CLINICAL GOVERNANCE & RISK MANAGEMENT PERFORMANCE REPORT
Report by Dr Lesley Anne Smith, Head of Clinical Governance & Risk Management
The Board is asked to note:· Performance against Complaints targets.
· Performance in relation to Patient Safety.
· Embedding Clinical Governance and Risk Management across the Operating Units.
1. COMPLAINTS
1.1 General
The complaints team have developed checklists to assist Investigating Officers deal with complaints. One checklist provides information on how to carry out a complaints investigation while the other gives guidance on how to prepare a response.
ISD introduced a prototype complaints database in mid March 2008, which is available to any health board in Scotland to manage complaints received by the board. The database includes the recently updated ISD Complaints Dataset which defines how we report complaints to meet with the requirements of the modern NHS in Scotland. The dataset for example includes how we define and record the issues and the staff involved in complaints in a standard way.
The NHS Highland Complaints Team has been involved since March in the testing of this database with ISD in Edinburgh, and has made a major contribution to the further development of the ISD complaints database as a practical tool. NHS Highland will be the first board to use the database to manage complaints and should start to use it by or on the 1st August 2008.
1.2 Performance
Performance against the target of responding to complaints within 20 working days in the last 2 months (April and May), was 86%. Complaints response time between April and March by operating unit is shown in Appendix 1.
36 complaints were received in April 2008 and 33 (92%) of these complaints were responded to in 20 working days. This compares to 37 complaints received in April 2007 and 26 (70%) were responded to in 20 days.
23 complaints were received in May 2008 and 18 (78%) of these complaints were responded to in 20 working days. This compares to 30 complaints received in May 2007 and 21 (70%) were responded to in 20 days.
Main issues Raised and Outcomes between 01.04.08 and 31.05.08
Issue / Number / Percentage / Outcome / Number / PercentageAttitude/ Behaviour / 7 / 12% / Upheld
Partly Met
Not Upheld / 6
1 / 86
14
Issue / Number / Percentage / Outcome / Number / Percentage
Clinical Treatment / 12 / 20% / Upheld
Partly Met
Not Upheld
Unresolved / 3
7
2 / 25
58
17
Communication / 12 / 20% / Upheld
Partly Met
Not Upheld
Unresolved / 8
2
2 / 67
17
17
Shortage / Availability / 10 / 17% / Upheld
Partly Met
Not Upheld / 5
4
1 / 50
40
10
Competence / 3 / 5% / Upheld
Partly Met
Not Upheld / 1
1
1 / 33
33
33
Comparison of main issues raised with April to May 2007 and the previous year
April & May 2008 / April & May 2007 / 1st April 2007 to 31st March 2008Issue / No. / % / No. / % / No. / %
Attitude/ Behaviour / 7 / 12% / 13 / 19% / 61 / 16%
Clinical Treatment / 12 / 20% / 16 / 24% / 90 / 23%
Communication / 12 / 20% / 9 / 13% / 63 / 16%
Shortage / Availability / 10 / 17% / 9 / 13% / 53 / 14%
Competence / 3 / 5% / 5 / 7% / 29 / 7%
1.3 Examples of lessons learned and changes implemented
Work has started to develop systems for recording learning from complaints and monitoring action taken as a result of complaints.
A patient who has some allergies left hospital with an IDL which said she had no allergies. Normally a nurse would go over the IDL with the patient as a safety check. This wasn’t done. Measures have been put in place to ensure this happens in the future. Also information relating to the religious needs of the patient was not relayed to nursing staff. Communication between administration and nursing staff will now be reviewed to ensure this doesn’t happen again.Complainant was concerned about the way her relative, who has dementia, was treated while in the hospital. The patient was not being treated with dignity and respect. The ward concerned is not a specialist dementia care unit but does look after patients with mild to moderate dementia, preventing the need for their transfer to the specialist dementia care ward at another more distant hospital. Some of the staff on this ward have not received formal training in working with patients with dementia.
As a matter of urgency training for these members of staff will now be arranged to ensure all patients are treated with dignity and respect.
Patient was referred by GP for a knee X-ray at Raigmore however the appointment received was for a completely different type of X-ray. The patient wanted to know how an error like this can occur.
Confirmed to the patient that the X-ray appointment mix up was due to human error which occurred due to the wrong letter being selected from the "drop-down" system which is used within the Booking Office to generate the appointment letter.
All staff within the Booking office have had the consequences of an error such as this highlighted to them to allow this to be a learning experience and so reduce the possibility of such an error occurring again.
1.4 Scottish Public Services Ombudsman
There were two reports from the Scottish Public Services Ombudsman during this quarter. One of these was partly upheld and one was not upheld. A summary of each case is detailed below.
Case 1The complainant raised a number of issues regarding the treatment and care provided by his late father (Mr A).
Specific Complaints and conclusions
The complaints which have been investigated are that:
(a) The treatment provided to Mr A was inadequate and this led to him sustaining a chyle leak (not upheld)
(b) Staff continued to replace Mr A’s TPN lines despite them continually becoming infected (not upheld)
(c) Staff failed to ensure Mr A received adequate nutrition (not upheld)
(d) Staff failed to clean Mr A’s room properly and this led to him becoming infected with MRSA (no findings)
(e) Staff failed to adequately communicate with Mr A’s family (upheld)
Redress and recommendations
The ombudsman recommends the NHS Highland Board:
(i) Remind staff of their responsibility under MRSA policy and ensure procedures are followed and audited for compliance; and
(ii) Remind staff to ensure a note is placed in the records where the patient has specifically refused to release of clinical information to relatives
The Board have accepted the recommendations and have explained the action which has taken place since the complaint was raised.
Case 2
The complainant (Mr C) was admitted to Raigmore Hospital following a car accident in December 2004. He suffered an injury to his shoulder. Mr C was concerned that this was not correctly diagnosed or followed-up at the time. He complained that subsequently he was seen by a number of different doctors at his General Practice and was not correctly diagnosed until May 2005.
Specific complaint and conclusions
The complaints which have been investigated are that:
(a) In December 2004, there was a failure by the Hospital to diagnose the extent of his injuries or arrange appropriate follow-up care (not upheld)
(b) At subsequent appointments the Practice failed to provide adequate care and treatment (not upheld)
(c) There was no continuity in the care provided by the Practice because Mr C was seen by so many different doctors (not upheld)
Redress and recommendations
The Ombudsman recommends that during periods when the continuity of care may be problematic the Practice reinforces with all staff the desirability of clarifying, wherever possible, the patient’s understanding of the full course of treatment at each contact.
The Practice has accepted the recommendations and will act on them accordingly.
The full reports are sent to the appropriate clinical and operational staff with a request that any recommendations are implemented as necessary. The Clinical Governance Support team will follow these up in six months time to ensure that implementation has occurred. The reports are also available on the NHS Highland website, are summarised in the Clinical Governance Newsletter and reported at DHS Management Team to ensure wider organisational learning.
1.5 Key Performance Indicators
KPI· Complaints procedure compliance of 80%
Monitoring
In April compliance across all of NHS Highland is 92% and in May the corresponding figure is 78%
2. PATIENT SAFETY
2.1 General
A project team has been established to plan for the implementation of the new DATIX incident management system. There has been some slippage, however, it is hoped that the new system will be in operation by October
2.2 Analysis of Clinical Incidents
Incidents occurring by Operational Unit from 01/04/2008 – 30/06/2008
Incident Category / Raigmore / Mid / North / SE / A&B / Total / Percentage of all incidentsAbsconder/Missing Patient/Client / 13 / 5 / 11 / 15 / 16 / 60 / 2%
Access / Admission / 4 / 3 / 0 / 0 / 28 / 36 / 1%
Bed Management / 7 / 0 / 0 / 0 / 5 / 12 / 0%
Blood Transfusion / 2 / 0 / 1 / 0 / 0 / 3 / 0%
Clinical Assessment / 14 / 1 / 1 / 0 / 0 / 19 / 1%
Consent / Communication / Confidentiality / 197 / 3 / 0 / 5 / 12 / 217 / 9%
Discrimination / Harassment / Victimisation / 0 / 1 / 1 / 1 / 0 / 3 / 0%
Disruptive / Violent / Aggressive Behaviour / 82 / 30 / 59 / 108 / 95 / 374 / 15%
Documentation / Clinical Information / 56 / 5 / 1 / 2 / 5 / 66 / 3%
Fire / 1 / 3 / 3 / 4 / 23 / 34 / 1%
Infection Control / 35 / 2 / 3 / 5 / 11 / 56 / 2%
Investigations (Scans/Xrays/Specimens) / 9 / 5 / 0 / 1 / 5 / 20 / 1%
Medical device / equipment / 25 / 7 / 4 / 5 / 18 / 59 / 2%
Medication (including vaccines) / 72 / 10 / 8 / 16 / 22 / 128 / 5%
Moving and Handling / 13 / 7 / 5 / 6 / 9 / 40 / 2%
Personal Accident / 39 / 6 / 9 / 25 / 27 / 106 / 4%
Radiation / 21 / 1 / 0 / 0 / 0 / 22 / 1%
Road Traffic Accident (RTA) / 1 / 4 / 2 / 5 / 0 / 12 / 0%
Security / 15 / 5 / 2 / 9 / 5 / 36 / 1%
Self Harming Behaviour / 11 / 1 / 4 / 22 / 1 / 39 / 2%
Sharps / 25 / 7 / 4 / 10 / 17 / 63 / 3%
Slips, Trips and Falls / 230 / 98 / 88 / 155 / 210 / 780 / 32%
Staff Availability / 17 / 15 / 1 / 0 / 42 / 75 / 3%
Test Results and Reports / 8 / 0 / 3 / 0 / 0 / 11 / 0%
Transfer / Discharge / 32 / 12 / 8 / 1 / 0 / 53 / 2%
Treatment / Procedure / 68 / 4 / 4 / 2 / 33 / 111 / 5%
Unknown - Unknown / 4 / 2 / 3 / 1 / 0 / 10 / 0%
Total / 994 / 244 / 225 / 398 / 584 / 2445 / 100%
Main Causes of Incidents 01/04/2008 – 30/06/2008
Incident Category / Raigmore / Mid / North / SE / A&B / Total / Percentage of all incidentsSlips, Trips and Falls / 229 / 98 / 88 / 155 / 210 / 780 / 32%
Disruptive / Violent / Aggressive Behaviour / 82 / 30 / 59 / 108 / 95 / 374 / 15%
Consent / Communication / Confidentiality / 196 / 4 / 0 / 5 / 12 / 217 / 9%
Medication (including vaccines) / 72 / 10 / 8 / 16 / 22 / 128 / 5%
Treatment / Procedure / 68 / 4 / 4 / 2 / 33 / 111 / 5%
Patient and Staff Incidents occurring by operational unit 01/04/2008 – 30/06/2008
2.3 Examples of lesions learned and changes implemented
Description: A baby received several overdoses of a drug due to a calculation error.Action: An investigation resulted in the following:-
· The Medicines Management Development Nurse has provided training to staff on the drug calculations. Consideration is now being given to develop a test for drug calculations which all staff will have to undergo on an annual basis across the hospital
· Staff have been made aware of the role of the second checker
· Review of prescription documents
· Managers need to be informed promptly when an incident has occurred. Further incident reporting education sessions are being planned
Description: A patient was changed from intravenous antibiotic therapy to oral antibiotic therapy. The doctor did not refer to the allergy section of the drug kardex which stated the patient was allergic to penicillin. Penicillin was prescribed
Action: An investigation resulted in the following:-
· Training on medicines management for ward staff and has been instigated
· Review of documentation to improve the highlighting of allergies
· Staff have been informed of the importance of not interrupting medication administration rounds
3. EMBEDDING CLINICAL GOVERNANCE AND RISK MANAGEMENT ACROSS THE OPERATING UNITS
A reporting template had also been developed which it was intended would be used by operational units and local clinical governance and risk management groups to report to DHS on specific issues. The new reporting template will be used from August/September
3.1 Clinical Governance and Risk Management Groups
North CHP