THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

COUNCIL OF GOVERNORS

CLINICAL ASSURANCE TOOLKIT (CAT)

EXECUTIVE SUMMARY

This paper provides the regular monthly report to supportNursing and clinical quality assurance.

Governors are aware that the Clinical Assurance Toolkit (CAT) is a monthly self-assessment process undertaken by Sisters/Charge Nurses, regarding clinical standards at Ward and Department level, as well as environmental cleanliness checks by the Matrons (in the acute setting) which are peer reviewed quarterly. This month’s report contains the following:

  • Trend information demonstrates that the overall CAT score continues to be above 96% in March. Question changes took effect from Aprilandmay impact on scores when April’s data is reported.
  • Each month an aspect of CAT is analysed in more detail. This month the focus is on thepaediatric assurance measures (medication, breastfeeding, and patient identification checks). Scores for these questions areremaining high overall, which demonstrates that Paediatric documentation was completed to a high standard in March. It is acknowledged that there is room for further improvement.
  • An overview of the areas with red scores for two months that have been escalated to Matrons. There were2 areas in March, compared with 6 in February. Cleanliness checks were red in 3 areasfor the two months ending March.
  • Details on the progress in the Acknowledging Continuous Excellence (ACE) Awards, which has been very positive over the last month.

RECOMMENDATION

To (i) note the content of this report (ii) comment accordingly.

Mrs Helen Lamont

Nursing & Patient Services Director

Mrs Elizabeth Harris

Deputy Director of Nursing & Patient Services (RVI)

11thApril 2016

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

COUNCIL OF GOVERNORS

CLINICAL ASSURANCE TOOLKIT (CAT)

1.INTRODUCTION

This is the fourthmonthly report since the updating of questions in the October 2015CAT survey.

2. CAT REPORT SUMMARY

2.1Scores & Trends

The table below demonstrates the trends within CAT over a period of six months. Scores by Directorate can be found in Appendix 1. Staff Knowledge scores have remained above 90%in March, followinga steady improvement in scores. It is likely that the question refresh in April will affect the scores reported to Governors at the next meeting.

The scores from Environmental Cleanliness continue to demonstrate high standards across the Trust. The next Matron peer review audit of cleanliness will be in May.

2.2Paediatric Assurance Measures

This month, the focus and analysis in this section is on the Paediatric assurance measures which are monitored through CAT. In particular, questions about breastfeeding mothers, documentation of medication, and ensuring every patient has an identification wristband, are monitored.

In Paediatric Wards, it is particularly important to ensure that there are adequate facilities for mothers who are breastfeeding. In March, the preferred feeding method was documented appropriately in 100% of cases (based on 10 mothers), and information was given to the mothers of patients on admission.

Medication is not yet prescribed via eRecord on Paediatric Wards, and therefore it is important to ensure that all mandatory information paper on records is appropriately completed. For Wards using eRecord, the system ensures thatmany mandatory fields are completed. In March, 49 patients’ medication records were checked as part of CAT. Patient details were recorded appropriately in 96% of cases and their drugs were signed for by a member of staff in 97% of cases. The date the drug was administered was recorded in 96% of cases and all discontinued drugs were amended on the documentation in 86% of cases.

Patient identification is an essential part of ensuring that patients receive the appropriate care and treatment, and minimises the risk of the wrong patient receiving the wrong treatment or procedure. In March, the patient wristbands of 45 patients were checked, and had been completed in line with policy in 97% of cases.

March’s results relating to Paediatric assurance measures are consistent with previous months demonstrate relatively high levels of compliance with documentation. Checks of the documentation and information given to breastfeeding mothers through CAT demonstrated excellent practice this month. There is some room for improvement with medication documentation in Paediatric Wards, particularly relating to discontinued drugs. Compliance with the patient identification policy was also high during March; this is supported by reporting of any breaches via Datix.

Next month the focus will be onthe new Outpatients questions.

2.3Escalation of ‘Red’ Areas

Any area that receives a red score (less than 91%) for the whole of the CAT over two consecutive months will appear on the escalation report. There were twoareas with an overall red score for two consecutive months in March, compared with six in February.

As reported previously, the changes made to CAT questions from April may have a negative impact on the number of areas receiving a red score, as we have seen in previous question changes. However, this will be positive as it will prompt closer scrutiny. The exception to this was October 2015, when changes were minor and were mostly used to clarify existing questions or to broaden other questions. CAT users were consulted throughout Marchand at the CAT User Group in February,in order to mitigate the chances of red scores resulting from a lack of understanding or clarity about the questions. Suggested changes from clinical staff were incorporated and all changes will be evaluated by the annual user evaluation survey in May.

The same process for two months of consecutive red scores applies to the Matrons’ cleanliness checks. There werethree areas with an overall red score for two consecutive months inMarch, compared with none in January. To give additional assurance, unannounced Deputy Director of Nursing & Patient Services cleanliness audits are undertaken on an ongoing basis, with input from the IPC Team and Hotel Services.

2.4ACE Awards

The Acknowledging Continuous Excellence (ACE) awards continue to be high priority, and the Senior Nursing Teamis working to develop the application process further and continue to highlight the fantastic work that underpins this process. Any clinical area which maintainshigh CAT scores for four out of six months is eligible to apply. Almost all areas completing CAT are eligible to apply for their Environmental Cleanliness ACE award due to the high standard across the Trust.

Six areas are at the stage of potentially achieving all five categories of the ACE awards.

  • Main Outpatients Freeman
  • Main Outpatients RVI
  • Sir Bobby Robson Unit
  • Clinical Ageing Research Unit
  • Clinical Research Facility
  • Dental Clinical Research Facility

The Governors were approached to ask if they would assist in the next stage of the process which is to perform a validation visit; three Governors have so far expressed an interest in this. Once this had been undertaken and the self-assessments validated, presentation of the awards will be arranged.

At the next Clinical Leaders Forum on 12th April, Radiology (Freeman) will receive ACE Awards in three categories. Additionally, the Musculoskeletal Matron has submitted applications for ACE Awards in eight clinical areas across a total of 25 categories.

There will be a continuous promotion of the ACE Awards.

3.NEW SOFTWARE FOR CAT

Patient Services and IT have started work to develop new software to house the CAT questions. The advantages of moving to a new system are:

  • Removal of a single point of failure (only one staff member understands the current system)
  • New system will be developed in-house and fully supported by IT
  • Improving experience of clinical staff who use CAT, modelled on the Nurse Day Count application which many Matrons and Sisters are familiar with
  • Better integration with existing data systems
  • Allows clinical staff to answer questions in whatever order is convenient for them (the current system forces users to answer questions in the order in which they appear)
  • Faster reporting on results, particularly after six-monthly question changes

4.RISKS AND RISK MITIGATION

The key focus of CAT is to mitigate risks through the monitoring of a range of patient safety issues. Ward Sisters/Charge Nurses and other Clinical Leaders are encouraged to view their results alongside other assurance data, such as the results of other audits and their Care Summary reports, in order to build a complete picture of their area’s strengths and weaknesses.

Monitoring Paediatric assurance measures such as patient identification mitigates the possibility of treatment being given to the wrong patient.

Governors have previously been made aware of the escalation process which highlights issues within clinical areas. No major issues or risks were identified from the red scores.

5.SUMMARY

The CAT continues to be viewed as a positive assurance method. Continued involvement from clinical staff in the development of the CAT ensures that the tool provides relevant assurance across a range of clinical settings. The focus of this month’s paper demonstrated the importance of Paediatric assurance measures documentation, ensuring that breastfeeding mothers are given information about available facilities, that medication is recorded correctly, and that patients have appropriate identification wristbands.

6.RECOMMENDATION

To note the contents of this report and comment accordingly.

7. KEY

Main CAT Measures

/ Less than 91%
/ Between 91% and 97.9%
/ 98% or more

Mrs Helen Lamont

Nursing & Patient Services Director

Mrs Elizabeth Harris

Deputy Director of Nursing & Patient Services (RVI)

11thApril 2016

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