities for 2015/16, which were approved at the Clinical Effectiveness, Policies and Practice Development Committee in May 2015. See Appendix I for the audit plan 2015/16. 3. Monitoring of the Clinical Audit Plan Once a CG1 registration form has been sent to the Clinical Audit and Effectiveness Facilitator, the department holds weekly approval meetings to ascertain whether the project is a quality clinical audit, and to discuss any implications for the Trust the clinical audit may have, such as Data Protection issues. During 2014/15, performance against the clinical audit plan was monitored via quarterly reports to the Clinical Audit and Effectiveness Committee. The table below shows the number of clinical audits commenced in relation to those included on the 2014/15 audit plan per Health Group.

Number of audits commenced

Current stage of audits Number of audits

completed

221

Data collection 17

187

Data analysis 1 Report 13 Complete 187 Ongoing 1 Abandoned 2

Number of audits due to have commenced

Number of audits due to have been

completed

227 207

The table shows that 97% of audits on the audit plan commenced. The Director of Clinical Effectiveness and the Clinical Audit and Effectiveness Manager have risk assessed the audits which did not commence. They were found to be priority 2 or 3 audits. The Clinical Audit and Effectiveness Team will confirm with the project lead whether the audits should be included on the audit plan for 2015/16. Some audits were approved in addition to the approved plan. This was mainly due to national audits emerging, the identification of risk issues which required an audit and audits commenced by specialties that did not include any audits on the plan. The table overleaf illustrates the progress of these audits.

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3.1 AUDITS APPROVED IN ADDITION TO THE PLAN

Number of audits

commenced Current stage of audits

Number of audits completed

82

Data collection 17

53

Data analysis 4 Report 5 Complete 53 Ongoing 0 Abandoned 3

NB. The reasons for abandoning 5 audits have been recorded on the audit plan. 2 of the audits were abandoned due to difficulties in obtaining the patient sample (due to coding) and insufficient sample size. 4. Monitoring of Clinical Audit Activity and Outcome Forms During 2014/15, performance against the clinical audit plan was monitored via quarterly reports to the Clinical Effectiveness, Policies and Practice Development Committee. In 2014/15, 303 audit projects were approved, compared to 339 in 2013/14, and 329 in 2012/13. The table below shows the number of approved clinical audits and completed outcome forms by Health Group:-

Health Group Approved

Clinical Audits

Number of Completed

Audits Clinical Support 55 34 Family and Women’s Health 92 76 Medicine 50 40 Surgery 99 89 Trust-wide 7 1 Total 303 240

NB. 28 audits are not due to be completed until 2015/16 (Clinical Support = 11, Family and Women’s Health = 12, Medicine =1 , Surgery = 4 ) The table shows that at the end of 2014/15, 79% of audits were complete which was the same as at the end of 2013/14. 10 learning audits were approved during 2014/15. These are audits that are undertaken primarily for educational purposes and are not included on the audit plan. During 2014/15, the Clinical Audit and Effectiveness Team started reviewing outcome forms at their weekly project approval meeting, to ensure the actions are relevant and have been signed off by the clinical lead. The aim is to improve the quality of the outcome forms and ensure actions will be implemented by the specialty. Due to the lack of follow up by some of the Health Groups, the central team also began following up actions from local audits. See Appendix II for the progress of the actions identified as a result of local clinical audits completed in 2013/14.

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5. Internal Audit During 2014, internal audit undertook a review of the clinical audit arrangements within the Trust. The report was published in December 2014 and presented to the Audit Committee. Clinical audit was given a rating of ‘significant assurance’ with 7 areas identified as requiring action. An action plan was developed and approved at the Clinical Effectiveness, Policies and Practice Development Committee in January 2015. 6. Amendment of Clinical Audit Report Template and Outcome Form In July 2014, the Clinical Effectiveness, Policies and Practice Development Committee approved a revised Clinical Audit report template and outcome form. A section on the level of assurance provided by the results of the audit has been added to both the report template and outcomes form. This was done at the request of the Audit Committee who wanted to be able to use the results of clinical audits as a form of assurance. The ‘Introduction to Clinical Audit’ and the six ‘how to’ guides for clinical audit were also reviewed and updated. They are available on the clinical audit Intranet site. 7. Clinical Effectiveness, Policies and Practice Development Committee The Clinical Effectiveness, Policies and Practice Development Committee met 11 times during this year. The aim of the new Committee (established in April 2014) is to monitor clinical audit and effectiveness activity within the Trust. This includes the monitoring of compliance with NICE guidance and NCEPOD recommendations. The committee also approves policies / guidelines and clinical practice and development applications, including patient group directives. The Committee reports to the Operational Quality Committee. 8. National Audits During 2014/15, 36 national clinical audits covered NHS services that Hull and East Yorkshire Hospitals NHS Trust provides. During that period Hull and East Yorkshire Hospitals NHS Trust participated in 100% of national clinical audits which it was eligible to participate in. During 2014/15, a new national audit outcomes form was created and approved at the Clinical Effectiveness, Policies and Practice Development Committee. The outcomes form summarises the results and where possible, compares the Trust against the national figures. The Clinical Audit and Effectiveness Team then meet with the national audit lead to agree an action plan and this is then presented at the Clinical Effectiveness, Policies and Practice Development Committee for ratification and escalation of any particularly good or poor results. The Clinical Audit and Effectiveness Team then follow up the agreed actions, to ensure they are implemented. See Appendix III for the progress of the actions identified as a result of national clinical audits completed in 2013/14. 9. NICE Guidance The Clinical Audit and Effectiveness Team liaises with clinicians from each Health Group who are responsible for demonstrating the Trust’s compliance with NICE guidance. Compliance with NICE guidance is reported via a quarterly report to the Clinical Effectiveness, Policies and Practice Development Committee. Regular updates are also provided to the commissioners via the Contract Management Board.

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9.1 Technology Appraisals and Interventional Procedures Technology appraisals are recommendations on the use of new and existing medicines and treatments within the NHS in England and Wales, such as medicines, medical devices, diagnostic techniques, surgical procedures and health promotion activities. When NICE recommends a treatment 'as an option', the NHS must make sure it is available within 3 months (unless otherwise specified) of its date of publication. Interventional procedures are recommendations about whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use. An interventional procedure is a procedure used for diagnosis or treatment that involves making a cut or a hole to gain access to the inside of a patient's body, gaining access to a body cavity without cutting into the body or using electromagnetic radiation (which includes X-rays, lasers, gamma-rays and ultraviolet light) For both Technology Appraisals and Interventional Procedures, the Trust has a well established process for determining compliance. Any issues regarding compliance were reported to the Clinical Effectiveness, Policies and Practice Development Committee within the quarterly report on NICE guidance. The table below shows the status of the Technology Appraisals that have been published during 2014/15.

Health Group

Technology Appraisals

Fully compliant

Partially compliant

Non compliant

Yet to be determined

Clinical Support 11 1 0 1

Family and Women’s Health

0 0 0 0

Medicine 6 0 0 1

Surgery 1 0 0 3

Trustwide 1 0 0 0

The table below shows the status of the Interventional Procedures that have been published during 2014/15.

Health Group

Interventional Procedures

Fully compliant

Partially compliant

Non compliant

Yet to be determined



0 2 0 0

Medicine 2 0 0 2

Surgery 5 0 0 4

NB. All of the guidance which is ‘yet to be determined’ is from the last quarter.

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9.2 NICE Guidelines The Clinical Audit and Effectiveness Team have been working with clinicians to complete the form and escalating non-compliance with individual guidelines where necessary. Many clinical leads have chosen to adopt the NICE guideline in its entirety and the Clinical Audit and Effectiveness Team facilitate the process of ensuring this is approved at the relevant Health Group governance meeting.

Health Group Fully

compliant Partially

compliant Non

compliant Yet to be

determined



0 1 0 3

Medicine 0 0 1 8

Surgery 0 0 0 3

Trustwide 0 1 0 3

9.3 Quality Standards Due to the limited success in determining compliance with the NICE Quality Standards, a new template was approved at the Clinical Effectiveness, Policies and Practice Development Committee in April 2014. Completion of this template for each of the Quality Standards, in conjunction with the clinical leads, has been a priority for the Clinical Audit and Effectiveness Team. The table below shows the progress in determining compliance with the Quality Standards to date:-

Health Group Current Status of Quality

Standards

Clinical Support

End of Life Completed


Glaucoma Completed

Breast Cancer Completed

Psoriasis Completed

The Epilepsies in Children and young People

Completed

Atopic Eczema in Children Completed

Antibiotics for Neonatal Infection Partially Completed

Medicine

Dementia Completed

Stroke Completed

COPD Completed

Delirium Completed

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Asthma Completed

Lung Cancer Partially completed

The Epilepsies in Adults Completed Supporting People to Live Well with Dementia

Completed

Diabetes Completed, awaiting sign off

Rheumatoid Arthritis Completed

Headaches in Young People and Adults Completed

Renal Replacement Therapy Services Completed

Acute Kidney Injury Completed

Surgery

VTE prevention Completed

Hip Fracture in Adults Completed

Lower Urinary Tract Infections in Men Completed 10. NCEPOD activity 2014/15 The Clinical Audit and Effectiveness Manager is the named local reporter for NCEPOD and acts as a link between the non-clinical staff at NCEPOD and individual consultants. This role includes compiling and sending datasets requested by NCEPOD. The Trust participated in the studies below during 2014/15:- National Confidential Enquiry into Patient Outcome and Death (NCEPOD) study

Participation (Yes/No)

% cases submitted

Sepsis Yes 100%

Gastrointestinal Haemorrhage Yes 80% clinical questionnaires

100% organisational

questionnaire

Acute Pancreatitis Data collection ongoing Mothers and Babies: Reducing Risk through Audits and Confidential Enquires across the UK (MBBRACE – UK)

Participation (Yes/No)

% cases submitted

Maternal Infant and Perinatal programme Yes 100%

This year, two NCEPOD reports were published that are relevant to this Trust. ‘On the Right Trach’ (Tracheostomy Care) and ‘Working Together’ (Lower Limb Amputation) were published.

The gap analyses are currently being completed and will be ratified at the Clinical Effectiveness, Policies and Practice Development Committee in June 2015. 11. Clinical Audit Training The Clinical Audit and Effectiveness Team provided several clinical audit training sessions to specialties during this year, as requested. The team provided training at specialty junior induction sessions. The team has continued to provide individuals undertaking clinical audit projects with advice and support.

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12. Clinical Audit Objectives 2015/16

To review the strategy of the clinical audit function To make clinical audit reports available on the Trust intranet site To develop a process to audit 7 day working To review the role of the team in relation to learning lessons from serious incidents

and Trustwide audits To include a page on the clinical audit intranet site regarding the way clinical audit

results are disseminated within specialties, to ensure lessons are learnt as a result of audit

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APPENDIX I

HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST 2015/16 AUDIT PLAN

CLINICAL SUPPORT HEALTH GROUP

Clinical Support Health Group

Audit Title Planned Start Date

Due Date Specialty

Biochemical Assessment of Hyperandrogenaemiain for the Diagnosis of PCOS 01-Mar-2015 01-Mar-2016 Biochemistry

National Comparative Audit into Blood Usage in Patients with Lower GI Bleeding 01-Sep-2015 31-Mar-2016 Blood Transfusion

National Comparative Audit of the Use of Blood in Haematology 01-Jan-2016 31-Jul-2016 Blood Transfusion

2015 National Comparative Audit of Patient Blood Management in Adults Undergoing Scheduled Surgery

01-Apr-2015 31-Oct-2015 Blood Transfusion

Management of High/Intermediate Risk Myelodysplastic Syndrome Patients Diagnosed in 2014 in Accordance with NICE Guidelines (Yearly Audit)

01-Jul-2015 29-Feb-2016 Clinical Haematology (Ward)

Patient Information & Consent Audit - Clinical Haematology 01-Jul-2015 29-Feb-2016 Clinical Haematology (Ward)

Record Keeping Audit - Clinical Haematology 01-Nov-2015 31-Jan-2016 Clinical Haematology (Ward)

The Use of Lenolidamide for 5q-Syndrome in accordance with NICE Guidance 01-Jul-2015 31-Mar-2016 Clinical Haematology (Ward)

The Use of Prophylactic Ciprofloxacin Post Autologous Transplant 01-Feb-2015 31-Mar-2016 Clinical Haematology (Ward)

End of Life Care Audit: Dying in Hospital 01-Jul-2015 31-Mar-2016 Clinical Oncology

Patient Information & Consent Audit - Clinical Oncology 01-Jul-2015 29-Feb-2016 Clinical Oncology

RE-AUDIT Audit on Following the Guidelines of Prescribing Regular Medication in In-Patients' Drug Charts

01-Jul-2015 29-Feb-2016 Clinical Oncology

RE-AUDIT Resource Utilization and Patient Flow of Renal Cell Cancer Patients 01-Jul-2015 29-Feb-2016 Clinical Oncology

Record Keeping Audit - Clinical Oncology 01-Jul-2015 29-Feb-2016 Clinical Oncology

Efficacy of Maintained Pemetrexed in Non Small Cell Lung Cancer 01-Apr-2015 31-Mar-2016 Clinical Oncology

Dietetic Record Card and Casenote Review 04-Jan-2016 31-Mar-2016 Dietetics

Patient Information & Consent Audit - Infectious Diseases 01-Jul-2015 29-Feb-2016 Infectious Diseases

Record Keeping Audit - Infectious Diseases 01-Jul-2015 29-Feb-2016 Infectious Diseases

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Due Date Specialty

HIV Testing in the TB Clinic 01-Apr-2015 31-May-2015 Infectious Diseases

Audit of HEY OT Student Placements Against National Placement Profiles 04-Jan-2016 31-Mar-2016 Occupational Therapy

Evaluation of Current OT Practice against NICE and COT Guidelines for Patients Following Total Hip Replcement

04-Jan-2016 31-Mar-2016 Occupational Therapy

Record Keeping Audit - Occupational Therapy 04-Jan-2016 31-Mar-2016 Occupational Therapy

Orthotic Service Documentation Audit 04-Jan-2016 31-Mar-2016 Orthotics

Antibiotic Indication, Duration and Allergy Status Prescribing Audit 01-Nov-2015 31-Mar-2016 Pharmacy

Audit of Compliance with the Methotrexate Safety Alert 01-Nov-2015 31-Mar-2016 Pharmacy

Audit of Medicines Adherence 01-Nov-2015 31-Mar-2016 Pharmacy

Audit of Medicines Reconciliation 01-Nov-2015 31-Mar-2016 Pharmacy

Audit of Safe and Secure Handling of Medicines 01-Nov-2015 31-Mar-2016 Pharmacy

Audit of Selected Prescribing Standards from the Drug Policy 01-Nov-2015 31-Mar-2016 Pharmacy

Audit of Ward and department 6 monthly Controlled Drug checks 01-Nov-2015 31-Mar-2016 Pharmacy

Audit on the Use of Injectable Medicines 01-Nov-2015 31-Mar-2016 Pharmacy

RE-AUDIT Physiotherapy Department Activity Audit 04-Jan-2016 31-Mar-2016 Physiotherapy

Record Keeping Audit - Physiotherapy 04-Jan-2016 31-Mar-2016 Physiotherapy

Report on the Locomotor Index Outcome Measure (LCI5) used with Lower Limb Amputee Patients attending HEYHT Physiotherapy Service

04-Jan-2016 31-Mar-2016 Physiotherapy

Accuracy of Interpretation of Emergency Abdominal CT in Adult Patients who Present with Non-Traumatic Abdominal Pain

01-Apr-2015 31-Mar-2016 Radiology

Patient Information & Consent Audit - Radiology 01-Jul-2015 29-Feb-2016 Radiology

RE-AUDIT CT Colonoscopy Audit 01-Jul-2015 29-Feb-2016 Radiology

Speech and Language Therapy Case-note Audit 04-Jan-2016 31-Mar-2016 Speech & Language Therapy

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FAMILY & WOMEN’S HEALTH GROUP

Family & Women’s Health Group


Due Date Specialty

BASO - British Association of Surgical Oncology Audit 01-Apr-2015 31-Mar-2016 Breast Screening; Breast Surgery

BCCOM - Breast Cancer Clinical Outcome Measures Audit 01-Apr-2015 31-Mar-2016 Breast Screening; Breast Surgery

Ceased Womens Audit 01-Apr-2015 29-Feb-2016 Breast Screening; Breast Surgery

Partial Mammography Audit 01-Apr-2015 29-Feb-2016 Breast Screening; Breast Surgery

Pathology Audit 01-Apr-2015 29-Feb-2016 Breast Screening; Breast Surgery

Patient Information & Consent Audit - Breast Services 01-Jul-2015 29-Feb-2016 Breast Screening; Breast Surgery

Record Keeping Audit - Breast Services 01-Jul-2015 29-Feb-2016 Breast Screening; Breast Surgery

Short Term Recall Audit 01-Apr-2015 29-Feb-2016 Breast Screening; Breast Surgery

Audit of Mammograms that Require More Than 4 Exposures 02-Mar-2015 31-Aug-2015 Breast Screening; Breast Surgery

Retrospective Audit of B3 Biopsy Outcomes - Humberside Breast Screening 2010-2013 01-Apr-2015 31-Oct-2015 Breast Screening; Breast Surgery

Patient Information & Consent Audit - Dermatology 01-Jul-2015 29-Feb-2016 Dermatology

Record Keeping Audit - Dermatology 01-Jul-2015 29-Feb-2016 Dermatology

Patient Information & Consent Audit - Gynaecology 01-Jul-2015 29-Feb-2016 Gynaecology

RE-AUDIT Management of Tubal Ectopic Pregnancy 01-Jul-2015 29-Feb-2016 Gynaecology

RE-AUDIT The Use of Oxytocin in Labour 01-Jul-2015 29-Feb-2016 Gynaecology

Record Keeping Audit - Gynaecology 01-Jul-2015 29-Feb-2016 Gynaecology

2 Year Follow Up and National Neonatal Audit Programme (NNAP) (Neonatal Intensive and Special Care)

01-Apr-2015 31-Mar-2016 Neonates

Record Keeping Audit - Neonates 01-Jul-2015 29-Feb-2016 Neonates

RE-AUDIT of Early Onset Sepsis Guidelines 01-Apr-2015 30-Sep-2016 Neonates

RE-AUDIT of Transfers from NICU to Paediatric Wards 01-Apr-2015 30-Sep-2016 Neonates

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Due Date Specialty

The Use of 4.5% Human Albumin Solution on NICU 01-Apr-2015 30-Sep-2016 Neonates

Fetal Fibronectin Test 01-Jun-2015 31-Mar-2016 Obstetrics

Massive Obstetric Haemorrhage 01-Jun-2015 31-Mar-2016 Obstetrics

Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK) 01-Apr-2015 31-Mar-2016 Obstetrics

Patient Information & Consent Audit - Obstetrics 01-Jul-2015 29-Feb-2016 Obstetrics

RE-AUDIT Handover of Care from Inpatient to Community 01-Jul-2015 29-Feb-2016 Obstetrics

RE-AUDIT of Elective Caesarean Section Lists 01-Jul-2015 29-Feb-2016 Obstetrics

Record Keeping Audit - Obstetrics 01-Jul-2015 29-Feb-2016 Obstetrics

Severe Pre-eclampsia (including Eclampsia) 01-Jun-2015 31-Mar-2016 Obstetrics

Severe Sepsis 01-Jun-2015 31-Mar-2016 Obstetrics

Patient Information & Consent Audit - Ophthalmology 01-Jul-2015 29-Feb-2016 Ophthalmology

Prospective Audit of Retinal Detachment Surgery via BEAVRs website 01-Apr-2015 31-Mar-2016 Ophthalmology

RE-AUDIT Endophthalmitis Secondary to Intra-Vitreal Injections Audit 01-Nov-2015 29-Feb-2016 Ophthalmology

Record Keeping Audit - Ophthalmology 01-Oct-2015 28-Feb-2016 Ophthalmology

Audit of the Management of Suspected Giant Cell Arteritis at Hull Eye Hospital 19-Feb-2015 30-Apr-2015 Ophthalmology

National Paediatric Diabetes Audit (NPDA) 01-Apr-2015 31-Mar-2016 Paediatric Medicine

Ongoing Morbidity / Mortality Analysis for Critical Care Patients 01-Apr-2015 31-Mar-2016 Paediatric Medicine

Paediatric Asthma - BTS 01-Nov-2015 30-Nov-2015 Paediatric Medicine

RE-AUDIT Referral of New Suspected/Diagnosed Cystic Fibrosis Patients From the Neonatal Unit to the Cystic Fibrosis Team

01-Jul-2015 29-Feb-2016 Paediatric Medicine

Record Keeping Audit - Paediatric Medicine 01-Jul-2015 29-Feb-2016 Paediatric Medicine

Record Keeping Audit - Paediatric Surgery 01-Jul-2015 29-Feb-2016 Paediatric Surgery

Patient Information & Consent Audit - Paediatric Surgery 08-Apr-2015 28-Feb-2016 Paediatric Surgery

Paediatric Intensive Care (PICANET) 01-Apr-2015 31-Mar-2016 PICU

Audit of Quality Measures of the Management of Diabetic Eye Disease Pathway (NHS Diabetic Eye Screening Programme)

01-Apr-2015 31-Mar-2016 Retinal Screening

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Due Date Specialty

Audit of Patients with Visual Acuity of 6/60 or Worse at Diabetic Eye Screening Episode 01-Apr-2015 31-Mar-2016 Retinal Screening

Audit of Twelve Month "Under the Care of Ophthalmology" Failsafe Trigger Cohort 01-Apr-2015 31-Mar-2016 Retinal Screening

A Qualitative and Quantitative Audit of Information Sharing Regarding Routine Enquiry into Domestic Abuse between HEYHT Midwifery Service and CHCP Health Visiting Service.

01-Apr-2015 29-Feb-2016 Safeguarding

Joint Agency Audit - Qualitative and Quantitative Audit of Safeguarding Referrals from the Midwifery Service to the Children's Social Care Service

01-Jul-2015 29-Feb-2016 Safeguarding

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MEDICINE HEALTH GROUP

Medicine Health Group


Due Date Specialty

Record Keeping Audit - AAU 01-Jul-2015 29-Feb-2016 AAU

Quality Indicators in AAU 01-Mar-2015 31-May-2015 AAU

Cardiac Rhythm Management (CRM) 01-Apr-2015 31-Mar-2016 Cardiology

Myocardial Ischaemia National Audit Project (MINAP) 01-Apr-2015 31-Mar-2016 Cardiology

National Audit of Percutaneous Coronary Interventions (PCI) 01-Apr-2015 31-Mar-2016 Cardiology

National Heart Failure Audit 01-Apr-2015 31-Mar-2016 Cardiology

Patient Information & Consent Audit - Cardiology 01-Jul-2015 29-Feb-2016 Cardiology

Record Keeping Audit - Cardiology 01-Jul-2015 29-Feb-2016 Cardiology

Stent Thrombosis: Evaluation of Magnitude, Causes and Outcome of Stent Thrombosis at our Unit 01-Jul-2015 29-Feb-2016 Cardiology

Tilt Test Activity in CHH 01-Jul-2015 29-Feb-2016 Cardiology

RE-AUDIT of Cardiology - Cardiothoracic MDT 01-Apr-2015 31-Aug-2016 Cardiology

Adult Community Acquired Pneumonia (BTS) 01-Apr-2015 31-Mar-2016 Chest Medicine

Adult Non-Invasive Ventilation(NIV) Local Audit (BTS) 01-Apr-2015 30-Jun-2015 Chest Medicine

National Adult Asthma Audit 01-Sep-2015 15-Jan-2016 Chest Medicine

National Adult Bronchiectasis Audit - BTS 01-Oct-2015 30-Nov-2015 Chest Medicine

National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme 01-Apr-2015 31-Mar-2016 Chest Medicine

National Emergency Oxygen Audit - BTS 15-Aug-2015 01-Nov-2015 Chest Medicine

National Lung Cancer Audit 01-Apr-2015 31-Mar-2016 Chest Medicine

National Pulmonary Hypertension Audit 01-Apr-2015 31-Mar-2016 Chest Medicine

Patient Information & Consent Audit - Chest Medicine 01-Jul-2015 29-Feb-2016 Chest Medicine

Record Keeping Audit - Chest Medicine 01-Jul-2015 29-Feb-2016 Chest Medicine

UK Cystic Fibrosis Registry 01-Apr-2015 31-Mar-2016 Chest Medicine

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Due Date Specialty

National Diabetes Audit (NDA) (Adult) 01-Apr-2015 31-Mar-2016 Diabetes & Endocrinology

National Diabetes Foot Care Audit (NDFA) 01-Apr-2015 31-Mar-2016 Diabetes & Endocrinology

National Diabetes Inpatient Audit ( NaDIA) 01-Apr-2015 31-Mar-2016 Diabetes & Endocrinology

National Pregnancy in Diabetes Audit (NPID) 01-Apr-2015 31-Mar-2016 Diabetes & Endocrinology

Record Keeping Audit - Diabetes & Endocrinology 01-Jul-2015 29-Feb-2016 Diabetes & Endocrinology

Audit of Use of Dementia and Delirium Screening Tool 01-Dec-2015 31-Mar-2016 Elderly Medicine

Record Keeping Audit - Elderly Medicine 01-Jul-2015 29-Feb-2016 Elderly Medicine

Procedural Sedation in Adults (CEM) 01-Jul-2015 29-Feb-2016 Emergency Department

Record Keeping Audit - Emergency Department 01-Jul-2015 29-Feb-2016 Emergency Department

Severe Trauma (Trauma Audit & Research Network, TARN) 01-Apr-2015 31-Mar-2016 Emergency Department

Vital Signs in Children (CEM) 01-Jul-2015 29-Feb-2016 Emergency Department

VTE Risk in Lower Limb Immobilisation (CEM) 01-Jul-2015 29-Feb-2016 Emergency Department

Non-Invasive Ventilation in Motor Neurone Disease: NICE CG105 01-Jul-2015 29-Feb-2016 Neurology

RE-AUDIT of 2014/15 Audit: Clinical Audit to Assess the Time from Referral to First Seizure Clinic 01-Jul-2015 29-Feb-2016 Neurology

Record Keeping Audit - Neurology 01-Jul-2015 29-Feb-2016 Neurology

UK Parkinson's Audit 01-Apr-2015 31-Mar-2016 Neurology

Adequacy of Kidney Transplant Biopsies 01-Apr-2015 31-Dec-2015 Renal

Audit of PD Peritonitis 01-Apr-2015 30-Sep-2015 Renal

Clinical Audit of Exposure of Cuffs in Tunnelled Dialysis Catheters 01-May-2015 01-Aug-2015 Renal

Patient Information & Consent Audit - Nephrology/Renal 01-Jul-2015 29-Feb-2016 Renal

RE-AUDIT Vascular Access – Patients Commencing HD via Catheters 01-Jul-2015 29-Feb-2016 Renal

Record Keeping Audit - Nephrology/Renal 01-Jul-2015 29-Feb-2016 Renal

Renal Replacement Therapy (Renal Registry) 01-Apr-2015 31-Mar-2016 Renal

A UK Multicentre Audit of the Management of Rheumatoid Arthritis Against Treat to Target Guidelines 01-Apr-2015 31-Aug-2015 Rheumatology

Assessing Factors Contributing to Delays in Carrying Out Investigations for Ward Patients 01-Jul-2015 29-Feb-2016 Rheumatology

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Due Date Specialty

National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis 01-Apr-2015 31-Mar-2016 Rheumatology

Record Keeping Audit - Rheumatology 01-Jul-2015 29-Feb-2016 Rheumatology

Review of Reference Range for ANA Test and its Clinical Correlation 01-Jul-2015 29-Feb-2016 Rheumatology

RE-AUDIT Potentially Preventable Strokes in High Risk Patients with Atrial Fibrillation 01-Jul-2015 29-Feb-2016 Stroke Medicine

Record Keeping Audit - Stroke 01-Jul-2015 29-Feb-2016 Stroke Medicine

Sentinel Stroke National Audit Programme (SSNAP) 01-Apr-2015 31-Mar-2016 Stroke Medicine

Accuracy of Discharge Letters 30-Jan-2015 30-Jun-2015 Stroke Medicine

Quality of Stroke Admission Documentation 30-Jan-2015 30-Jun-2015 Stroke Medicine

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SURGERY HEALTH GROUP

Surgery Health Group


Due Date Specialty

Patient Information & Consent Audit - Acute Surgery 01-Jul-2015 29-Feb-2016 Acute Surgery

Record Keeping Audit - Acute Surgery 01-Jul-2015 29-Feb-2016 Acute Surgery

Audit of Critical Care Bed Usage Following Coiling for Subarachnoid Haemorrhage 01-Jul-2015 29-Feb-2016 Anaesthetics (Inpatient)

Audit of Preassessment in Day Surgery 01-Jul-2015 29-Feb-2016 Anaesthetics (Inpatient)

Re-audit of Pain Relief Following Gynaecological Procedures 01-Jul-2015 29-Feb-2016 Anaesthetics (Inpatient)

RE-AUDIT Technique of Anaesthesia for Caesarean Section 01-Jul-2015 29-Feb-2016 Anaesthetics (Inpatient)

RE-AUDIT The rate of Dural Puncture after Epidural Insertion on the Labour Ward 01-Jul-2015 29-Feb-2016 Anaesthetics (Inpatient)

UK Collaborative on Anaemia in Cardiac Surgery Audit 01-Apr-2015 31-Mar-2016 Anaesthetics (Inpatient)

Venous Thromboembolism Audit 01-Jul-2015 29-Feb-2016 Anaesthetics (Inpatient)

VTE Risk Assessment Ward 7, HRI 04-Mar-2015 31-Mar-2016 Anaesthetics (Inpatient)

National Adult Cardiac Surgery Audit (CABG and Valvular Surgery) 01-Apr-2015 31-Mar-2016 Cardiothoracic Surgery

Patient Information & Consent Audit - Cardiothoracic Surgery 01-Jul-2015 29-Feb-2016 Cardiothoracic Surgery

Record Keeping Audit - Cardiothoracic Surgery 01-Jul-2015 29-Feb-2016 Cardiothoracic Surgery

Bowel Cancer (NBOCAP) 01-Apr-2015 31-Mar-2016 Colorectal Surgery

National Complicated Acute Diverticulitis Audit 01-Apr-2015 31-Mar-2016 Colorectal Surgery

Patient Information & Consent Audit - Colorectal Surgery 01-Jul-2015 29-Feb-2016 Colorectal Surgery

Record Keeping Audit - Colorectal Surgery 01-Jul-2015 29-Feb-2016 Colorectal Surgery

Adult Critical Care - ICNARC Audit 01-Apr-2015 31-Mar-2016 Critical Care (ICU & HDU)

National Emergency Laparotomy Audit (NELA) 01-Apr-2015 31-Mar-2016 Critical Care (ICU & HDU)

Record Keeping Audit - Critical Care (ICU & HDU) 01-Jul-2015 29-Feb-2016 Critical Care (ICU & HDU)

ICU Delirium 04-Mar-2015 31-Mar-2016 Critical Care (ICU & HDU)

18


Due Date Specialty

WYCCN 6 Hour Sepsis Care Bundle 04-Mar-2015 31-Mar-2016 Critical Care (ICU & HDU)

RE-AUDIT Specimen Collection in Theatre - Compliance with the WHO Surgical Checklist and Day Surgery Care Plan

01-Jul-2015 29-Feb-2016 Day Surgery

Patient Information & Consent Audit - ENT 01-Jul-2015 29-Feb-2016 ENT

Record Keeping Audit - ENT 01-Jul-2015 29-Feb-2016 ENT

Inflammatory Bowel Disease (IBD) 01-Apr-2015 31-Mar-2016 Gastroenterology & Endoscopy

JAG Endoscopy Quality Audits 01-Apr-2015 31-Mar-2016 Gastroenterology & Endoscopy

Multi-Regional Audit of Management of Autoimmune Hepatitis 01-Apr-2015 31-Mar-2016 Gastroenterology & Endoscopy

Patient Information & Consent Audit - Gastroenterology & Endoscopy 01-Jul-2015 29-Feb-2016 Gastroenterology & Endoscopy

Record Keeping Audit - Gastroenterology & Endoscopy 01-Jul-2015 29-Feb-2016 Gastroenterology & Endoscopy

Patient Information & Consent Audit - Head & Neck Max Fax 01-Jul-2015 29-Feb-2016 Head & Neck Max Fax

Record Keeping Audit - Head & Neck Max Fax 01-Jul-2015 29-Feb-2016 Head & Neck Max Fax

Audit of the Pathological Margins in OMFS Head and Neck SCC Patients having Operative Treatment in 2014

04-Mar-2015 31-Mar-2016 Head & Neck Max Fax

BOS/BAOMS National Agreement on a Minimum Records Dataset for Orthognathic Patients 04-Mar-2015 31-Mar-2016 Head & Neck Max Fax

RE-AUDIT Suture Removal on Paediatric Patients with Facial Lacerations 04-Mar-2015 31-Mar-2016 Head & Neck Max Fax

National Acromgaly Audit 01-Apr-2015 31-Mar-2016 Neurosurgery

National Cauda Equina Audit 01-Apr-2015 31-Mar-2016 Neurosurgery

National Shunt Registry 01-Apr-2015 31-Mar-2016 Neurosurgery

Neurosurgical National Audit Programme 01-Apr-2015 31-Mar-2016 Neurosurgery

Orion Network - Skull Base Module University of Cambridge 01-Apr-2015 31-Mar-2016 Neurosurgery

Patient Information & Consent Audit - Neurosurgery 01-Jul-2015 29-Feb-2016 Neurosurgery

Record Keeping Audit - Neurosurgery 01-Jul-2015 29-Feb-2016 Neurosurgery

Audit for Time Interval Between First Scan and First MDT 03-Mar-2015 31-Mar-2016 Neurosurgery

Audit of Delayed Discharges of the Orthopaedic Trauma Admissions 01-Jul-2015 29-Feb-2016 Orthopaedics (Elective)

Audit on Adequacy of Pelvic Xrays in Patients with Femoral Neck Fractures 01-Jul-2015 29-Feb-2016 Orthopaedics (Elective)

19


Due Date Specialty

Audit on Pelvis X-rays of Patients Admitted with Neck of Femur Fracture 11-Mar-2015 31-Mar-2016 Orthopaedics (Elective)

Audit on Follow Up of Paediatric Clavicle and Buckle Fractures 11-Mar-2015 31-Mar-2016 Orthopaedics (Elective)

Audit of the Adequacy of Ankle Fracture Reduction Intra-operatively 11-Mar-2015 31-Mar-2016 Orthopaedics (Elective)

Auditing of Intertan Nailing System 11-Mar-2015 31-Mar-2016 Orthopaedics (Elective)

Record Keeping Audit - Orthopaedics 01-Jul-2015 29-Feb-2016 Orthopaedics (Elective); Orthopaedics (Trauma)

Patient Information & Consent Audit - Orthopaedics 11-Mar-2015 28-Feb-2016 Orthopaedics (Elective); Orthopaedics (Trauma)

Falls And Fragility Fractures Audit Programme (FFFAP) - National Hip Fracture Database (NHFD) 01-Apr-2015 31-Mar-2016 Orthopaedics (Trauma)

National Joint Registry (NJR) 01-Apr-2015 31-Mar-2016 Orthopaedics (Trauma)

Patient Information & Consent Audit - Pain Services 01-Jul-2015 29-Feb-2016 Pain Services

Record Keeping Audit - Pain Services 01-Jul-2015 29-Feb-2016 Pain Services

Patient Information & Consent Audit - Plastic Surgery 01-Jul-2015 29-Feb-2016 Plastic Surgery

Record Keeping Audit - Plastic Surgery 01-Jul-2015 29-Feb-2016 Plastic Surgery

Oesophago-Gastric Cancer (NAOGC) 01-Apr-2015 31-Mar-2016 Upper GI

Patient Information & Consent Audit - Upper GI 01-Jul-2015 29-Feb-2016 Upper GI

Record Keeping Audit - Upper GI 01-Jul-2015 29-Feb-2016 Upper GI

National Prostrate Cancer Audit 01-Apr-2015 31-Mar-2016 Urology

Patient Information & Consent Audit - Urology 01-Jul-2015 29-Feb-2016 Urology

Record Keeping Audit - Urology 01-Jul-2015 29-Feb-2016 Urology

Prostate Cancer 2 Week Wait Breaches 03-Mar-2015 31-Mar-2016 Urology

Does Sub-Classification of Grade 2 Transitional Cell Carcinoma of the Bladder Influence the Natural Course of the Disease

01-Jul-2015 29-Feb-2016 Urology

AAAQIP 01-Apr-2015 31-Mar-2016 Vascular Surgery

CEA Audit 01-Apr-2015 31-Mar-2016 Vascular Surgery

Lower Limb Bypass Audit 01-Apr-2015 31-Mar-2016 Vascular Surgery

20


Due Date Specialty

National Vascular Registry 01-Apr-2015 31-Mar-2016 Vascular Surgery

NCEPOD Audit of Lower Limb Amputation 01-Jul-2015 29-Feb-2016 Vascular Surgery

Patient Information & Consent Audit - Vascular Surgery 01-Jul-2015 29-Feb-2016 Vascular Surgery

Record Keeping Audit - Vascular Surgery 01-Jul-2015 29-Feb-2016 Vascular Surgery

Transfer Times and Clinical Outcome for Patients with Acute Limb Ischaemia 03-Mar-2015 31-Mar-2016 Vascular Surgery

21

TRUSTWIDE

Trustwide


Due Date Specialty

7 Day Working 01-Apr-2015 31-Mar-2016 Trustwide

Classic Safety Thermometer 01-Jul-2015 29-Feb-2016 Trustwide

Duty of Candour Audit 01-Apr-2015 31-Mar-2016 Trustwide

Handover of Care Audit 01-Apr-2015 31-Mar-2016 Trustwide

HEY Safer Care 01-Jul-2015 29-Feb-2016 Trustwide

Medication Safety Thermometer 01-Jul-2015 29-Feb-2016 Trustwide

National Cardiac Arrest Audit (NCAA) 01-Apr-2015 31-Mar-2016 Trustwide

The 3 G's Audit 01-Jul-2015 29-Feb-2016 Trustwide

Transfer of Care Audit 01-Apr-2015 31-Mar-2016 Trustwide

22

APPENDIX II

PROGRESS OF ACTIONS FROM LOCAL CLINICAL AUDITS COMPLETED IN 2013/14

Clinical Support Health Group

Ref Audit Title Action Priority Description of Action Due Date Status Action Lead

2013.175 Actions

CSHG - Information Governance Audit Action 1 1 Local process in place on receipt of HG CG1 forms 30-Mar-2014 Julie Fountain

Action 2 1 to repeat the audit annually 31-Dec-2014 Janet Dickinson

Imaging Division Radiology


2013.008 Actions

Radiology - Patient information and Consent Action 1 3 Record that the patient has been informed of the right to refuse the proposed treatment in discussion notes or on the consent form

31-Mar-2015

Dr Chris Rowland-Hill

Action 2 3 Ensure that all are aware of the need to ensure that the patients name is printed on the consent form

31-Mar-2015


Action 3 3 Ensure that all are reminded of the need to print the name of the person obtaining consent on the form

31-Mar-2015


2013.055 Actions

An Audit of the Outcomes at Our Institution Following Testicular Vein Embolisation For Symptomatic Varicocele

Action 1 3 MRV prior to right-sided varicocele embolisation to delineate the right testicular vein anatomy / origin

28-Jun-2014

Dr Vivek Shrivastava

Pathology Division Biochemistry


2013.075 Actions

Diagnosis and Identification of Patient and Relatives with Definite or Possible Familial Hypercholesterolemia - Adherence to NICE (CG71) Guidelines

Action 1 1 Family tree and cascade documents need Trust approval as new documents

30-Apr-2014

Action 2 2 Following approval of documents pilot period of use in Lipid Clinic for 6 months

31-Oct-2014

Action 3 3 Re-audit for pilot period 31-Aug-2015 Pathology Division Histopathology

23


2013.264 Actions

Audit of Quality of Specimen Handling and Preparation Action 1 3 To feedback to lab staff 31-Dec-2014 Dr Renee Tiam

Action 2 3 to encourage error reporting at all levels 31-Dec-2014 Dr Renee Tiam

Action 3 3 To explore programme of targeted training by seniors and advanced practitioners

31-Dec-2014

Dr Renee Tiam

Pathology Division Microbiology


2013.025 Actions

Adherence to NICE Guidance on TB Diagnosis - Sputum Sample Replicates for Investigation of Tuberculosis

Action 1 3 Disseminate results to infection and respiratory departments 31-Mar-2014

Dr Debbie Wearmouth

Action 2 3 Add summary of audit and request for repeat specimens to Pathology newsletter

31-Mar-2014

Dr Debbie Wearmouth

Pathology Division Virology


2013.022 Actions

Respiratory Syncytial Virus Result Timeliness Re-audit Action 1 3 Report to Microbiology audit group 31-May-2014 Dr Rolf Meigh

Action 2 3 Report to Sister 120, Matron Paediatrics 30-Jun-2014 Dr Rolf Meigh

Action 3 3 Report to Clinical Support Governance Committee 30-Jun-2014 Dr Rolf Meigh

Specialist Service Division Clinical Haematology (Ward)


2013.008 Actions

Clinical Haematology - Patient Information and Consent Audit

Action 1 2 to hold a departmental educational session on consent and consent form completion

31-Oct-2014

Dr James Bailey

Action 2 2 To re-audit 2014/15 31-Mar-2015 Dr James Bailey

2013.261 Actions

Treatment of Patient with Suspected Fungal Infection in the Haematology Setting

Action 1 3 Consider obtaining Microbiological evidence of fungal infection before commencing treatment

31-Dec-2013

Dr Nneka Obisi

Action 2 3 Re-audit in about 6-12 months 30-Nov-2014 Dr Nneka Obisi

24


2013.269 Actions

Management of High/Intermediate Risk Myelodysplastic Syndrome Patients Diagnosed in Years 2008 - 2013 in Accordance with NICE Guidelines

Action 1 Training of middle grade staff performing bone marrow biopsy - emphasizing importance of cytogenetics

07-Apr-2014

Dr Sahra Ali

Action 2 3 Re-audit within one year 31-Mar-2015 Dr Sahra Ali

Specialist Service Division Clinical Oncology


2013.008 Actions

Clinical Oncology - Patient Information and Consent Action 1 Re-Audit 31-Mar-2015

Dr Waqas Ali

2013.063 Actions

Audit of End of Life Care for Patients with End Stage Liver Disease

Action 1 2 Dissemination of the results to the Gastroenterology department who manage these patients

31-Oct-2013

Dr Elaine Boland

Action 2 2 Education on the availability of palliative services in Hull, potentially through Clinical Governance meeting

31-Oct-2013

Dr Elaine Boland

Action 3 2 Future presentation of the results at conference level in abstract form 30-Jun-2014 Dr Elaine Boland

Action 4 2 Re-audit in the next 1-2 years (not sooner as it is felt that this length of time is needed to obtain a sufficient number of cases to compare).

31-Mar-2016

Dr Elaine Boland

2013.064 Actions

Concurrent Chemo-Radiotherapy for Locally Advanced Non-Small Cell Lung Cancer

Action 1

3

Re-audit current patients and patients due to have concurrenct chemo-radiotherapy for non-small cell lung carcinoma initiated between August 2013-July2014

31-Dec-2014

Dr Andrzej Wieczorek

2013.065 Actions

A Retrospective Audit to Identify the Quality of Palliative Care Patients Diagnosed with Head and Neck Cancer Receive Towards the End of Life

Action 1 2 To re-audit of the utilisation of new end of life guidance for this patient group

31-Dec-2014

Debra Marsh

Action 2 2 To support teams with ongoing end of life education 31-Dec-2014 Debra Marsh

2013.290 Actions

Evaluation of Compliance with the use of Clerking Document for all Patients Admitted to Queen's Centre for Oncology/Haematology

Action 1 3 Encourage and educate junior doctors to continue use of clerking documents and improve quality

30-Apr-2014

Dr Mohammad Butt

Action 2

3

Re-audit

30-Jun-2014

Dr Mohammad Butt

2013.295 Actions

Resource Utilization and Patient Flow of Renal Cell Cancer Patients

Action 1 To review clinic location 28-Feb-2015

Stephen Miller; Steve Oliver

Action 2 To appoint to key worker and sign post role 28-Feb-2015


Action 3 To investigate use of non-medical prescribers 28-Feb-2015

Prof Anthony Maraveyas; Sarah Scargill

25


Action 4 To review the quantity of follow up appointments 28-Feb-2015


Action 5 To develop survivorship programme for renal cell cancer patients 28-Feb-2015

Prof Anthony Maraveyas

Action 6 To re-audit in August 2015 31-Aug-2015

Prof Anthony Maraveyas

2013.326 Actions

VTE Risk Assessment in Cancer Patients in Queen's Centre, CHH

Action 1

2

To print VTE form and attach it to drug charts

30-Apr-2014

Dr Sunil Uphadhyay

Specialist Surgery Division Clinical Oncology


2013.287 Actions

Audit of the Outpatient Incidental PE Pathway - a Review of Outcomes and Risk Factors

Action 1 2 To present audit to the VTE working group 30-Sep-2014

Dr Georgios Bozas; Prof Anthony Maraveyas

Action 10 3 To obtain publication of current report in the form of peer-review article. 31-Dec-2014


Action 2 1 To address need for improvement of staffing at the Nurse Specialist Level 31-Jul-2015

Action 3 2 To reinforce ongoing development of training tools with a view to roll the service to Hull Royal Infirmary

31-Dec-2014

Action 4 1 To continue to review cases with complications 31-Jul-2015


Action 5 2 To improve data collection (a new data manager has already been involved)

30-Jul-2015


Action 6 2 To re-audit the updated database with a comparison of outcomes between different periods of the service, i.e. before and after the implementation of the enhanced prediction tool incorporating PS and the presence of new/worsening symptoms which took place in 2012

30-Jul-2015


Action 7 2 To develop and incorporate the prognostic score in the service (as par of re-audit)

30-Jul-2015


Action 8 1 Working group to formally survey patient satisfaction report 31-Dec-2014

26


Action 9 3 To disseminate current audit results to clinicians in the QCOH 30-Sep-2014


Therapy & Therapeutics Division Occupational Therapy


2013.071 Actions

Benchmarking the Occupational Therapy Service Against the College of Occupational Therapists Evidence Based Guidelines with People Who Have Had Lower Limb Amputations

Action 1 1 Amendment of audit tool to eliminate subjectivity 31-Dec-2014 Debbie Parker

Action 2 1 Re-audit of the Occupational Therapy service with a larger sample size 31-Dec-2014 Karen Button

Action 3 1 Presentation to Vascular Clinical Governance and Occupational Therapy Clinical Governance Team

31-Dec-2013

Debbie Parker

2013.187 Actions

An Evaluation of Occupational Therapy (OT) Service Provision to AAU, SSW and ESSU.

Action 1 1 Continued designated OT to cover AAU/SSW providing a responsive service.

30-May-2014

Clare Allen

Action 2 2 Project lead to liaise with senior managers regarding impact of OT within A&E

30-May-2014

Clare Allen

Action 3 1 Project lead to liaise with senior managers regarding impact of OT service in ambulatory care

07-Apr-2014

Clare Allen

Therapy & Therapeutics Division Pharmacy


2013.262 Actions

Antibiotic Indication and Duration Prescribing Audit Action 1 1 Re-audit - continue monthly until appropriate to reduce to quarterly 31-Mar-2015 Anna Steele

Action 2 1 Present at Trust boards and feedback to health group leads 31-Mar-2015 Anna Steele

Action 3 2 Maternity drug cards to be updates from old charts to include A-B section with prescribing prompts

31-Mar-2015

Anna Steele

2013.263 Actions

Monitoring the Trust's Compliance with the Medicines Reconciliation Policy

Action 1 1 To designate a member of pharmacy staff to have AAU and Ward 1 as their daily ward

31-Oct-2014

David Corrall

Action 2 2 Pharmacy Staff to receive communication training including dementia training

31-Jan-2015

Janice Hawkings

Action 3 2 To re-audit to evaluate all wards 30-Nov-2014 Claire Doyles

Action 4 3 To review junior doctors training around medicines reconciliation 30-Sep-2014 Claire Doyles

27


2013.266 Actions

Compliance with Use of Patient's Own Drug Policy Action 1 3 Re-audit 31-Mar-2015 Emily Hardaker

Action 2 3 Endorse POD’s clearly either on a drug card or for paperless prescribing introduce electronic recording system embedded in electronic prescribing.

31-Mar-2015

Claire Doyles

Action 3 2 Negotiate with a view to amend several criteria in the patients’ own drug policy: - Change statement that a patient must be discharged with a minimum of 14 days medication to if they can easily obtain a repeat prescription from their usual source or have plenty of medicines at home they do not need to be provided with these. - Alter the statement that blister strips should be deemed unusable to can be used as long as the patients’ dose and frequency have been confirmed and the product and expiry date can clearly be identified on the blister strips.

31-Mar-2015

David Corrall; Julie Randall

Action 4 3 Designate one central location for all staff to document PODs in the patients’ clinical record .

31-Mar-2015

Julie Randall

Action 5 3 Alter the location PODs are kept by introducing POD trolleys with individual drawers for patients on wards.

31-Mar-2015

Caroline Grantham

Action 6 3 Promote usage of PODs through bi-annual training for Nurses. 31-Mar-2015 Caroline Grantham

2013.267 Actions

Compliance with Lithium Guidelines Action 1 1 Make all staff who are involved in the prescribing and supply of lithium aware of the clinical guideline

31-Mar-2014

Smarah Hayyat

Action 2 2 Report results of audit to Safe Medication and Practice Committee 31-May-2014 Julie Randall

Action 3 3 Report results of audit to Medicines Management interface group 30-Sep-2014 Marie Miller

2013.271 Actions

Biennial National Patient Safety Agency Injectables Audit

Action 1 2 Report findings to SMPC 31-May-2014 Janet Page

Action 2 2 Report findings to the Clinical Quality Committee 31-May-2014 David Corrall

Action 3 1 Re-audit NPSA high Risk Practice Audit - completed every 2 years To be undertaken during 2015

30-Aug-2015

Janet Page

2013.276 Actions

Therapeutic Drug Monitoring of Gentamicin Action 1 1 To update, launch and implement gentamicin guidelines 31-Oct-2013 Ana Megias Bas

Action 2 2 To print and display posters with the step by step guide in the HEY wards where gentamicin is available as stock. To be available on Trust intranet

31-Oct-2013

Pharmacy

Action 3 2 To design and print a sticker to put on drug cards when gentamicin is prescribed to aid documentation and compliance with guidelines.

31-Oct-2013

Pharmacy

Action 4 3 To re-audit gentamicin guidelines during 2015/16 31-Mar-2016 Pharmacy

28


2013.277 Actions

Compliance with Selected Prescribing Standards in the Trust Drug Policy

Action 1

2

Present audit report to SMPC to agree any appropriate actions

31-Mar-2014

Farzana Afzal

2013.278 Actions

An Audit on the Completion of Patients Own Drugs Information on IDLs in Pharmacy

Action 1

Raise awareness with Medicines Management Teams

02-Jul-2015

Julie Randall

2013.285 Actions

How Much Can We Save by Transferring Patients Drugs From AAU to Longer Stay Wards?

Action 1

Pharmacist / Technician to attend AAU daily

31-Dec-2014

Steve Bayston; Janice Hawkings; Ann Page

2013.286 Actions

Audit the Implementation of the Self-Administration Policy to Ensure it is Working in Practice

Action 1 The self-administration patient assessment to be reformatted and incorporated into the corporate nursing assessment document and a copy of this report to be circulated to all senior nurses to action finding within their clinical areas

31-Mar-2015

Caroline Grantham

Action 2 Poster re self-administration to be resent to all clinical areas 31-Mar-2015 Caroline Grantham

Action 3 To re-audit organisation 31-Mar-2015 Caroline Grantham

2013.296 Actions

Audit of the Drug Policy for the Supply of Unlicensed Medicines

Action 1 2 Review what the Trust requires to ensure best practice is followed 01-May-2014 Robert Stark

Action 2 2 Rewrite the drug policy 01-Jul-2014 Robert Stark

Action 3 3 Review the pharmacy's internal SOP 30-Oct-2014 Robert Stark

Action 4 2 Disseminate the new requirements to prescribers and pharmacy staff. 01-Aug-2014 Robert Stark

2013.311 Actions

Audit of Medicines Reconciliation Process for Insulin Action 1 2 Add insulin audit to audit plan for 2014/15 31-Jul-2014 Julie Randall

Action 2 3 Add medicines reconciliation audit to audit plan for 2014/15 31-Jul-2014 Julie Randall

Action 3 2 Review drug policy information on insulin prescribing (including self administration section)

01-Oct-2015

Marie Miller

Action 4 2 Feedback information on use of insulin passport to Pharmacy team, secondary specialists and primary care

30-Jun-2014

Marie Miller

Therapy & Therapeutics Division Physiotherapy


2013.020 Actions

Re-audit Physiotherapy Acute Respiratory COPD Service (PARCS) Outcomes Measures Audit

Action 1 2 Identify realistic CCQ and EQ-5D service standards in order to benchmark future service quality by end of April 2014

30-Apr-2014

Claire Seaborne

29


Action 2 2 Share audit findings with therapies, clinical governance committee and the clinical support health group quality and safety managers

31-Mar-2014

Kate Allen; Angela Green

Action 3 2 to promote service via NICE shared learning database and possible publication by December 2014

31-Dec-2014

Kate Allen; Angela Green

2013.068 Actions

Lower Limb Amputation Pathway Milestones: How does HEY/ Contributory Regional Vascular Centres Perform Against Regionally Agreed Quality and Operational Standards in Amputee Management

Action 1 2 Disseminate findings to vascular MDT to identify actions for improvement. 30-Jun-2014 Amanda Hancock

Action 2 3 Investigate if comparative data will be available from York 30-Jun-2014 Amanda Hancock

2013.069 Actions

Physiotherapy Workforce Review Action 1 1 Review of duty activity and skill mix with Section heads at 1:1's undertaking further audit as necessary

31-Mar-2015

Liz Minnich

Action 2 1 Re-audit annually to ensure clinical time is maximised 31-Mar-2015 Liz Minnich

Action 3 1 Review of skill-mix as vacancies occur or in line with service reconfiguration across the Trust

31-Mar-2015

Liz Minnich

Therapy & Therapeutics Division Speech & Language Therapy


2013.024 Actions

Are Speech and Language Therapy Dysphagia Recommendations Included on Immediate Discharge Letters?

Action 1 3 Discuss results of the audit with the named doctor (Dr F Thomson) 31-Mar-2014 Hannah Watterson

Action 2 1 Present the audit findings to Cancer & Clinical Support Health Group PESHR Meeting

30-Jun-2014

30

Family & Women’s Health Group


2013.175 Actions

Information Governance Audit - FWHG Action 1 2 Audit findings to be discussed at each of the speciality audit meetings and speciality governance meetings

31-May-2014

Tracey Milner

Action 2 2 Discuss audit findings at Senior Staff Meeting 31-May-2014

Mr Kevin Phillips; Mr Simon Tyrell

Action 3 2 Shared folders have been set up for each speciality however this needs embedding. All audit data to be stored within these folders and to be shared by all members of the project team including the Supervisor/Educational Supervisor

31-May-2014

Tracey Milner

Action 4 2 When project leads leave the speciality the audit project must be handed over and a new project lead established to ensure the project is completed

31-May-2014

Tracey Milner

Children, Ophthalmology & Dermatology Division Dermatology


2013.241 Actions

Effectiveness of Narrow Band UVB TL01 Phototherapy in Patients with Psoriasis

Action 1 Review current phototherapy pathway 31-Dec-2014

Dr Javed Mohungoo

2013.257 Actions

An Audit of the Appropriateness of 2 Week Wait Referrals at HRI for Suspected Skin Cancer

Action 1 3 Educational intervention - further education in primary care to increase confidence in diagnosis seborrhoeic keratoses

30-Sep-2014

Dr Christine Wong

Action 2 3 Re-audit - to include a search for appointment re-arrangements 30-Sep-2014

Dr Javed Mohungoo

Action 3 3 Submit abstract to RCGP Conference to raise awareness of the audit findings

30-Sep-2014

Dr Christine Wong

Action 4 3 Present the audit findings to HRI dermatology department 30-Sep-2014

Dr Javed Mohungoo

Children, Ophthalmology & Dermatology Division Neonates


2013.089 Actions

Thromboembolic Complication of Neonatal Umbilical Lines

Action 1

3

Discuss with Dr Horton about routine scans for babies with UACs to assess for thromboses

30-Nov-2013

Dr Joanna Preece

2013.090 Actions

Outcomes for Shoulder Dystocia Action 1 2 Midwifery to be asked to file a copy of of shoulder dystocia proforma completed by obstetric team in baby's notes.

01-Aug-2013

Dr Joanna Preece

31


Action 2 2 Discuss with obstetric team at resus group regarding sending 2222 bleep for neonatal team to attend shoulder dystocia deliveries (as per Trust Guidelines)

07-Aug-2013

Dr Joanna Preece

Action 3 2 Encourage neonatal team to examine all babies with shoulder dystocia at birth for signs of injury as soon as possible, and document this clearly in the baby's notes. Re-audit of this and documentation copied into baby notes.

31-Aug-2014

Dr Joanna Preece

Action 4 2 Neonatal common post-natal ward problems guidelines section for shoulder dystocia to be updated to include wording regarding examining patient and documenting this.

31-Aug-2013

Dr Joanna Preece

Action 5 3 Discuss with Physiotherapy and Orthopaedics about developing a local flow chart guidance for the management of brachial plexus injury secondary to shoulder dystocia.

30-Sep-2013

Dr Joanna Preece

2013.091 Actions

Admission Temperature Audit Action 1 3 If an infant is admitted hypothermic, then Doctors should record strategies taken to improve this on the Badger admission proforma

31-Mar-2015

Dr Hilary Klonin

Action 2

3

Clarify on the next audit the age of the baby at admission and who stabilised/resuscitated and the preceding measures taken to support

31-Mar-2015

Dr Joanna Preece

2013.092 Actions

Audit of Home Nasogastric Tube Feeding Programme Action 1 2 Report to NSG 31-Dec-2013

Dr Joanna Preece

2013.093 Actions

Infants Nursed on Neonatal Unit Beyond 44+6 Weeks Corrected Gestation - A Service Evaluation

Action 1 3 Add "approaching discharge" tickbox to neonatal grand round NHDU/SCBU proformas

28-Aug-2013

Dr Clare Magson

Action 2

3

Audit discharge procedure for these babies and transfer process to general paediatrics

28-Feb-2016

Dr Joanna Preece

2013.244 Actions

Audit of Transfers from NICU to Paediatrics for Ongoing Inpatient Care

Action 1 3 Re-audit in 1 year - Completion of transfer check list for all patient transfers - receiving team to verbally verify this prior to transfer

28-Feb-2016

Dr Peter Pairaudeau

Action 2 2 Discuss with ward clerk about printing transfer checklist on coloured paper so that it is easier to identify in the notes

31-Mar-2014

Dr Joanna Preece

Action 3 2 Formalise transfer of care operating policy 30-Jun-2014 Dr Joanna Preece

2013.247 Actions

Investigation and Management of Neonatal Sepsis Action 1 2 Introduce new gentamicin chart with room for clinical review and repeat CRP, reminders to check blood cultures, pre and post gentamicin level, chase the results & to stop antibiotics at 36hrs if the risk is low or antibiotic treatment proforma available to medical staff as well as nursing and midwifery team in neonatal unit and post natal ward respectively

30-Apr-2014

Dr Hilary Klonin

Action 2 1 Disseminate information about prevention of early onset sepsis guideline 31-Jan-2014 Dr Joanna Preece

32


to midwifery staff

Action 3 1 Re-audit 30-Dec-2016 Dr Joanna Preece

2013.248 Actions

High-Flow Oxygen and CPAP in the Neonatal Unit Action 1 3 Promotion of guideline including at junior doctors induction 31-Mar-2014 Dr Joanna Preece

Action 2 3 Laminated high flow weaning prompt cards covering weaning/indication 31-Mar-2014 Dr Joanna Preece

2013.254 Actions

Audit on Admission Documentation & NIPE Action 1 3 Include the audit results in new doctors induction pack and to review notes in March-July

31-Mar-2014

Dr Joanna Preece

2013.255 Actions

Clinical Audit on Chronic Lung Disease in Preterm Babies

Action 1 3 Discussion with Obstetric team about Antenatal steroids 31-Mar-2015 Dr Chris Wood

Action 2 3 Training to improve speed at delivery to ensure prophylactic surfactant was given early

31-Mar-2015

Dr Joanna Preece

Children, Ophthalmology & Dermatology Division Ophthalmology


2013.213 Actions

Vision Screening Audit Hull & East Riding Action 1 3 Implement opt-out consent procedure 01-Dec-2013

Dr Mohammed Aftab Maqsud

Action 2 3 Reduce OLS appointment waiting times 31-Mar-2014


Action 3 3 Patient satisfaction survey and re-audit 31-Mar-2014


2013.242 Actions

Quality Measures of the Management of Eye Disease Pathway

Action 1 1 Re-audit 2013-14 CVI Data 31-Oct-2014 Ms Helen Cook

Action 2 1 Review of Ophthalmology Failsafe processes including "Under the Care of Ophthalmology" failsafe trigger system already underway

28-Feb-2014

Nick Gregory

Children, Ophthalmology & Dermatology Division Paediatric Medicine


2013.079 Actions

FWHG Record Keeping Audit 1 Action 1 3 Keep notes in ring binders 15-Jan-2014 Dr Kylav Turnham

Action 2

3

Alter PASSU admission sheet and continuation sheet

15-Jan-2014

Dr Kylav Turnham

33


2013.094 Actions

Diarrhoea and Vomiting in Children under 5 Years Old Action 1 2 Update local guidelines for gastroenteritis in children 30-Nov-2013 Dr Amer Azaz

Action 2 2 Consultants to put into effect the implementation of guidelines 28-Feb-2015 Dr Amer Azaz

Action 3

2

Re-audit

30-Jun-2015

Dr Amer Azaz

2013.258 Actions

Use of Infliximab in the Treatment of Paediatric IBD Action 1 2 To give IBD information packs to patients and carers 31-Mar-2015 Dr Amer Azaz

Action 2 2 Pre-prepared information pack for patients who are suggested for treatment of Inflixmab

31-Mar-2015

Dr Amer Azaz

2013.280 Actions

Diagnosis of Asthma in Children 5 years and Under Action 1

2

Audit results to be presented to medical staff

30-Jun-2014

Dr Mary Barraclough

2013.289 Actions

Assessing the Diagnosis and Management of Urinary Tract Infection (UTI) in Children

Action 1

2

Increased awareness of the NICE Guidance (specially in terms of antibiotic use and imaging) by publishing user friendly version on intranet.

31-Aug-2014

Dr Vikas Gupta

2013.306 Actions

Audit of Referral of New Suspected/Diagnosed Cystic Fibrosis Patients From the Neonatal Unit to the Cystic Fibrosis Team

Action 1 2 Develop proforma for referral 31-May-2014

Dr Mary Barraclough

Action 2

3

Re-audit to be undertaken 2015/16

31-Mar-2015

Dr Mary Barraclough

Children, Ophthalmology & Dermatology Division Paediatric Surgery


2013.008 Actions

Paediatric Surgery - Patient Information and Consent Audit

Action 1 2 Twice a year teaching on consent within the department. 31-Aug-2014

Miss Sanja Besarovic

Action 2 2 Clarify what happens with pink form - look into standardising with Day Surgery Unit where form is given to patient by the nurses

31-Aug-2014


Action 3 2 Produce leaflets explaining common procedures for patients and families 31-Aug-2014


Action 4 2 Rework consent form to include statement of patient's right to refuse treatment as this is not clear on present form and causing confusion in data collection

28-Feb-2015


Action 5 2 Re-audit 28-Feb-2015


2013.097 Actions

Ward Attendees Audit: Are We Seeing Patients Appropriately

Action 1 3 Paediatric surgical team encouraged to schedule ward reviews for Friday morning

31-Dec-2013


34


Action 2 3 Paediatric surgical team to take responsibility for ensuring ward reviews are documented on patient centre

31-Dec-2013


Action 3 3 Ward clerk and nurses educated to record as doctor led consultations if seen by doctor rather than

31-Dec-2013


Action 4 2 Nurses to be trained to admit patients and book ward attendees on patient centre and given active log ins. Ideally there would always be a nurse on duty who was able to log patients onto the system on the ward rather than relying on a message being passed on for the ward clerk to catch up the next day. (All adult wards with Cayder boards rely on realtime recording of which patients are on the ward and this will need to be addressed when the paediatric wards introduce Cayder boards).

31-Dec-2014

Lesley Harrison

2013.098 Actions

Audit of Management and Outcomes in Congenital Oesophageal Anomalies

Action 1 2 Design leaflet with information on what to do when things happen. This leaflet should have a section for parents to fill so that they have ownership and can control the information they receive.

01-Aug-2014

Dr Alison Campbell

Action 2 2 Circulate leaflet to parent groups before getting approval 01-Oct-2014 Dr Alison Campbell

Action 3

1

Allocate nurse who will continue with training in surgical patients. Clear plan on discharge - who and when will continue to look after TOF patients

01-Aug-2014

Dr Alison Campbell

Children, Ophthalmology & Dermatology Division Safeguarding


2013.099 Actions

Retrieval & Safe Storage of Postnatal Care Plans Action 1 1 Re-audit January 2014 with revised proforma to provide assurance that the actions have addressed the issues/concerns raised in this initial audit

31-Jan-2015

Zoe Dale

Action 2 3 Cascade through by managers to staff through meetings. 30-Sep-2013 Zoe Dale

Action 3

3

Liaise with community office staff to review process and revise documentation

30-Sep-2013

Zoe Dale

Women's Services Division Breast Screening; Breast Surgery


2013.256 Partial Mammography Audit - Retrospective Analysis of Action 1 3 Make best practice guidance available at every screening location 01-Mar-2014 Helen Warren

35


Actions Documentation Action 2 3 Load correct software onto laptops used remotely 01-Mar-2014 Helen Warren

Women's Services Division Gynaecology


2013.021 Actions

Termination of Pregnancy Care Pathway Re-audit Action 1 Re-Audit 30-Sep-2014

Dr Kate Guthrie

2013.078 Actions

Communication of Diagnosis to GP Audit Action 1 3 Date in which the information was faxed to the GP - to inform all staff to print on forms

31-Dec-2013

Dr Marina Flynn

Action 2

3

To inform all staff to send a copy of the form to the MDT co-ordinator

31-Dec-2013

Dr Marina Flynn

2013.079 Actions

FWHG Record Keeping Audit 2 - Gynae Action 1 Checklist proforma to be discussed during induction 31-Mar-2015 Mrs Jane Allen

Action 2 Discuss at Senior staff meeting and email proforma with minutes. This information is to be disseminated amongst all junior medical staff for immediate action

31-Mar-2015

Mrs Jane Allen

2013.114 Actions

Management of Postmenopausal Bleeding Action 1 2 Consider introduction of hysteroscopic morcellator and to re-review the conversion rates if introduced.

31-Oct-2014

Mrs Jane Allen; Mr Kevin Phillips

Action 2 2 Assess if support required for consultant with higher conversion rate to GA 31-Oct-2014

Mrs Jane Allen; Mr Kevin Phillips

2013.200 Actions

Ovarian Mass RMI Audit Action 1

3

Document RMI and results of chest X-Ray in an obvious place in the medical notes

31-Mar-2015

Mr Theo Giannopoulos

2013.207 Actions

Management of Tubal Ectopic Pregnancy Action 1 To change clinical notes to have all results on one page 31-Aug-2014 Mr Frank Biervlet

Action 2 2 To re-audit in 2016 31-Aug-2016 Mr Frank Biervlet

2013.210 Actions

Audit of Local Anaesthetic Evacuation of Products of Conception

Action 1 2 To reduce the waiting time to <1week before LA ERPC is performed- more clinic slots

31-Mar-2015

Mr Frank Biervlet

Action 2 2 Re audit to complete the cycle 31-Mar-2015 Mr Frank Biervlet

2013.211 Actions

Management of Urinary Stress Incontinence Action 1 1 To present results in departmental meeting 30-Jun-2014 Mr Jagdish Gandhi

Action 2 1 To re-audit 31-May-2015 Mr Jagdish Gandhi

2013.243 Actions

Audit on Immediate Discharge Letters in Gynaecology Ward

Action 1 2 Email to all doctors in O&G about the importance of filling in all necessary fields

31-Dec-2014

Dr Kamalaveni Soundararajan

36


Action 2 2 To include IDL policy in junior doctors induction 31-Dec-2014 Mr Alex Oboh

Women's Services Division Obstetrics


2013.101 Actions

Caesarean Section Grade 1 LSCS Audit Action 1 2 Results disseminated at Labour Ward Forum 30-Apr-2014 Helen Dent

Action 2 1 Continue with quarterly audit 31-Mar-2014 Helen Dent

2013.102 Actions

Induction of Labour Action 1 2 Monitor the introduction of out-patient IOL (when it is introduced) via audit and patient satisfaction questionnaire. Continue with audit in patient IOL.

31-Mar-2015

Karen Thompson

Action 2 2 Explore ways of encouraging adherence to recording maternal observations and for improving planning for failure e.g. look at change management strategies, 'reminder' tools etc

31-Mar-2015

Karen Thompson

2013.103 Actions

Severe Pre-eclampsia (including Eclampsia) (Annual) Action 1 1 Continue to audit all identified cases through MDT and address individuals where appropriate as part of the feedback

31-Mar-2014

Sue Sallis

Action 2 1 Highlight the guideline through YMET training 31-Mar-2014 Sue Sallis

Action 3 1 Feedback given to individuals as part of MDT process & general learning themes included in LWP newsletter

31-Mar-2014

Sue Sallis

2013.104 Actions

Post Partum Haemorrhage Action 1 1 Continue audit through MDT meetings 31-Mar-2014 Sue Sallis

Action 2 1 Educate staff regarding new Massive Haemorrhage Protocol 10-Dec-2013 Sue Sallis

Action 3 1 Address with individuals where fluid balance has not been appropriately completed via feedback from MDT case

31-Mar-2014

Sue Sallis

2013.106 Actions

Missed Appointments (Annual) Action 1 3 Discuss with AN Managers and Clerical Officers to enable copies of correspondence to GP and Women if non attending for booking.

31-Oct-2013

Kath Hodgson; Sallie Ward

Action 2 3 Re-audit August 2014 31-Aug-2014

Kath Hodgson; Sallie Ward

2013.107 Actions

Antenatal Clinic Risk Assessment Action 1 1 Agenda issues with ante-natal checklist for next Community Meeting 30-Sep-2013 Kath Hodgson

Action 2 1 Re audit monthly three sets of notes 31-Jul-2013 Kath Hodgson

Action 3 1 To support development of new hand held notes to be completed in a timely manner

31-Dec-2015

Jill Harrison

37


2013.108 Actions

Patient Information and Discussion (Annual) Action 1 3 To discuss results at next unit meeting and managers meeting 31-Jan-2014

Kath Hodgson; Tricia Trevor

Action 2 3 To email areas of results 31-Oct-2013


Action 3 3 Re-audit August 2014 31-Aug-2014


2013.109 Actions

Perinatal Mental Health Action 1 1 Information to be cascaded via the managers meeting, community midwives meeting - e-mail to midwives

31-Mar-2014

Zoe Dale

Action 2 1 Information to be shared at audit meeting 30-Apr-2014 Zoe Dale

2013.110 Actions

Handover of Care Action 1 2 To raise staff awareness 31-Jan-2014

Kath Hodgson; Sue Sallis

Action 2 3 To review current documentation to ensure compliance 31-Mar-2014


Action 3 1 To re-audit October 2014 31-Oct-2014


2013.111 Actions

Maternal Transfer by Ambulance Action 1 1 Circulate findings to community and L&D midwives 28-Apr-2014


2013.112 Actions

Antenatal Screening Tests in Pregnancy (Annual) Action 1 2 To monitor review of ID results within 10 working days through monthly SoM record keeping audit

31-May-2015

Jane McFarlane

Action 2 2 To raise awareness with midwives in community and antenatal clinic regarding documentation of normal results being reported back to women at the next antenatal appointment.

31-May-2015

Jane McFarlane

Action 3 1 To raise awareness with midwives regarding women who it has not been possible to obtain scan information for 1st Trimester Combined Screening (if consented) to offer an appointment for quadruple test if this has not been arranged) and if this is then declined to document this in maternity records

31-May-2015

Jane McFarlane

Action 4 2 To raise awareness with midwives around documentation of reporting rubella antibody negative results to women and their GP and postnatal information to the GP re MMR vaccine

31-May-2015

Jane McFarlane

2013.116 Actions

Anaesthetic Staffing Audit Action 1

1

disseminate to interested parties

31-Oct-2013

Dr Joanne Goring-Morris

2013.117 Actions

Delays to the ELCS List Action 1 1 Ensure relevant clinical leads are aware of findings 31-Oct-2013

Dr Joanne Goring-Morris

Action 2

1

Present at Labour Ward Forum

30-Oct-2013

Mrs Reeta Jha

38


2013.215 Actions

Record Keeping Monthly Spot Checks Action 1 3 Review / refine audit tool for 2014 audit to address areas of concern from annual audit

31-Jan-2014

Sue Cooper

Action 2 2 Standard for good practice raised to 80% for 2014 audit in line with Trust standard

28-Dec-2014

Sue Cooper

Action 3 1 Individual standards highlighted in action plan, to continue mandatory training of record keeping for 2014

31-Dec-2014

Sue Cooper

2013.216 Actions

Record Keeping Audit Local Supervising Authority Supervisors of Midwives

Action 1 3 Review / refine audit tool for 2014 audit to address areas of concern 31-Mar-2015 Sue Cooper

Action 2 Areas requiring improvement highlighted in action plan, to continue mandatory training of record keeping for 2014

31-Mar-2015

Sue Cooper

2013.217 Actions

Fetal Blood Sampling (Annual) Action 1 2 To disseminate results to staff 31-Jan-2014 Julia Chambers

Action 2 2 Educate medical staff around ensuring documented plan of care 31-Jan-2014 Julia Chambers

2013.219 Actions

The Use of Oxytocin in Labour Action 1 3 To obtain instruction from the consultant obstetrician to commence syntocinon for multi-gravidae and to document in the labour record.

31-Oct-2014

Mrs Reeta Jha

Action 2 3 To clearly document in the labour record when oxytocin is to be stopped 31-Oct-2014 Mrs Reeta Jha

Action 3 3 To re-audit in 2015/16 31-Mar-2016 Mrs Reeta Jha

2013.220 Actions

High Dependency Care Action 1 1 Continue audit through MDT meetings 31-Mar-2015 Sue Sallis

Action 2 2 Address with individuals where fluid balance has not been appropriately completed via feedback from MDT case reviews

28-Feb-2014

Sue Sallis

2013.221 Actions

Vaginal Birth After Caesarean Section Action 1 2 Raise the profile of use of VBAC sticker 30-Apr-2014 Julia Chambers

Action 2 2 Medical staff to look at the sticker and change if required 31-Jul-2014 Julia Chambers

Action 3 2 Re-audit 2014/15 to ensure improvement in compliance 30-Mar-2015 Julia Chambers

2013.222 Actions

Operative Vaginal Delivery Action 1 1 Continue to audit all identified cases through MDT & address individuals where appropriate as part of the feedback

31-Mar-2015

Julia Chambers

Action 2 1 Feedback results through Labour Ward Practitioners Newsletter 31-Mar-2014 Julia Chambers

2013.225 Actions

Perineal Trauma (Midwifery) Action 1 1 Education of staff regarding importance of documentation of consent, swab/sharp checking and advice - highlight at MDT Meeting

30-Jun-2014

Catharine Atkinson; Joanna House

Action 2 1 Education of staff regarding what advice should be given to women post-delivery with regard to perineal care reference patient information leaflet

30-Jun-2014


39


Action 3 1 Education of staff of the importance of appropriate pain relief for women post delivery

30-Jun-2014


Action 4 2 Review of paperwork in use to support staff in documentation completion 31-Jul-2014


2013.227 Actions

Shoulder Dystocia Action 1 1 Continue audit through MDT meetings, individuals addressed through feedback from these meetings

31-Mar-2014

Julia Chambers

Action 2 2 Feedback given to staff through MDT processes & proformas completed 31-Mar-2014 Julia Chambers

Action 3 1 Importance of completion of proforma & cord gases through yearly Obstetrics Emergencies training

31-Mar-2014

Julia Chambers

Action 4 1 General learning points disseminated to staff through LWF Newsletter and ward 'bubbles'

31-Mar-2014

Julia Chambers

2013.228 Actions

Venous Thromboembolism - Risk Assessment and Prophylaxis

Action 1 1 To finalise the maternity specific risk assessment form within the new drug cards

30-Apr-2014

Julia Chambers

Action 2 2 To educate all staff in maternity services surrounding the completion of VTE risk assessment documentation

30-Apr-2014

Julia Chambers

2013.229 Actions

Pre-Existing Diabetes Action 1 To introduce new diabetic specific documentation for the obstetric notes 31-Mar-2015

Action 2

To re-audit post introduction for new documentation

31-Mar-2015

Mrs Shaeda Azeez

2013.230 Actions

Obesity in Pregnancy Action 1 3 Raise profile of importance of healthy lifestyle in pregnancy particularly for women with BMI 30 - 34.9

31-Mar-2015

Fiona Robinson

Action 2 2 If large BP cuff used seldom recorded – a need to address whether large cuffs are available

31-Mar-2015

Fiona Robinson

Action 3 2 VTE is currently audited therefore does not need to be included in Obesity audit in future. The guideline is based around CNST recommendations which are no longer in existence therefore the guideline requires amendment

01-Jun-2014

Fiona Robinson

2013.231 Actions

Non-Obstetric Maternity Care (Annual) Action 1 1 E-mail managers to discuss and action in area 31-Dec-2013 Kath Hodgson

Action 2

1

Re-audit in 2015/16

31-Mar-2016


2013.232 Actions

Referral When Fetal Abnormality Detected (Annual) Action 1 2 Review role of Fetal abnormality MDT 30-Jun-2014

Mrs Reeta Jha; Jane McFarlane

Action 2 2 Explore reasons why women are not supported by a midwife following initial diagnosis and confirmatory diagnosis

31-May-2014

Jane McFarlane

40


Action 3 2 Prospectively audit action 2 for three months starting May 2014 30-Sep-2014 Jane McFarlane

2013.233 Actions

Newborn Life Support - Documentation to Evidence Resuscitation Equipment is Checked, Stocked and Fit For Use (Annual)

Action 1 1 Presentation of report at LWF 14-Nov-2013

Julia Chambers; Sue Sallis

Action 2 1 Reminder in LWP Newsletter re completion of the checklists on Labour & Delivery suite

05-Nov-2013


Action 3 1 MA’s to be highlighted on off duty for theatre checks on a daily basis to try and increase compliance with Resuscitaire Checks

14-Nov-2013


2013.237 Actions

Recovery Action 1 1 Circulate findings to Maternity Managers, for dissemination to ward staff 31-May-2014 Sue Sallis

Action 2 1 Inform Labour Ward staff of short falls in documentation and areas where improvements have been made.

31-May-2014

Sue Sallis

2013.238 Actions

Support for Parents Action 1 To highlight at the labour ward team meetings to document the discussion of support groups in the woman’s care plan

30-Jun-2014

Angie Rymer

Action 2 To highlight at NNU meetings the importance of documenting leaflets and support groups have been discussed and what has been provided

30-Jun-2014

Valerie Christian

Action 3

To highlight at labour ward team meetings the documentation of language support needs and the support provided

30-Jun-2014

Angie Rymer

2013.273 Actions

Audit of Bereavement Checklist used on Labour Ward Action 1 1 Circulate findings to L&D Manager/Co-ordinators/Midwives and rotational staff

30-May-2014

Sue Sallis

Action 2 1 Redesign the front cover of the checklist 30-Apr-2014 Sue Sallis

Action 3 1 Email the staff with the findings and action plan 30-Apr-2014 Sue Sallis

2013.293 Actions

Intrapartum Assessment of Fetal Wellbeing in Labour Action 1 Share findings with Labour Ward Practitioners for consideration in the mandatory training

30-Sep-2014


2013.294 Actions

Use of Antenatal Corticosteroid in Preterm Delivery Action 1 1 Change Trust Management of Preterm Labour Guideline to reflect that steroids are to be given up to 34+6 weeks gestation

31-Mar-2015

Mrs Reeta Jha

Action 2 1 Neonatologist to ask for help from labour ward practitioners when maternal records show no administration of steroid

31-Mar-2015

Mrs Reeta Jha

Action 3 1 Re-Audit during 2015/16 31-Dec-2015 Mrs Reeta Jha

41

Medicine Health Group


2013.050 Actions

VTE Policy and VTE Guideline Audit - MHG Action 1 3 Lack of robust process for flagging lack of electronic VTE risk assessments within General Medicine All wards are given access to the Daily VTE file which is reviewed daily

31-Jul-2013

James Hutton

Action 2 3 Lack of robust process for flagging lack of electronic VTE risk assessments within Specialist Medicine All wards are given access to the Daily VTE file which is reviewed daily

31-Jul-2013

James Hutton

Action 3 3 Lack of validation process for electronic VTE compliance Monthly validation exercise undertaken across the HG to validate electronic VTE compliance

31-Jul-2013

Diane Holden

Action 4 3 Lack of robust method to target problem/underperforming wards Monthly performance metrics (down to patient level) are discussed at Speciality Business Teams

31-Aug-2013

James Hutton

2013.175 Actions

Information Governance Audit - Medicine Health Group Action 1

3

To ensure that all staff state that their IG training is current on the CG1 form, prior to sign off, by raising awareness with Governance and Audit leads.

01-Jun-2014

James Hutton

Emergency Medicine Division AAU


2013.002 Actions

Management of Suspected Pulmonary Embolism in AAU

Action 1 3 Staff education and training in regards to the management of PE. 31-Mar-2015 Dr Ed Middleton

Action 2 3 Use of wells score for patients suspected to have PE, mandatory and appropriate use of D-Dimers.

31-Mar-2015

Dr Ed Middleton

Action 3 3 Wells score must be mentioned on the CTPA request. 31-Mar-2015 Dr Ed Middleton

Action 4 3 Use of PESI score ambulatory exclusion criteria to identify patients suitable for ambulatory management.

31-Mar-2015

Dr Ed Middleton

Action 5 3 Better documentation of time of clerking. 31-Mar-2015 Dr Ed Middleton

Action 6 3 Investigation of unprovoked VTE. 31-Mar-2015 Dr Ed Middleton

Action 7 3 Re-audit in next 6 months. 31-Mar-2015 Dr Ed Middleton

2013.003 Actions

Antibiotic Prescribing in Hull Royal Infirmary Acute Assessment Unit (AAU)

Action 1 2 Education of junior doctors through induction and consultant leadership on AAU for recommendations 1, 2 and 4.

30-Sep-2013

Dr Ed Middleton

42


Action 2 3 Reinforce recommendations 1 and 4 in antibiotic prescribing section of AAU induction document.

30-Jun-2013

Dr Ed Middleton

Action 3 2 To liaise with ID/microbiology re: recommendation 3 and disseminate next edition of trust antibiotic guidelines once produced.

30-Sep-2013

Dr Ed Middleton; Dr Emma Williamson

Action 4 3 Provide stamp for all acute consultants, registrars and junior doctors. 30-Sep-2013 Dr Ed Middleton

Action 5 2 Present audit findings to acute medicine clinical governance meeting. 30-Jun-2013 Dr Mukesh Thakur

2013.156 Actions

Medical Ambulatory Care Audit Action 1 2 It has been agreed at the Acute Medicine Clinical Governance meeting that the MAC will remain functional between 09:00 - 20:30 only. Thereafter it will be a waiting area not suitable for patients with clinical needs, unless staffed appropriately.

31-Mar-2015

Dr Mukesh Thakur

Emergency Medicine Division Emergency Department


2013.159 Actions

Pneumonia Bundle in Emergency Department Action 1 3 Staff training to be carried out regularly to coincide with staff rotations. 31-Mar-2015 Dr Ben Rayner

Action 2 3 CURB scores are to be recorded on patient records in the Emergency Department.

31-Mar-2015

Dr Ben Rayner

General Medicine Division Chest Medicine


2013.118 Actions

Characterisation and Evaluation of the Management of COPD Patients Admitted to HEYHT between May 2012 and May 2013

Action 1 3 Re-audit COPD prescribing practices following the pathway redesign. 31-Mar-2015

Dr Michael Crooks

General Medicine Division Diabetes & Endocrinology


2013.029 Actions

Inpatient Antibiotics Prescription Action 1 1 Communicate the results to wards 31-Aug-2013 Dr Alain Al Helou

Action 2 1 Communicate findings to pharmacy 31-Aug-2013 Dr Alain Al Helou

43


2013.166 Actions

REAUDIT Accuracy of RadCentre Data Entry for Bone Density (DXA) Scans

Action 1

3

Undertake a re-audit.

31-Mar-2015

Ann Goodby

General Medicine Division Elderly Medicine


2013.033 Actions

Audit of Standards of Completion of Do Not Attempt Cardiopulmonary Resuscitation (DNA CPR) Forms on Elderly Medical Wards at Castle Hill Hospital

Action 1 3 To include information regarding discussions with next of kin and documentation at junior doctors induction meeting.

31-Mar-2015

Dr Alan Farnsworth

2013.034 Actions

Adherence to Trust Antibiotic Prescribing Policy Action 1 3 Re-audit after another presentation to the current set of doctors 30-Nov-2013

Dr Manoj Saraswat

2013.035 Actions

Drug Prescription Errors Action 1 1 Presentation to Grand Round and to DME juniors. 31-Mar-2015 Kirsten Richards

Action 2 1 Ongoing longterm audit cycle. 31-Mar-2015 Kirsten Richards

General Medicine Division Renal


2013.008 Actions

Nephrology/Renal - Patient Information and Consent Audit

Action 1 1 To add advice to the Specialist Registrar induction. 01-Sep-2014

Dr Matthew Edey

2013.036 Actions

Measurements of Folate Levels in Dialysis Patients Action 1 1 Review of Haemodialysis Protocols 31-Aug-2013 Dr Matthew Edey

Action 2 2 Re-Audit in 12-18 months 31-Aug-2014 Dr Matthew Edey

2013.037 Actions

Epidemiology of Haemodialysis Central Venous Catheter Infections

Action 1 2 To develop a strategy to reduce Catheter Related Blood Stream Infections (CRBSI).

01-Apr-2015

Dr Martin Chanayireh; Dr Muhammad Imran

Action 2 1 To improve blood sampling technique from a dialysis catheter. 31-Dec-2014 Jacqueline Limon

Action 3 3 To develop a dialysis catheter surveillance tool. 01-Apr-2015

Dr Martin Chanayireh

2013.038 Actions

Management of Acute Kidney Injury: The Impact of Automated Alerts in Improving Quality of Care as Defined in the NCEPOD 2009 recommendations

Action 1 2 The AKI eAlert system, which automatically alerts the clinical team about the possibility of AKI in a patient based on changes in serum creatinine will be implemented to all clinical areas of the hospital.

31-Mar-2015

Action 2 2 The renal department has developed AKI management pathway. 31-Mar-2015 Dr Sarah Naudeer

44


Action 3 3 Re-audit the implemented changes. 31-Mar-2015 Dr Adil Hazara

2013.168 Actions

Recording of Transplant Status in Notes of New RRT Patients

Action 1 1 Feed back to department. Encourage efforts to commence work-up earlier 31-Dec-2013 Dr Helen Ford

Action 2 1 Establish standardised criteria for pre-emptive listing 31-Dec-2013 Dr Matthew Edey

Action 3 1 Re-audit 31-Jan-2015 Dr Matthew Edey

2013.169 Actions

Vascular Access - Patients Commencing HD via Catheters

Action 1 1 Re-audit in 2014. 01-Feb-2015 Dr Matthew Edey

Action 2 1 Continue efforts to improve definitive access rates via "Pioneer Team". 31-Mar-2015 Dr Matthew Edey

2013.170 Actions

Rate of CMV Viraemia in Post Transplant Patients - 2011 Cohort

Action 1 1 Re-audit early 2014 31-Mar-2014 Dr Matthew Edey

Action 2 1 Review of CMV Policy 31-Dec-2014 Dr Matthew Edey

2013.171 Actions

Use of Northern Risk Score in Transplant Work-up Action 1 1 Disseminate use of regional database/risk tool. 31-Mar-2015

Dr Matthew Edey

2013.172 Actions

Availability of Renal Patient View Action 1 2 Re-issue usernames and passwords to those who have lost these details. 31-Aug-2014 Dr Adil Hazara

Action 2 3 Distribute leaflets and posters around the department promoting the renal patient view program.

31-Aug-2014

Dr Adil Hazara

Action 3 3 Re-audit in one year. 30-Nov-2014 Dr Adil Hazara

2013.252 Actions

Cincalcet Audit 2013 Action 1

3

Good documentation and aim to follow guidance particularly dose increments and stopping the drug

30-Sep-2014

Dr Muhammad Imran

2013.304 Actions

Aluminium as Phosphate Binder Action 1 3 All patients who are on alucaps should have aluminium levels monitored 3 monthly

30-Sep-2014

Dr Muhammad Imran

Action 2

3

Staff awareness about prescription / monitoring of aluminium

30-Oct-2013

Dr Muhammad Imran

General Medicine Division Rheumatology


2013.043 Actions

Audit Assessing Compliance with Criteria Needed for Achieving Best Practice Tariff Diagnosis and

Action 1

2

Design a database to capture patient details

31-Mar-2015

Dr Sathish Kallankara

45


Management of Inflammatory Arthritis

2013.044 Actions

Assessment of the compliance with Hull & East Yorkshire Hospitals NHS Trust Drug Policy with regards to correct drug prescription in the Medical Short Stay Ward

Action 1 3 Build awareness in junior doctors 31-Dec-2013

Dr Mohamed El-Sayed

Specialist Medicine Division Cardiology


2013.007 Actions

Cardiology - Cardiothoracic MDT Audit Report Action 1 3 Ensure attendance at MDT: contact relevant parties. 31-Mar-2015

Dr Thanjavur Bragadeesh

2013.008 Actions

Cardiology - Patient Information and Consent Audit Action 1 2 To ensure doctors and nurses have up to date information on how to consent patients.

31-Mar-2015

Dr Michael Cunnington

Action 2 3 Consider the development of a specific form for common procedures i.e angiogram, proceed and pacemakers.

31-Mar-2015


Action 3 3 Consider inclusion of additional sections on consent forms for discussion with patients regarding alternative treatments, and statement whether pink form has been offered.

31-Mar-2015


Action 4 3 Ensure additional information is available and that health professionals know where to find it.

31-Mar-2015


46

Surgery Health Group


2013.079 Actions

Record Keeping Surgery Action 1 To disseminate results to all clinical leads 31-Mar-2015

Dr Ahmed Saleh

Cardio/Vascular & Critical Care Division Cardiothoracic Surgery


2013.008 Actions

Cardiothoracic Surgery - Patient Information and Consent

Action 1 1 Cardiothoracic Speciality to establish delegated consent register. 31-Mar-2015

Mr Mubarak Chaudhry

Cardio/Vascular & Critical Care Division; Theatres Division Critical Care (ICU & HDU)


2013.250 Actions

Audit to Assess Treatment of Acute Kidney Injury in a Critical Care Setting

Action 1 Business case for Citrate anticoagulation to be developed 31-Mar-2015 Dr Mohsan Mallick

Action 2 Enhanced teaching on AKI to be undertaken 31-Mar-2015 Dr Mohsan Mallick

Digestive Diseases Division Colorectal Surgery


2013.141 Actions

Role of Early Diagnostic Laparoscopy in the Management of Lower Abdominal Pain in Female Patients

Action 1 3 Ensure careful selection of patients requiring USS. 31-Mar-2015

Action 2 3 Consider early laparoscopy for carefully selected patients 31-Mar-2015

2013.142 Actions

An Audit of the Incidence and Resource Implications of Perineal Hernias Post AP Resection

Action 1 2 To add perineal hernia to the complications mentioned in the consenting process for APER/ELAPE

31-Mar-2015

Action 2 2 To add perineal reconstruction as a further procedure during the consenting process for APER/ELAPE

31-Mar-2015

Action 3 2 Pre-operative involvement of a plastic surgeon for patients undergoing ELAPE who may require a myocutaneous flap.

31-Mar-2015

47

Specialist Surgery Division Head & Neck Max Fax


2013.149 Actions

Maxillofacial SHO Knowledge and Management of Dental Trauma in HRI A&E

Action 1 1 Training of staff. 31-Mar-2015

Mr Suresh Nayar

Theatres Division Anaesthetics (Inpatient)


2013.151 Actions

Cardiothoracic theatre start times Action 1 1 To start a cardiac recovery unit to facilitate flow of cardiac surgical patients through the critical care unit

31-Mar-2015

Action 2 1 To improve decision making and communication between GICU1 and theatres

31-Mar-2015

Action 3 2 Ensure adequate staff numbers in GICU1 31-Mar-2015

Action 4 Make arrangements to fetch patients from wards 15 minutes before the scheduled theatre start times

31-Mar-2015

Action 5 2 Ensure patients are booked evenly during the week in the GICU1 31-Mar-2015

Mr Mubarak Chaudhry

2013.153 Actions

The Rate of Dural Puncture after Epidural Insertion on the Labour Ward

Action 1 3 Review departmental guidelines 31-Mar-2015

Action 2 Re-audit 31-Mar-2015

2013.239 Actions

Technique of Anaesthesia for Caesarean Section Action 1 3 Re-audit to look into why increased number of failed spinals. 30-Dec-2016

Dr Makani Purva

Trauma Division Neurosurgery


2013.325 Actions

RE-AUDIT Repatriation of Neurosurgical Patients Action 1 Raise the issue identified with senior management. 31-Mar-2015 Mr George Spink

Action 2 Raise the issue of the possible addition to the risk register. 31-Mar-2015 Mr George Spink

48

Trauma Division Plastic Surgery


2013.138 Actions

Excision Margins of Cutaneous Squamous Cell Carcinoma of the Scalp

Action 1 3 Present findings at audit meeting 31-Mar-2015 Mr Paolo Matteucci

Action 2 3 Add session on SCC excision margins to next regional teaching session. 31-Mar-2015 Mr Paolo Matteucci

2013.139 Actions

Use of MRA in Breast Reconstruction with Free Abdominal Tissue Transfer

Action 1 3 Re-audit 31-Mar-2015

Mr Paolo Matteucci

Action Status

Cancelled

Overdue

Check Progress

In Progress

Completed

49

APPENDIX III

Progress of the actions identified as a result of national clinical audits completed in 2013/14

An update regarding the implementation of the actions identified as a result of a national clinical audit report published in 2013/14 has been provided below. Actions taken in response to reports published in 2014/15 will be included in the Quality Accounts for 2015/16.

Audit Proposed actions Progress

National audit

Neonatal intensive and special care (National Neonatal Audit Programme ‐ NNAP)

To revise the Trust antenatal steroid policy

(as part of Clinical Guideline 133) to comply

with national guidance

To train neonatal junior staff at induction

onto Neonatal Unit (and subsequent

monitoring of practice) regarding recording

of data items in BadgerNet database

To develop and implement a system for

capturing and recording of 2 year outcome

data obtained at outpatient follow up of

babies born at <30 weeks gestation in

BadgerNet database

To audit ‘missed’ antenatal steroid cases

identified to determine accuracy and

reasons for missed opportunities

The policy has been revised and is

available on the Trust intranet site

The training of neonatal junior staff

has been completed

A system is currently being set up

to capture this data in clinic at the

time children attend, with a review

of data accuracy every January to

ensure all cases have been

included.

The audit has been completed. The

results showed that the Trust was

100% with its guideline, however

the standards differed from

national guidance. The Trust

guideline has since been amended

to reflect the change in national

guidance and will be audited in

2015/16.

Chronic pain (National Pain Audit)

To ensure full participation in future

national audits.

To review patient questionnaire at first

appointment.

The Trust is participating in this

national audit.

The questionnaire has been

reviewed.

Lung cancer (National Lung Cancer Audit)

To undertake a service review based around

the histological diagnosis and CT before

bronchoscopy results.

A service review has been

undertaken which identified two

separate issues relating to CT

waiting times and perceived low

histology results

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To undertake an investigation into the lung

biopsies and lung cancer not otherwise

specified results.

To discuss with colleagues the availability of

nurse specialists at appropriate clinics.

Paediatric Fever (College of Emergency Medicine)

To increase the awareness of blood pressure

measurements within the nursing team.

To include the College of Emergency

Medicine standards within the training of

new staff members.

The nursing staff are aware of the

need to record blood pressure in

children with abnormal pulse or cap

refill

This is undertaken as part of the

induction of new staff

National dementia audit (NAD)

To establish a Dementia care Lead in

Clinician, Nursing and Managerial teams.

To work in partnership with the Education

team and the Dementia Academy to design a

training package for HEYHT.

To deliver basic dementia awareness training

to all staff working with older people.

To deliver higher dementia training to all

Dementia Champions.

To develop a Dementia program board with

representation from all key partners.

To ensure HEYHT is represented at local,

regional and national networks.

To implement a monthly dementia carer

survey at HEYHT.

To develop a Dementia screening tool for all

patients admitted to our organisation.

To audit the screening tool to ensure

improvements in patient care.

A Dementia Programme Board has

been established including a

Consultant representative, nurse

and managerial representative

Training package has been designed

and implemented

Dementia awareness training

currently being delivered

Training is being delivered to all

dementia link nurses

A Dementia Programme Board with

key representation has been

established

Consultant representation at all

levels

A survey has been implemented a

leaflet developed for carers

A screening tool has been

developed and implemented

The screening tool has been audited

which has showed that it has

improved identification, assessment

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To develop a web‐based patient tracker tool

to assist in patient placement and

assessment.

To implement the “Butterfly Scheme” trust

wide.

To appoint Dementia Champions in all clinical

and non‐clinical team.

To reduce the use of antipsychotics in the

management of behavioural and

psychological symptoms of dementia

To use Dementia Mapping in our wards to

understand delivery of care from the

patient’s perspective.

To develop Trust guidance on the

management of Delirium.

To introduce Digital Reminiscence Therapy

for patients in HEYHT.

To develop a Dementia Dashboard to report

on healthcare outcomes for patients with

Dementia.

To refurbish ward environments to enhance

the healing environment for people with

dementia.

and referral of patients with

cognitive impairment

The patient tracker tool has been

implemented and is used on a daily

basis to assist in patient placement

and assessment

The Butterfly Scheme, which is a

way of providing reassurance that

the patient’s memory problems will

be taken into account when

planning care, has been

implemented throughout the Trust

Small teams of champions have

been appointed on each ward and

attend regular link nurse meetings

A regional audit has shown that the

Trust is the lowest prescriber of

antipsychotics in the region

The dementia academy and the

Trust have been looking at different

ways of mapping to see which will

be the most appropriate to use.

Several wards will be mapped

during the next few months.

A Delirium policy has been written

and approved.

Digital Reminiscence Therapy has

been introduced

A series of key performance

indicators have been developed

Money has been obtained to

refurbish the ward environments. A

programme of refurbishment will

take place during 2015.

Cardiac arrhythmia (CRM)

To improve the education received by junior

doctors within the Acute Assessment Unit for

this condition.

This will take place when there is

Consultant cardiology presence on

the Acute Assessment Unit

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To increase the presence of cardiology

physicians on the Acute Assessment Unit

(expected late 2015)

Acute Myocardial Infarction and other Acute Coronary Syndrome (Myocardial Ischaemia National Audit Project ‐ MINAP)

To hold bi‐monthly meetings to review

compliance with targets

To meet the clinical leads from the

emergency departments of referring

hospitals regarding the timely transfer of

patients

To undertake an ongoing audit of pre‐alert

acceptance rates against criteria

To review the training needs of paramedic

ambulance providers.

Bi‐monthly meetings are now held

where targets are reviewed

Various meetings have been

planned however, due to clinical

pressures, this piece of work hasn’t

progressed

The audit has been completed and

outcomes reported. The pre‐alert

form has been amended. An audit is

to be conducted in the future to

assess the effectiveness of the new

form

Training needs of paramedic

ambulance providers has been

conducted. The training has now

been provided

Heart failure (Heart Failure Audit)

To increase the availability of specialist heart

failure cover for Hull Royal Infirmary

Have NHS rather than academic heart failure

service

To recruit to the heart failure nurse post

To configure an inpatient heart failure service

with specialist nurse and consultant cover

An NHS Consultant specialising in

heart failure has been appointed

An additional heart failure nurse has

been appointed

Diabetes (Royal College of Paediatrics and Child Health ‐ RCPCH National Paediatric Diabetes Audit)

To aim to reduce mean HbA1C by 0.5% with

measures such as intensive insulin regimen,

more frequent follow up and psychology

input as indicated

Achieved

(evidence in publication of report in October 2014)

NADIA To increase the frequency of foot risk

assessments undertaken during inpatient

episodes

To ensure patients admitted with foot

disease are seen by the multi‐disciplinary

The latest audit report (published in

2013) shows that 83.2% of patients

received a diabetic foot risk

assessment during their admission,

increasing from 30.4% in 2012

The latest audit report (published in

2013) shows that 68.8% of patients

admitted with foot disease were

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team within 24 hours

To reduce the number of insulin errors

To increase the awareness of diabetes

through an e‐learning package

seen by the multidisciplinary

diabetic foot team (MDT),

increasing from 58.8% in 2012

An article for METRIC (the Trust's

research journal) highlighting the

number of insulin errors has been

published and an IV insulin chart is

to be produced

An article on the e‐learning package

is due to be published in METRIC

(the Trust research and education

journal) in May 2015.

National cardiac arrest audit (NCCA)

To write ceilings of care for all acute

admissions with altered NEWS

To improve documentation for advanced

care planning in the Trust

To review the resuscitation policy

The Chief Medical Officer has sent

an e‐mail to all Consultants

reminding them to write ceilings of

care. A pilot process for

documenting ceilings of care is

currently being piloted in the

Queen’s Centre. Audit of ceilings of

care to be undertaken during

2015/16.

An end of life flow chart has been

developed and implemented

Resuscitation policy has been

reviewed and updated.

Fractured neck of femur (College of Emergency Medicine)

Information from the report will be used to

feed into new working practices in new

Emergency Department eg. Controlled drugs

available at interventional triage

New emergency care record to have pain

scoring

The audit results have been used in

the design of the new emergency

department with lead lined rooms

adjacent to initial assessment to

reduce the delay in diagnosis as

patients no longer need to be

transferred outside of the

department for Xray. Analgesia is

available within initial assessment,

including local nerve block

The new emergency care record

includes a pain score

Adult asthma (British Thoracic Society)

To undertake an inhaler technique review The review has commenced and is

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and an educational audit in healthcare

professionals to be started in the new

financial year.

To promote the importance of Peak Flow

monitoring.

To increase the awareness of smoking

cessation services in asthmatics.

due to be completed within the next

2 months.

These actions are complete. The

ARAS team and Respiratory Nurse

team are continuously promoting

the importance of peak flow

monitoring and raising awareness of

smoking cessation services.

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Documents

HULL AND EAST YORKSHIRE HOSPITALS NHS … HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST Clinical Audit and Effectiveness Annual Report 2014 / 15 1. Introduction The Clinical Audit and