UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS TRUST

TRUST BOARD MEETING

To be held on 26 May 2010 Agenda No 9a

Report of: / Jackie Holt and Peter Dyer
Paper Prepared by: / Jackie Holt and Peter Dyer
Date of Paper: / 14th May 2010
Subject: / How the Board is Assured of Quality
Care Quality Commission Standards: / Outcome 16
Assurance Framework Link:
Auditors Local Evaluation (ALE) Link:
Background Papers: / Integrated Performance Report. 26th May 2010
NICE Report to the Board 26th May 2010
Item Considered at Earlier Committees
(pls detail mtgs):
Patient & Public Involvement:
In case of query, please contact: / Peter Dyer 46642
Purpose of Paper:
To assure the Board that the Quality agenda is reported to the Board.
The Board is asked to note the contents of the report

AGENDA ITEM NO 9a

TRUST BOARD MEETING: 26 MAY 2010

HOW THE BOARD IS ASSURED OF QUALITY

Introduction

Lord Darzi clearly defined Quality as consisting of three parts, safety, effectiveness and patient experience. Since January 2009, the governance structure of the University Hospitals of Morecambe Bay (UHMB) has reflected this definition within its committee structure.

The purpose of this paper is to assure the Board that the governance arrangements are robust and that the right information is being received by the Board in a timely and clear fashion.

Committee Structure

The Clinical Quality and Safety Committee (CQSC) is a Board committee, chaired by Dr June Greenwell, a non-executive director. The terms of reference detail the membership of the committee which includes executive and non-executive directors. The CQSC receives reports from the Clinical Audit and Effectiveness Sub-committee, chaired by the Medical Director, the Integrated Risk Sub-committee, chaired by the Medical Director, the Patient Experience Sub-committee, chaired by the Director of Nursing and Modernisation and the Medicines Management Sub-committee, chaired by the Medical Director.

Each of the sub-committees receives reports from the divisions and relevant groups and these are detailed in the respective terms of reference.

Patient Safety Incidents

A patient safety incident is defined as any unintended or unexpected incident(s) that could have or did lead to harm for one or more persons receiving NHS-funded healthcare. The reporting of patient safety incidents, including “near misses”, is the key to understanding the risks in the Trust and the subsequent action taken to minimise future risks. (A “near miss” is now known as a patient safety incident (prevented) and is defined as any patient safety incident that had the potential to cause harm but was prevented, resulting in no harm to patients receiving NHHS-funded care.)

A serious incident is one in which a patient or patients suffer major permanent harm or death.

The reporting and investigation of a patient safety incident or a serious incident is governed within the scope of three policies, which should be read in conjunction:

1. Patient Safety Incident Reporting Policy

2. Patient Safety Incident Investigation Policy

3. Serious Untoward Incident Policy

The following appendices, taken form the policies illustrate the reporting and investigation procedures in place in the Trust:

a) The Patient Safety Incident Reporting Policy Flowchart, details the pathway for reporting an incident. (attached)

b) The Patient Safety Incident Investigation Policy. Investigation Flowchart. (attached)

c) The Patient Safety Incident Investigation Policy – Risk Ratings, details the National Patient Safety Agency (NPSA) guidelines for assessing the seriousness of a patient safety incident. (attached)

The Medical Director has introduced a meeting with the Integrated Risk Manager on a monthly basis to assess the “red” and “orange” graded incidents and to ensure that the policy for investigation has been undertaken. The Head of Clinical Governance prepares a quarterly report for the Integrated Risk Sub-committee detailing all the incidents in the preceding quarter and their respective action plans.

If an incident is reported that requires attention by the Medical Director before the monthly meeting, the Integrated Risk Manager will liaise immediately with the Medical Director and an action plan instituted.

Incidents requiring wider dissemination to PCT’s are reported through the Strategic Executive Information System (StEIS) and are initiated by the Chief Executive or Medical Director.

Mortality Rates

A monthly report detailing the Hospital Standardised Mortality Rates (HSMR) is compiled by the Head of Clinical Governance and distributed to the Executive Committee via the Medical Director. The information is based on the data which is collected by clinical coding and used by CHKS. This is included in the Integrated Performance Report to the Board (May 2010).

National Incident for Clinical Excellence (NICE)

Details of all NICE directives and our action plans for implementation are reported to the CQSC. There is a 6-monthly report to the Board (May 2010).

References

Terms of reference for:

i) Clinical Quality and Safety Committee

ii) Clinical Audit and Effectiveness Sub-committee

iii) Integrated Risk sub-committee

iv) Patient Experience Sub-committee

v) Medicines Management Sub-committee

The Board is asked to note the contents of the report.

What are the risk ratings?

Risk rating is a process based on NPSA guidelines that allows an objective assessment of the seriousness of a patient safety incident. The risk rating then determines the action to be followed.

There are 4 risk ratings:

·  Very Low (Green)

·  Low (Yellow)

·  Moderate (Orange)

·  High (Red) - Patient safety incidents dealt with under the Serious Incident Policy are always classified as high (red).

The risk rating is determined by specialist risk staff after assessing the likelihood of recurrence and the outcome or severity of an incident. Definitions of these and the matrix used to calculate the risk rating are shown below:

Likelihood / Description
Rare / Can’t believe this will ever happen again
Unlikely / Do not expect to happen again, but it is possible
Possible / May occur occasionally
Likely / Will probably happen, but is not a persistent issue
Almost certain / Will recur, possibly frequently
Severity / Description
None / No harm
Minor / Required extra observation or minor treatment
Moderate / Moderate increase in treatment and which caused significant but not permanent harm.
Major / Permanent harm
Catastrophic / Death
Risk Rating Matrix
Severity / None / Minor / Moderate / Major / Catastrophic
Likelihood / Almost certain / Low / Low / Moderate / High / High
Likely / Low / Low / Moderate / High / High
Possible / Very Low / Low / Moderate / High / High
Unlikely / Very Low / Very Low / Low / Moderate / High
Rare / Very Low / Very Low / Low / Moderate / High