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HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST

Clinical Audit and Effectiveness Annual Report 2012/13

1. Introduction The Clinical Audit and Effectiveness Team now 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 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 role of the Quality Facilitators / Quality and Safety Managers is to monitor the audit plan for their Health Group, including obtaining outcome forms and monitoring of actions arising from audits. The Clinical Audit and Effectiveness Team consists of 1 Clinical Audit and Effectiveness Manager (0.5 WTE), supported by 2.4 WTE Clinical Audit and Effectiveness Facilitators. This year, there have only been 1.5 WTE Clinical Audit and Effectiveness Facilitators with the replacement post due to be filled in April 2013. In addition, the team is supported by an Audit Clerk (0.7 WTE), who is based at the Medical Records site. This report summarises the clinical audit and effectiveness activity for 2012/13 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. 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 and patient opinion. All clinical audit projects approved during 2012/13 had a suitably completed CG1 and corresponding checklist completed, therefore all audits were conducted in line with the approved process for audit. Last year, the CG1 form was amended to include a section on information governance training. The Clinical Audit and Effectiveness Team have monitored this closely throughout the year and no audits were approved, unless the information governance training was in date for the whole audit project team. In March 2013, the Trust purchased Covalent, an integrated suite of applications that will enable more efficient monitoring of the audit plan and implementation of actions following an audit. Action

To transfer the audit plan and project documentation to Covalent to enable more efficient monitoring and reporting of the implementation of the plan – Clinical Audit and Effectiveness Manager

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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 NPSA Audits (including Patient Safety Alert Notices, Rapid Response Alerts, Safer Practice Notices, Patient Safety Information)

1

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

1

NCEPOD audits 1 National audits 1 NHSLA audits (eg. record keeping, consent) 1 Audits identified as a result of risk issues (including SUIs, incidents, PALS/complaints)

1

National Patient Surveys 1 Local patient surveys 2 Staff surveys 2 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 2013/14. See Appendix I for the audit plan 2013/14. 3. Monitoring of the Clinical Audit Plan During 2012/13, 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 2012/13 audit plan per Health Group.

Number of audits commenced

Current stage of audits Number of audits completed

271

Planning 1

222

Data collection 7 Data analysis 0 Report 1 Complete 222 Ongoing 14 Abandoned 26

Number of audits due to have commenced

Number of audits due to have been

completed

271

262

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The table shows that 100% of audits on the audit plan were commenced compared to 69% last year. However, 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 below illustrates the progress of these audits. 1.2 AUDITS APPROVED IN ADDITION TO THE PLAN

Number of audits

commenced Current stage of audits Number of audits

completed

58

Planning 0

49

Data collection 4 Data analysis 0 Report 4 Complete 49 Ongoing 0 Abandoned 1

3. Monitoring of Clinical Audit Activity and Outcome Forms During 2012/13, performance against the clinical audit plan was monitored via quarterly reports to the Clinical Audit and Effectiveness Committee. In 2012/13, 329 audit projects were approved, compared to 523 in 2011/12 and 522 in 2010/11. The number of approved audits is significantly lower than in previous years to ensure projects were of a good quality and likely to be completed. 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

Number of Completed Audits which Include an Outcomes Form

Clinical Support 78 63 51 Family and Women’s Health 87 81 73 Medicine 79 70 40 Surgery 85 67 38 Trust-wide 0 0 0 Total 329 280 202

NB . 12 audits are not due to be completed until 2013/14 (Clinical Support = 1, Family and Women’s Health = 1, Medicine = 6, Surgery = 4) NB. 27 audits were abandoned and reasons for each of these have been recorded on the audit plan. The main reason for abandoned audits is that the audit was no longer relevant to the service when the time came for the project to commence. NB. National audits have had not had an outcome form completed during 2012/13 as they do not suit the current template. A new template summarising the results and including an action plan will be developed in 2013/14. For a list of actions the Trust intends to take as a result of audits completed during 2012/13, see Appendix II. A significant number of audits list ‘re-audit’ as their only proposed action without stating whether this is because no areas of concern were identified as a result of the audit or whether they were unable to agree other actions.

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Action

To devise a new template to record the results of national audits, which includes the action plan – Clinical Audit and Effectiveness Manager

To increase the number of outcomes forms for completed clinical audits – Health

Group Medical Directors

To improve the quality of outcome forms, including the requirement to state the reason for a re-audit being the only identified action – Health Group Medical Directors

4. Clinical Audit Policy In January 2012, the Clinical Audit Policy was ratified. The policy was created to meet the requirements of the NHSLA standards and in doing so, provide guidance to staff undertaking clinical audit projects within the Trust. The policy clearly details the stages of the clinical audit process with particular emphasis on the completion of the outcomes form at the end of the project, to ensure actions have been identified to improve practice. The policy includes a new form, the Clinical Audit Action Plan Monitoring template, which should be completed every 3 months until the actions have been implemented. The completed forms should be sent to the relevant Quality Facilitator / Quality and Safety Manager. Action

The effectiveness of the policy to be monitored via quarterly reports to the Clinical Audit and Effectiveness Committee – Clinical Audit and Effectiveness Manager

5. Clinical Audit and Effectiveness Committee The Clinical Audit and Effectiveness Committee met 6 times during this year. The committee is chaired by the Deputy Chief Medical Officer and there is representation from each Health Group, pharmacy, nursing and therapies. The Clinical Audit and Effectiveness Manager also attends. During the early part of the year, attendance from the Health Groups was poor and this issue was put on the risk register. However, attendance did improve and the Health Groups now usually send a deputy if the usual Health Group representative is unable to attend. The aim of the Committee 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 reports to the Operational Governance Committee. 6. National Audits During 2012/13, 44 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 98% of national clinical audits which it was eligible to participate in. The national clinical audits that Hull and East Yorkshire Hospitals NHS Trust participated in, and for which data collection was completed during 2012/13, are listed overleaf alongside the number of cases submitted to each audit as a percentage of the number of registered cases required by the terms of that audit.

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National audit Participation

(Yes/No) % cases

submitted

Peri- and Neonatal

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

Yes Ongoing - full participation

currently

Children

Paediatric pneumonia (British Thoracic Society) Yes 100%

Paediatric asthma (British Thoracic Society) Yes 100%

Paediatric fever (College of Emergency Medicine) Yes 100%

Childhood epilepsy (Epilepsy 12 RCPH National Childhood Epilepsy Audit)

Yes 100%

Paediatric intensive care (Paediatric Intensive Care Audit Network - PICANet)


currently

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


currently

Acute care

Emergency use of oxygen (British Thoracic Society) Yes 100%

Adult community acquired pneumonia (British Thoracic Society)

Yes 100%

Non invasive ventilation (NIV) – adults (British Thoracic Society)

Yes 100%

Renal Colic (College of Emergency Medicine) Yes 100%

Adult critical care (Case Mix Programme) Yes Ongoing - full participation

currently

Potential donor audit (NHS Blood and Transplant) Yes Ongoing - full participation

currently

Long term conditions

Diabetes (National Adult Diabetes Audit) Yes Ongoing – full participation

currently

National Inpatient Diabetes Audit (NADIA) Yes 100%

Adult asthma (British Thoracic Society) Yes 100%

Bronchiectasis (British Thoracic Society) Yes 100%

Elective procedures

Hip, knee and ankle replacements (National Joint Registry)


currently

Elective surgery (National Patient Reported Outcome Measures Programme - PROMs) Unilateral Hip Replacement Unilateral Knee Replacement Groin Hernia Surgery Varicose Vein surgery

Yes

94% 88% 92% 96%

Coronary angioplasty (National Institute for Clinical Outcome Research - NICOR Adult cardiac interventions

Yes Ongoing – full participation

6


(Yes/No) % cases

submitted audit) currently

Peripheral vascular surgery (Vascular Society of Great Britain and Ireland Vascular Surgery Database - VSGBI VSD)


currently

Carotid interventions (Carotid Intervention Audit) Yes Ongoing - full participation

currently

Coronary Artery Bypass Graft (CABG) and Valvular surgery (Adult cardiac surgery audit)


currently

Heart

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


currently

Heart failure (Heart Failure Audit) Yes 100%

Cardiac arrhythmia (Cardiac Rhythm Management Audit) Yes 100%

National cardiac arrest audit (NCCA) Yes 100%

Renal disease

Renal replacement therapy (Renal Registry) Yes Ongoing – full participation

currently

Cancer

Lung cancer (National Lung Cancer Audit) Yes Ongoing – full participation

currently

Bowel cancer (National Bowel Cancer Audit Programme) Yes Ongoing - full participation

currently

Head and neck cancer (Data for Head and Neck Oncology - DAHNO)


currently

Oesophago-gastric cancer (National O-G Cancer Audit) Yes Ongoing - full participation

currently

Trauma

Hip fracture (National Hip Fracture Database) Yes Ongoing - full participation

currently

Severe trauma (Trauma and Audit Research Network) Yes Ongoing – full participation

currently

Blood transfusion

Audit of Blood Sampling and Labeling (National Comparative Audit of Blood Transfusion)

Yes 100%

Older People

National dementia audit (NAD) Yes 100%

Parkinson’s disease (National Parkinson’s Audit) Yes 100%

Acute stroke (Sentinel Stroke National Audit Programme - SSNAP)

Yes 100%

7


(Yes/No) % cases

submitted

Fractured neck of femur (College of Emergency Medicine)

Yes 100%

Action plans are developed as a result of the national audit reports that are produced. For a list of actions the Trust proposes to take, see Appendix III. Action

To monitor the actions identified in relation to national audit reports via the corporate action tracking template – Clinical Audit and Effectiveness Manager

7. NICE Guidance The Clinical Audit and Effectiveness Team liaises with clinicians from each Health Group who are responsible for demonstrating the Trusts compliance with NICE Guidance. Compliance with NICE guidance is reported via a quarterly report for the Clinical Audit and Effectiveness Committee. Regular updates are also provided to the commissioners via the Contract Management Board. During 2012/13, the procedure on the implementation of NICE guidance was revised to incorporate a new simpler system for measuring compliance with NICE guidelines. The revised procedure was agreed in March 2013 at the Operational Governance Committee and will be implemented during 2013/14. Number of NICE Guidance Identified as Relevant to our Services April 2012 - March 2013

HEALTH GROUP

TAGs IPGs Guidelines Quality Standards

Clinical Support 10 0 1 0 Family and Women’s Health

0 0 4 5

Medicine 3 0 4 4 Surgery 0 1 3 1 Trust-wide 1 0 1 3 TOTAL 14 1 13 13

7.1 NICE Guidelines

Health Group

Fully

compliant

Partially

compliant

Non

compliant

Yet to be

determined

Clinical Support 0 0 0 10

Family and Women’s Health

1 0 0 34

Medicine 1 1 1 39

Surgery 0 0 0 16

Trust-wide 1 0 0 14

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The above table shows that there was very little progress made in terms of completion of the Baseline Assessment Tools hence the revised procedure which now requires the completion of a much simpler Baseline Compliance Review form, with an action plan if required. Action

To email the Clinical Leads the revised BCR form for the NICE guidelines to determine compliance – Clinical Audit and Effectiveness Manager

8. NCEPOD activity 2012/13 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 2012/13:- National Confidential Enquiry into Patient Outcome and Death (NCEPOD) study

Participation (Yes/No)

% cases submitted

Tracheostomy Yes Data collection is ongoing

Alcohol Related Liver Disease Yes 100%

Subarachnoid Haemorrhage Study Yes 100% 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%

Other Enquiries/Reviews Participation

(Yes/No) % cases

submitted

Asthma Deaths (NRAD) Yes 100%

Child Health (CHR – UK) Yes Not known

This year, two NCEPOD reports were published that are relevant to this Trust. ‘Time to Intervene: Cardiac Arrest Procedures’ and ‘Too Lean a Service: Bariatric Surgery’ were published.

A gap analysis for the Cardiac Arrest Procedures report will be presented to the Clinical Audit and Effectiveness Committee in May 2013. A gap analysis, including an action plan, for the Bariatric Surgery report was agreed at the Clinical Audit and Effectiveness Committee and the actions have been fully implemented.

Action

To monitor the identified actions from the Cardiac Arrest study via the corporate action tracking template and report to the Clinical Audit and Effectiveness Committee – Clinical Audit and Effectiveness Manager

9. Clinical Audit Training The Clinical Audit and Effectiveness Team provided several clinical audit training sessions to specialties during this year, as requested. The team also provided 3 audit training sessions as part of the F2 doctors training and also provided training at specialty junior induction

9

sessions. The team has continued to provide individuals undertaking clinical audit projects with advice and support.

10

APPENDIX I

HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST AUDIT PLAN 2013-4

TRUST-WIDE AUDITS

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity

Evidence Ref (e.g.. NHSLA

standard number, CQC, SUI number)

Co

rpo

rate

Ob

ject

ive

Audit Title Audit Project Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Corporate Trust-wide NHSLA 1 NHSLA RM Standard 4.8

1 DNACPR (Do Not Attempt Cardio Pulmonary Resuscitation) Audit (10 patients per Health Group monthly)

Neil Jennison Dr Oade Monthly Monthly

Corporate Trust-wide NHSLA 1 NHSLA RM Standard 4.8

1

DNACPR (Do Not Attempt Cardio Pulmonary Resuscitation) Audit (Annual ALL WARDS) Compliance with Resus Equipment

Neil Jennison Dr Oade Nov-13 Dec-13

11

CLINICAL SUPPORT AUDIT PLAN 2013-14

Division Specialty

Rationale (e.g. NICE, NSF,

CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive

Audit Title Audit Project

Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion Date

Health Group

NHSLA Audit – Trust wide

1

NHSLA Standard

Health Record Keeping

1.8

1,5 Record Keeping Audit

(30 patients per Health Group, twice a year) Health Group Jul / Jan

Aug / Feb

Health Group


1

NHSLA Standard


4.8

1,5

Management of Acutely Ill Adult Patients in

Hospital (twice a year, all adult inpatients on a given day)

Outreach Team

Jul / Jan Aug / Feb

Health Group


1

NHSLA Standard Discharg

e 4.10

1,5

Discharge (5 patients per ward per quarter)

Divisional Nurse

Managers

May / Aug / Nov / Feb

Jun / Sept / Dec / Mar

Health Group


1

NHSLA Standard Transfusions 5.8

1,5

Policy for the Collection of Samples, Prescriptions, Collection and Transfusion of Blood

and Blood Components (20 casenotes per Health Group per quarter)

Hospital Transfusion

Team



Health Group


1

NHSLA Standard Venous

Thromboembolism

5.9

1,5 VTE Policy and VTE Guideline Audit

(25 casenotes per Health Group 3 times per year)

Health Group Medical Directors

May / Sept / Jan

Jun / Oct / Feb

Health Group NHSLA Audit

1

NHSLA Standard MedicineManage

ment 5.10

1,5 Drug Policy Prescribing Standards

(annual, minimum 100 sample) Chief

Pharmacist Jun-13 Aug-13

Health Group NHSLA Audit

1 NHSLA

Standard 1,5

Audit of Medicines Reconciliation (annual, both sites, minimum of 30 on each site)

Chief Pharmacist

Oct-13 Dec-13

12

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date


MedicineManage

ment 5.10

Health Group


1

NHSLA Standard Clinical

Handover of Care

4.9

1,5 Clinical Handover of Care (15 per Health Group

annually)

Divisional Nurse

Managers Sept-13 Mar-14

Imaging Division

RADIOLOGY


1


e 4.10

1,5

Patient Information and Consent Audit (10 patients)

Quality and Safety

Managers

Eileen Henders

on Aug-13 Mar-14

Imaging Division

RADIOLOGY Local 1 3 RE-AUDIT Quality of Posterior Anterior Chest X-Rays in CHH Match Up to the Standards Set Out

by the European Guidelines Sept-13 Mar-14

Imaging Division

RADIOLOGY Local 1 3 RE-AUDIT The Effects of Collimation and Lead Rubber Equivalent on Doses to the Thyroid and

Gonad in Relation to Chest Imaging Sept-13 Mar-14

Imaging Division

RADIOLOGY Local 1 3 RE-AUDIT Professional Practice Self Audit of

Clinical Reporting Skills 2012 Sept-13 Mar-14

Imaging Division

RADIOLOGY Local 3 3 Radiation Protection in the CT Department: A

Retrospective Patient Shielding Study Christopher

Burns

Dr Rowland-

Hill Feb-13 Jun-13

Imaging Division

RADIOLOGY Local 3 3 A Clinical Audit Investigating the Appropriate Usage of Gonad Shields on Paediatric Pelvic

Examinations within the Radiology Department Melanie Gray Dr Hauff Feb-13 Apr-13

Imaging Division

RADIOLOGY Local 3 3 An Audit of the Outcomes at our Institution Following Testicular Vein Embolisation for

Symptomatic Varicocele

Dr Shrivastava

Dr Robinson

Feb-13 May-13

Imaging Division

RADIOLOGY Local 3 3 The Use of Current Anatomical Markers in Plain

Film Radiography in the Emergency X-ray Department

Michael Atkinson

Dr Hauff Apr-13 May-13

13

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date


Imaging Division

RADIOLOGY Local 3 3 Accuracy of Request Cards in the CT Department Abigail Collins

Dr Hauff Apr-13 Jul-13

Specialist Service Division

CLINICAL HAEMATOLOGY


1


e 4.10

1,5


Quality and Safety

Managers

Eileen Henders

on Aug-13 Mar-14



Local 3 3 Nutritional Support of Haematology Patients Having Undergone High Dose or Intensive

Chemotherapy – Retrospective Audit

Sadie Millington Mar-13 Apr-13



Local 3 3 Chronic Myeloid Leukaemia – Dasatinib, Nilotinib

and Standard Dose Imatinib Sadie

Millington Dr Ali Mar-13 Apr-13


CLINICAL ONCOLOGY


1


e 4.10

1,5


Quality and Safety

Managers

Eileen Henders

on Aug-13 Mar-14


CLINICAL ONCOLOGY

Local 3 3 Audit of End of Life Care for Patients with End

Stage Liver Disease Dr Boland

Dr Saharia

Feb-13 May-13


CLINICAL ONCOLOGY

Local 3 3 Concurrent Chemo-radiotherapy for Locally

Advanced Non Small Cell Lung Cancer Dr Wieczorek Apr-13 Mar-14


CLINICAL ONCOLOGY

NICE 1 TAG268 3 Melanoma - Use of Ipilimumab Dr Roy Dr Roy Sept-13 Mar-14


CLINICAL ONCOLOGY

NICE 1 TAG269 3 Melanoma - Use of Vemurafenib Dr Roy Dr Roy Sept-13 Mar-14


CLINICAL ONCOLOGY

Local 3 3 A Retrospective Audit to Identify the Quality of

Palliative Care Patients Diagnosed with Head and Neck Cancer Receive Towards the End of Life

Debra Marsh Dr

Saharia Apr-13 Aug-13


DIETETICS Local 3 Local 3

Audit to Assess the Indications for the Administration of Parenteral Nutrition (PN) to

Patients in the Queens Centre for Oncology and Haematology

Liz Graham Jul-13 Mar-14

14

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date



DIETETICS Local 3 3 Referral and Dietetic Treatment Times for Adult

Inpatients

Sue Perry/ Jo Donaldson-Smith/ Tina McDougall

Apr-13 Sept-13


DIETETICS Local 3 3 Dietetic Outcome Measures: A Baseline Audit

Sue Perry/ Jo Donaldson-Smith/ Tina McDougall

Sept-13 Mar-14


PHARMACY Local 3 3 MDS (Monitored Dosage Systems) For Patients

Discharged from HEY Hospitals Mairin Flynn

Julie Randall

Jan-13 Sep-13


PHYSIOTHERAPY Local 1 3 RE-AUDIT Physiotherapy Acute Respiratory

COPD Service (PARCS) Outcomes Measures Audit.

Claire Seabourne

Apr-13 Oct-13


PHYSIOTHERAPY Local 3 3

Lower Limb Amputation Pathway Milestones: How Does HEY/ Contributory Regional Vascular Centres Perform Against Regionally Agreed

Quality and Operational Standards in Amputee Management

Amanda Hancock

Liz Minnich

Mar-13 Nov-13


PHYSIOTHERAPY Local 3 3 Physiotherapy Workforce Review Nicola

Gilchrist May-13 Sep-13


SPEECH AND LANGUAGE THERAPY

Local 3 3 Are Speech and Language Therapy Dysphagia

Recommendations Included on Immediate Discharge Letters?

Hannah Waterson

Apr-13 Sep-13


OCCUPATIONAL THERAPY

Local 3 3

Evaluation of Occupational Therapy interventions to Patients Readmitted Within 30 Days of Original

Hospital Admissions to Identify Areas of Improvement to Practice

Debbie Parker Sept-13 Mar-14



Local 3 3

Benchmarking the Occupational Therapy Service against the College of Occupational Therapists

Evidence Based Guidelines with People who have had Lower Limb Amputations

Karen Button Patience Young

Jan-13 Mar-14

15

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date




Local 3 3 Does Occupational Therapy Input to AAU Impact

on Length of Stay? Ann Linnane-

Kelly

Ann Linnane-

Kelly Sept-13 Mar-14

Pathology Division

BLOOD TRANSFUSION

NHSLA Audit - Trustwi

de

1 CP113 1,5

NHSLA level 3 Audit on the process for the administration of transfusions, including patient identification and care of patients receiving a

transfusion

Transfusion team

Dr Ali Sept-13 Mar-14

Pathology Division

BLOOD TRANSFUSION

Local 2 CP113 1,5 Audit into Out of Hours Transfusion Requests

including Turnaround Times for Laboratory Tests and Administration of Transfusions

Transfusion team

Dr Ali Apr-13 Jun-13

Pathology Division

BLOOD TRANSFUSION

Local 2 SOPT 216

1,5 Audit into the Clinical Impact of Transfusion

Sample Rejection Transfusion

team Dr Ali Jun-13 Sep-13

Pathology Division

BIOCHEMISTRY Local 3 3 An Audit of HbA1c values in Hull and East

Yorkshire Diabetes Patients Following a Change in Test Units

Dr Kilpatrick Dr

Wilmot Mar-13 May-13

Pathology Division

INFECTIOUS DISEASES

Local 3 3 HIV Testing in TB clinic Dr Adams Sep-13 Mar-14

Pathology Division

MICROBIOLOGY Local 1 3 RE-AUDIT Adherence to NICE guidance of TB

Diagnosis – Sputum sample replicates for investigation of Tuberculosis

Dr Wearmouth

Dr Meigh Sept-13 Mar-14

Pathology Division

MICROBIOLOGY NICE 1 3

Diagnosis and Identification of Patient and Relatives with Definite or Possible Familial

Hypercholesterolarmia - adherence to NICE (CG71) guidelines

Dr Desborough

Dr Wilmot

Apr-13 Jul-13

Pathology Division

CYTOLOGY Nation

al 1 1 Audit of Invasive Cervical Cancers Sue Gilbert

Angela Carling

Ongoing Ongoing

Pathology Division

VIROLOGY Local 1 3 RE-AUDIT Time to Report of Respiratory Syncitial

Virus Testing Dr Meigh Dr Meigh Apr-13 Oct-13

16

FAMILY & WOMENS HEALTH AUDIT PLAN 2013-14

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity



Co

rpo

rate

Ob

ject

ive


Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Health Group


1

NHSLA Standard


1.8


(30 patients per Health Group, twice a year)

Health Group Jul / Jan Aug / Feb

Health Group


1

NHSLA Standard


4.8

1,5

Management of Acutely Ill Adult Patients

in Hospital (twice a year, sample size to be

determined)

Outreach Team

Jul / Jan Aug / Feb

Health Group



e 4.10

1,5


Divisional Nurse

Managers



Health Group


1


1,5

Policy for the Collection of Samples, Prescriptions, Collection and Transfusion

of Blood and Blood Components (20 casenotes per Health Group per

quarter)


Team



Health Group


1


Thromboembolism

5.9

1,5

VTE Policy and VTE Guideline Audit



May / Sept / Jan

Jun / Oct / Feb

Health Group


1


Handover of Care

1,5 Clinical Handover of Care (15 per Health

Group annually)

Divisional Nurse

Managers Sep-13 Mar-14

17

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity



Co

rpo

rate

Ob

ject

ive


Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

4.9 Children

and Young

People's Services

NEONATES/ PICU


1


e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Children and

Young People's Services

NEONATES/ PICU

National 1 National 1 Neonatal Intensive and Special Care

(NNAP) Dr Wood Ongoing Ongoing

Children and


NEONATES/ PICU

Local 3 Local 3 Thromboembolic Complication of

Neonatal Umbilical Lines Clare

Magson Dr Preece Feb-13 Aug-13

Children and


NEONATES/ PICU

Local 3 Local 3 Outcome for Babies with Shoulder

Dystocia at Birth Simon

Richardson Dr Wood Mar-13 Jul-13

Children and


NEONATES/ PICU

Local 3 Local 3 Admission Temperature Audit Michael Hayes

Dr Preece Mar-13 Jul-13

Children and


NEONATES/ PICU

Local 3 Local 3 Audit of Home Nasogastric Tube Feeding

Programme Philippa

Satchwell Dr Preece Mar-13 Jul-13

Children and

Young People's

NEONATES/ PICU

Local 3 Local 3 Infants Nursed on Neonatal Unit Beyond

44+6 Weeks Corrected Gestation – A Service Evaluation

James Houston

Hassan Gaili

Mar-13 Jul-13

18

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity



Co

rpo

rate

Ob

ject

ive


Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Services

Children and


NEONATES/ PICU

NCEPOD 1 NCEPOD 1 Audit of Parenteral Nutrition Practice Dr Preece Jan-14 Mar-14

Children and


PAEDIATRIC MEDICINE

National 1 National 1 Diabetes (Paediatric) Mr Mathew Ongoing Ongoing

Children and


PAEDIATRIC MEDICINE

National 1 National 1 Epilepsy 12 Dr Jose Feb-13 Mar-14

Children and


PAEDIATRIC MEDICINE

National 1 National 1 Paediatric Asthma (BTS) Dr Toko Nov-13 Jan-14

Children and


PAEDIATRIC MEDICINE

National 1 National 1 Paediatric Intensive Care (PICANET) Dr Klonin Ongoing Ongoing

Children and


PAEDIATRIC MEDICINE

National 1 National 1 Child Health Programme Dr Toko Ongoing Ongoing

19

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity



Co

rpo

rate

Ob

ject

ive


Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Children and


PAEDIATRIC MEDICINE

National 1 National 1 Paediatric Bronchiectasis Audit Dr Toko Oct-13 Nov-13

Children and


PAEDIATRIC MEDICINE

Local 3 Local 3 Infants with Bronchiolitis Requiring Hi-Flo,

CPAP and/or Ventilation Lesley

Harrison Mar-13 Oct-13

Children and


PAEDIATRIC MEDICINE

Local 3 Local 3 Diarrhoea and Vomiting in Children Under

5 Years Old Dr Azaz May -13 Sept-13

Children and


PAEDIATRIC SURGERY



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Children and


PAEDIATRIC SURGERY

Local 3 Local 3 Ward Attendees Audit: Are we seeing

patients appropriately Shwan Maroof

Miss Besarovic

Jan-13 Apr-13

Children and


PAEDIATRIC SURGERY

Local 3 Local 3 Audit of Management and Outcomes in

Congenital Oesophageal Anomalies Alison

Campbell Miss

Besarovic Mar-13 Jul-13

Women's Services

BREAST SCREENING &

SURGERY



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

20

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity



Co

rpo

rate

Ob

ject

ive


Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Women's Services

BREAST SCREENING &

SURGERY Local 3 Local 3

Initial Audit of the Outcomes of the Holistic Needs Assessment at the End of

the First Year of the Survivorship Programme for Breast Cancer follow up and Review of Number of Further Follow

up Contacts Required

Julia Massey Miss

McManus Dec-12 Jun-13

Women's Services

BREAST SCREENING &


Re-excision Rates in Lobular Breast Cancer with and without MRI

Mr Kneeshaw May-13 Dec-13

Women's Services

GYNAECOLOGY



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Women's Services

GYNAECOLOGY National 1 National 1 Ovarian Mass RMI Audit Dr Flynn May-13 Mar-14

Women's Services

GYNAECOLOGY National 1 National 1 Cyto-reversion Rates at 8 months After

Treatment Kofi Yamoah Dr Flynn May-13 Mar-14

Women's Services

GYNAECOLOGY National 1 National 1 Confirmed Histological Treatment Failures

at 12 months Kofi Yamoah Dr Flynn May-13 Mar-14

Women's Services

GYNAECOLOGY Local 3 Local 3 Hysterectomy-approach and Outcome Mr Oboh Apr-13 Apr-14

Women's Services

GYNAECOLOGY Local 3 Local 3 Laparoscopic Surgical Injuries Mr Oboh Apr-13 Apr-14

Women's Services

GYNAECOLOGY Local 3 Local 3 Management of Pregnancy of Unknown

Location Mr Oboh Apr-13 Apr-14

Women's Services

GYNAECOLOGY Local 3 Local 3 Management of Tubal Ectopic Pregnancy Mr Oboh Apr-13 Apr-14

Women's Services

GYNAECOLOGY Local 3 Local 3 Management of Hyperemesis Gravidarum

in the Day-case Setting Mr Oboh Apr-13 Apr-14

Women's Services

GYNAECOLOGY Local 3 Local 3 Outcome of Hysteroscopic Sterilisation Mr Oboh Apr-13 Apr-14

Women's Services

GYNAECOLOGY Local 3 Local 3 Audit of Medical Termination of

Pregnancy Mr Oboh Apr-13 Sept-13

Women's Services

GYNAECOLOGY Local 3 Local 3 Audit of Local Anaesthetic Evacuation of

Products of Conception Mr Oboh Apr-13 Sept-13

21

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity



Co

rpo

rate

Ob

ject

ive


Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Women's Services

GYNAECOLOGY Local 3 Local 3 Management of Urinary Stress

Incontinence Mr Oboh Apr-13 Apr-14

Women's Services

OBSTETRICS



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Women's Services

OBSTETRICS National 1 National 1 Maternal, Infant and Newborn Clinical

Outcome Review Programme (MBRRACE-UK)

Mr Lindow Ongoing Ongoing

Women's Services

OBSTETRICS CNST 1 CNST 1 Record Keeping Monthly Spot Checks

(Annual) Sue Cooper Apr-13 Mar-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Record Keeping Audit Local Supervising

Authority Supervisors of Midwives (Annual)

Lorraine Cooper

Apr-13 Mar-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Fetal Blood Sampling (Annual) Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Use of Oxytocin (Annual) Julia

Chambers/ Mr Tyrrell

Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Caesarean Section Grade 1 LSCS Audit

(Quarterly) Helen Dent

Apr/July/Oct/Jan

July/Oct/Jan/ Apr

Women's Services

OBSTETRICS CNST 1 CNST 1 Induction of Labour (6 monthly) Karen

Thompson May/Oct Aug/Jan

Women's Services

OBSTETRICS CNST 1 CNST 1 High Dependency Care (Annual) Julia

Chambers/ Mr Tyrrell

Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Vaginal Birth After Caesarean Section

(Annual) Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Severe Pre-eclampsia (including

Eclampsia) (Annual) MDT Team Oct-13 Mar-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Operative Vaginal Delivery (Annual) MDT Team Sept-13 Feb-14

22

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity



Co

rpo

rate

Ob

ject

ive


Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Women's Services

OBSTETRICS CNST 1 CNST 1 Multiple Pregnancy and Birth (Annual) Mr

Maguiness Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Perineal Trauma (Medical) (Annual) Medical Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Perineal Trauma (Midwifery) (Annual) Julia

Chambers Oct-13 Mar-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Perineal Trauma (Returns) (Annual) Medical/ Midwifery

Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Shoulder Dystocia (Quarterly) MDT Team Apr/July/Oct/Jan

July/Oct/Jan/ Apr

Women's Services

OBSTETRICS CNST 1 CNST 1 Post Partum Haemorrhage (Quarterly) Sue Sallis Apr/July/Oct/Jan

July/Oct/Jan/ Apr

Women's Services

OBSTETRICS CNST 1 CNST 1 Venous Thromboembolism - Risk

assessment and prophylaxis (Annual) Kathryn King Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Pre-existing Diabetes (Annual) Linda

Wilkinson Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Obesity (Annual) Fiona

Robinson Jun-13 Dec-13

Women's Services

OBSTETRICS CNST 1 CNST 1 Booking Appointments (Annual) Kath

Hodgson/ Tricia Trevor

Jun-13 Jan-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Missed Appointments (Annual) Kath


Jun-13 Jan-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Antenatal Clinical Risk Assessment

(Annual)

Kath Hodgson/

Tricia Trevor Jun-13 Jan-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Patient Information and Discussion

(Annual)

Kath Hodgson/

Tricia Trevor Jun-13 Jan-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Mental Health (Annual) Kath


Jun-13 Jan-14

23

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity



Co

rpo

rate

Ob

ject

ive


Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Women's Services

OBSTETRICS CNST 1 CNST 1 Handover of Care (Annual) Kath


Jun-13 Jan-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Maternal Transfer by Ambulance (Annual) Kath


Jun-13 Jan-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Non-obstetric Maternity Care (Annual) Kath


Jun-13 Jan-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Antenatal Screening Tests in Pregnancy

(Annual) Jane

McFarlane Jun-13 Jan-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Referral When Fetal Abnormality

Detected (Annual) Jane

McFarlane Jun-13 Jan-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Newborn Life Support - Documentation to

evidence resuscitation equipment is checked, stocked and fit for use (Annual)

Julia Chambers/Su

e Sallis Jan-14 Mar-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Admission to Neonatal Unit - Criteria for

aAdmission to NICU (Annual)

Dr Pairaudeau/r

Dr Gaili Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Immediate Care of the Newborn (Annual) Dr Preece Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Examination of the Newborn (Annual) Dr Preece Sept-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Bladder Care (Annual) Angie Rymer Aug-13 Feb-14

Women's Services

OBSTETRICS CNST 1 CNST 1 Recovery (Annual) Sue Sallis Jul-13 Dec-13

Women's Services

OBSTETRICS CNST 1 CNST 1 Support for Parents (Annual) Jacqui Powell Jul-13 Dec-13

Women's Services

OBSTETRICS Local 3 Local 3 Management of Postmenopausal

Bleeding Kofi Yamoah Dr Allen Mar-13 May -13

Women's Services

OBSTETRICS Local 3 Local 3 An Audit of Practice of Spinal

Anaesthesia for Parturients in our Dr Yusaf Dr Balaji Apr-13 Sept-13

24

Division Specialty

Rationale (e.g.

NICE, NSF,

CNST)

Prio

rity



Co

rpo

rate

Ob

ject

ive


Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Obstetric Unit

MEDICINE HEALTH GROUP AUDIT PLAN 2013-14

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Health Group


1

NHSLA Standard


1.8



Health Group Jul / Jan Aug / Feb

Health Group


1

NHSLA Standard


4.8

1,5



determined)

Outreach Team Jul / Jan Aug / Feb

Health Group



e 4.10

1,5

Discharge (5 patients per ward per

quarter)

Divisional Nurse

Managers



Health Group


1


1,5



quarter)


Team



25

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Health Group


1


Thromboembolism

5.9

1,5




May / Sept / Jan

Jun / Oct / Feb

Health Group


1


Handover of Care

4.9

1,5

Clinical Handover of Care (15 per Health

Group annually) Divisional

Nurse Managers

Sept-13 Mar-14

Emergency Medicine

ACUTE ASSESSMENT

UNIT (AAU) Local 3 3 Management of PE on AAU Dr Anand Dr Middleton Apr-13 Aug-13

Emergency Medicine

ACUTE ASSESSMENT

UNIT (AAU) Local 3 3 Audit of Ambulatory Care Dr Thakur Dr Middleton Sept-13 Mar-14

Emergency Medicine

ACUTE ASSESSMENT

UNIT (AAU) Local 1 3

RE-AUDIT Clinical Quality Indicators on AAU

Dr Thakur Dr Thakur Sept-13 Mar-14

Emergency Medicine

ACUTE ASSESSMENT

UNIT (AAU) Local 3 3 Antibiotic Prescribing in AAU Dr Middleton Dr Middleton Mar-12 May-13

Emergency Medicine

ACUTE ASSESSMENT

UNIT (AAU) Local 1 1 RE-AUDIT Management of Sepsis on AAU Dr May Dr Thakur Sept-13 Mar-14

Emergency Medicine

EMERGENCY DEPARTMENT

National Audit

1 1 Severe Sepsis and Septic Shock Dr Perez / Dr

Arundel Dr Rayner Sept-13 Mar-14

Emergency Medicine


National Audit

1 1 Paracetamol Overdose Dr Perez/ Dr

Gonzalez Dr Rayner Sept-13 Mar-14

Emergency Medicine


Local 3 3 Pneumonia Bundle in ED Dr Rayner / Dr

Manou Dr Rayner Sept-13 Mar-14

Emergency Medicine


Local 3 3 Audit of Management of Suspected

Scaphoid Fractures Presenting to the Dr Higson Dr Perez May-13 Jul-13

26

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Emergency Department

Emergency Medicine


NICE 1 1 NICE Head Injury Guidance Dr Pickering Mr Rayner Apr-13 Dec-13

Emergency Medicine


National Audit

1 1 Asthma in Children Dr Perez Mr Rayner TBC TBC

Emergency Medicine


National Audit

1 1 Trauma Audit Research Network: Severe

Trauma (TARN) Chris Hampson Dr Rayner Ongoing Ongoing

Emergency Medicine


Local 3 3 Trauma Team Activation Dr Perez Dr Perez Aug-13 Mar-14

General Medicine

CHEST MEDICINE


1

NHSLA Standard Discharge

4.10

1,5 Patient Information and Consent Audit

(10 patients) Quality and

Safety ManagersEileen

Henderson Aug-13 Mar-14

General Medicine

CHEST MEDICINE National

Audit 1 1 Emergency Oxygen Mark Major

Dr Greenstone

Aug-13 Nov-13

General Medicine


Audit 1 1 National COPD Audit TBC TBC TBC TBC

General Medicine


Audit 1 1 NLCA Lung Cancer Dr Anderson Dr Anderson Ongoing Ongoing

General Medicine


Audit 1 1 National Pulmonary Hypertension Database Mark Major

Professor Morice

Apr-13 Ongoing

General Medicine

DIABETES AND ENDOCRINOLOGY

National Audit

1 1 National Diabetes Audit - NHS DIABETES Dr Patmore Dr Patmore TBC TBC

General Medicine


National Audit

1 1 National Diabetes Inpatient Audit - NHS

DIABETES Dr Allan Dr Allan Sept-13 Sept-13

General Medicine


Local 1 3 RE-AUDIT Audit of Bone Density (DXA)

Requests Received Ann Goodby Ann Goodby Sept-13 Nov-13

General Medicine


National Audit

1 1 National Diabetes in Pregnancy Audit

(NCAPOP) Dr Allan/Mr

Lindow Dr Allan Apr-13 Ongoing

General Medicine


National Audit

1 1 National Post-Radioiodine Management of

Patients with Graves' Disease Dr Sathyaplan

Dr Sathyaplan

TBC TBC

27

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

General Medicine


Local 3 3 DKA audit Dr Pothina/Dr

Allan Dr Allan Jun-13 Mar-14

General Medicine


Local 3 3 Root Cause Audit of Diabetic Lower Limb

Amputations Marie Walker/Dr

Patmore Dr Patmore May-13 Aug-13

General Medicine


Local 3 3 Audit of Implementation of Insulin PassportMarie Miller/Dr

Allan Dr Allan Jun-13 Mar-14

General Medicine


Local 3 3 Referrals for Prolactin Day Series in

Patients Referred to The Endocrine Clinic with Hyperprolactinaemia

Dr Kyaw Dr

Sathyaplan Sept-13 Mar-14

General Medicine


Local 3 3 Re-audit of Patient Satisfaction with OPD

Experience Dr Walton/Dr

Allan Dr Allan May-13 Nov-13

General Medicine


Local 3 3 Outcome of Mild Obesity (BMI 30-35) in

Gestational Diabetes Dr Ruprai Dr Allan Apr-13 Aug-13

General Medicine


Local 3 3 Audit of Blood Ketone Testing in the

Emergency Department: Appropriateness of use and Clinical Outcomes

Dr Allan Dr Allan May-13 Nov-13

General Medicine


Local 1 3 RE-AUDIT Accuracy of RadCentre Data Entry for Bone Density (DXA) Scans

Ann Goodby Ann Goodby Aug-13 Oct-13

General Medicine

MEDICAL ELDERLY

Local 1 3 RE-AUDIT Audit of the Use of Antibiotics for

Treatment of Urinary Tract Infections Dr Ninan Dr Richards Sept-13 Mar-14

General Medicine

MEDICAL ELDERLY

Local 3 3 DNAR Form Completion Dr Dimond Dr

Farnsworth Apr-13 May-13

General Medicine

MEDICAL ELDERLY

Local 3 3 Adherence to Trust Antibiotic Policy

Prescribing Dr Saraswat Dr Saraswat Apr-13 May-13

General Medicine

MEDICAL ELDERLY

Local 3 3 Drug Prescription Errors Helen

Marsden/Rachel Hepherd

Dr Richards May-13 Jun-13

General Medicine

NEPHROLOGY / RENAL


1


4.10





General Medicine

NEPHROLOGY / RENAL

National Audit

1 1 Renal Replacement Therapy

(Renal Registry) Archie Lamplugh Dr Edey Ongoing Ongoing

28

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

General Medicine

NEPHROLOGY / RENAL

CQUIN 1 1 Recording of Transplant Status in Notes of

New RRT Patients Dr Edey Dr Edey Sept-13 Mar-14

General Medicine

NEPHROLOGY / RENAL

CQUIN 1 1 Vascular Access - Patients Commencing

HD via Catheters Dr Hilton Dr Edey Sept-13 Mar-14

General Medicine

NEPHROLOGY / RENAL

Local 3 3 RE-AUDIT - CMV Viraemia After

Transplantation Dr Hoefield Dr Edey Sept-13 Mar-14

General Medicine

NEPHROLOGY / RENAL

NSF 1 1 Use of Northern Risk Score in Transplant

Work-up Dr Edey Dr Edey Sept-13 Mar-14

General Medicine

NEPHROLOGY / RENAL

NSF 1 1 Availability of Renal Patient View Dr Hazara Dr Edey Sept-13 Mar-14

General Medicine

NEPHROLOGY / RENAL

Local 3 3 Measurement of Folate Levels in Dialysis

Patients Dr Walsh Dr Edey Sept-13 Mar-14

General Medicine

NEPHROLOGY / RENAL

Local 3 3 Epidemiology of Haemodialysis Central

Venous Catheter Infections Dr Syed

Dr Chanayireh

Apr-13 Oct-13

General Medicine Division

NEPHROLOGY / RENAL

Local 3 3

Management of Acute Kidney Injury: the Impact of automated alerts in improving

quality of care as defined in the NCEPOD 2009 recommendations

Dr Naudeer Dr Edey Apr-13 Jun-13

General Medicine

RHEUMATOLOGY Local 3 3

Audit Compliance with MHRA & EMA Recommendations for Long Term

Bisphosphonate Treatment and The Risk of Atypical Fractures

Dr Kallankara Dr Kallankara May-13 Aug-13

General Medicine


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

Arthritis

Dr Kallankara Dr Kallankara May-13 Jul-13

General Medicine


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

Dr El-Sayed Dr Kallankara Apr-13 May-13

General Medicine

RHEUMATOLOGY Local 3 3 A UK Multicentre Audit of the Management

of Rheumatoid Arthritis Against Treat to Target Guidelines’

Dr Patel Dr Kallankara Apr-12 Mar-14

29

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Specialist Medicine

DERMATOLOGY


1


4.10





Specialist Medicine

DERMATOLOGY Local 1 3 RE-AUDIT Clinical Audit of Day Care

Management of Patients with Psoriasis within the Dermatology Department

Dr Graham Dr Walton Dec-13 Mar-14

Specialist Medicine

DERMATOLOGY Local 1 3 RE-AUDIT of Isotretinoin Prescribing in the

Dermatology Department Dr Graham Dr Walton Feb-14 Mar-14

Specialist Medicine

DERMATOLOGY National

Audit 1 1 Psoriasis National Audit

Dr Mohungoo/ Dr Walton

Dr Walton May-13 May-13

Specialist Medicine

DERMATOLOGY Local 3 3 Phototherapy audit Dr Mohungoo Sept-13 Dec-13

Specialist Medicine

CARDIOLOGY


1


4.10





Specialist Medicine

CARDIOLOGY National

Audit 1 1 Heart Failure Mandy Walters

Professor Cleland

Ongoing Ongoing

Specialist Medicine

CARDIOLOGY National

Audit 1 1

Coronary Angioplasty (NICOR Adult Cardiac Interventions Audit)

Dr Oliver Dr

BragadeeshOngoing Ongoing

Specialist Medicine

CARDIOLOGY National

Audit 1 1 MINAP Wendy Holiday Dr Hoye Ongoing Ongoing

Specialist Medicine

CARDIOLOGY Local 3 3 MDT Patient Selection and Outcome Dr Waleed Dr Hoye Apr-13 Sept-13

Specialist Medicine

CARDIOTHORACIC SURGERY


1


4.10





Specialist Medicine

CARDIOTHORACIC SURGERY

National Audit

1 1 Adult Cardiac Surgery (CABG and Valvular

Surgery) Mr Chaudhry Mr Chaudhry Ongoing Ongoing

30

Division Specialty


CNST)

Pri

ori

ty



Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Specialist Medicine

CARDIOTHORACIC SURGERY Local 3 3 VATS Biopsy for Benign Lung disease Dr Hardman Mr Loubani Apr-13 May-13

Specialist Medicine

NEUROLOGY National

Audit 1 1

National Audit of Seizure Management (NASH)

Dr Ming Dr Ming Apr-13 Jul-13

Specialist Medicine

NEUROLOGY Local 3 3 Re-audit of the 2 week-wait Referral

Pathway for People with Suspected CNS Tumour

Dr Khalil Dr Harley Apr-13 May-13

Specialist Medicine

NEUROLOGY Local 3 3 Audit of Patient Medical Records Dr Agrawal Dr Harley Apr-13 Dec-13

Specialist Medicine

OPHTHALMOLOGY


1


4.10


(10 patients annually) Quality and



Specialist Medicine

OPHTHALMOLOGY National

Audit 1 1,5

Audit of Quality Measures in Ophthalmology Patients

Miss Cook Miss Cook Ongoing

Ongoing

Specialist Medicine


Audit 1 1,5 British Ophthalmological Surveillance Unit Miss Cook Miss Cook

Ongoing

Ongoing

Specialist Medicine


Audit 1 1,5

Prospective Audit of Retinal Detachment Surgery via BEAVRs website

Mr Costen Mr Costen Ongoing Ongoing

Specialist Medicine

STROKE National

Audit 1 1,5

SSNAP - Stroke National Audit Programme (combined Sentinel and SINAP)

Dr Abdul-HamidDr Abdul-

Hamid Ongoing Ongoing

31

SURGERY HEALTH GROUP AUDIT PLAN 2013-14

Division

Sp

ecia

lty

Rationale (e.g.

NICE, NSF,

CNST, risk, local

issue)

Pri

ori

ty

Evi

den

ce R

ef

Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Health Group


1

NHSLA Standard


1.8



Jul / Jan Aug / Feb

Health Group


1

NHSLA Standard


4.8

1,5



determined)

Outreach Team

Jul / Jan Aug / Feb

Health Group



e 4.10

1,5


Divisional Nurse

Managers

May / Aug /

Nov / Feb


Health Group


1


1,5



quarter)


Team

May / Aug /

Nov / Feb


Health Group


1


Thromboembolism

5.9

1,5




May / Sept / Jan

Jun / Oct / Feb

Health Group NHSLA Audit – Trust

1 NHSLA

Standard Clinical

1,5 Clinical Handover of Care (15 per Health

Group annually)

Divisional Nurse

Managers Sept-13 Mar-14

32

Division

Sp

ecia

lty

Rationale (e.g.

NICE, NSF,

CNST, risk, local

issue)

Pri

ori

ty

Evi

den

ce R

ef

Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

wide Handover of Care

4.9

Trauma NEUROSUR

GERY



e 4.10


(10 patients)

Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Trauma NEUROSUR

GERY Local 3 Local 3

Imaging and Admission of Children with Head Injuries - Compliance with NICE

Guidelines

Sarah Braungart

Gerry O'Reilly

Mar-13 Jul-13

Trauma ORTHOPAE

DICS



e 4.10

1,5

Patient Information and Consent Audit (10 patients per specialty, annually)

Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Trauma ORTHOPAE

DICS National 1 National 1 National Joint Registry (NJR) Amr Mohsen Ongoing Ongoing

Trauma ORTHOPAE

DICS National 1 National 1 NHFD: Hip Fracture Amr Mohsen Ongoing Ongoing

Trauma ORTHOPAE

DICS Local 3 Local 3

Evaluation of Current Practice for the Use of Abduction Splints/Braces after Closed

Reduction of Dislocated THR Amr Elkhouly Mr Gopal Apr-13 Oct-13

Trauma PLASTIC

SURGERY



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Trauma PLASTIC


Excision Margins of Cutaneous Squamous Cell Carcinoma of the Scalp

Simon Nicholson

Apr-13 Dec-13

Trauma PLASTIC


Use of MRA in Breast Reconstruction with Free Abdominal Tissue Transfer

Simon Nicholson

Apr-13 Jan-14

Trauma PLASTIC


Audit of Rates of Metastasis in Squamous Cell Carcinoma

Ryian Mohamed

Mr Matteucci

Mar-13 Jun-13

33

Division

Sp

ecia

lty

Rationale (e.g.

NICE, NSF,

CNST, risk, local

issue)

Pri

ori

ty

Evi

den

ce R

ef

Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

General Surgery

VASCULAR SURGERY



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

General Surgery

VASCULAR SURGERY

National 1 National 1 National Vascular Registry (NVR) Ongoing Ongoing

General Surgery

VASCULAR SURGERY

National 1 National 1 National Carotid Interventions Audit

(included in VSSGBI VSD) Mr Khan Ongoing Ongoing

General Surgery

VASCULAR SURGERY

Local 3 Local 3 EVAR Pathway Mr

Akomolafe Nov-13 Jan-14

General Surgery

VASCULAR SURGERY

Local 3 Local 3 Audit of Uptake of Exercise Programme

for Claudicants Mr

Akomolafe Oct-13 Dec-13

General Surgery

VASCULAR SURGERY

Local 3 Local 3 Audit of Vascular Waiting List Mr

Akomolafe Jul-13 Oct-13

General Surgery

ACUTE SURGERY



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

General Surgery

ACUTE SURGERY

National 1 National 1 National Emergency Laparotomy Audit

(NELA) TBC TBC

General Surgery

ACUTE SURGERY

Local 3 Local 3 Audit of MRCP Protocol Mr Gunn Dec-13 Feb-14

General Surgery

ACUTE SURGERY

Local 3 Local 3 Diagnostic Value of Ultrasound on Acute

Surgical Floor Mr Gunn/Mr Lockwood

Jul-13 Oct-13

General Surgery

COLORECTAL SURGERY



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

General Surgery

COLORECTAL SURGERY National 1 National Bowel Cancer (NBOCAP) Mr Gunn Ongoing Ongoing

General Surgery

COLORECTAL SURGERY Local 3 Local 3

Role of Early Diagnostic Laparoscopy in the Management of Lower Abdominal

Pain in Female Patients Arif Zafar Apr-13 Jan-14

34

Division

Sp

ecia

lty

Rationale (e.g.

NICE, NSF,

CNST, risk, local

issue)

Pri

ori

ty

Evi

den

ce R

ef

Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

General Surgery


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

Resection Adele Sayers Apr-13 Jan-14

General Surgery


The Use of Brush Cytology in the Diagnosis of Colorectal Cancer within the

Bowel Cancer Screening Programme

Ruth Loveday

Professor Duthie

Mar-13 Jul-13

General Surgery

UROLOGY



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

General Surgery

UROLOGY National 1 National 1 Prostate Cancer Ongoing Ongoing

General Surgery

UROLOGY Local 3 Local 3 Adequacy of VTE Assessments Jamal Omara Mr Myatt Jun-13 Sept-13

General Surgery

UROLOGY Local 3 Local 3 Evaluation of Rectal Flora of Patients

Undergoing Trans-rectal Ultrasound and Biopsy

Ahmad Abdul-

Rahman Mr Myatt Nov-13 Feb-14

General Surgery

UROLOGY Local 3 Local 3 Role of MRI Baseline in Active

Surveillance Lehana Yeo Mr Myatt Nov-13 Feb-14

General Surgery

UROLOGY Local 3 Local 3 The Role of Contrast and Enhanced

Ultrasound in the Evaluation of Localised Prostate Cancer

Pejman Kheirandish

Mr Myatt Nov-13 Feb-14

General Surgery

UROLOGY Local 3 Local 3 Semenalysis in Patients who Have Been

Treated for Testes Cancer John Powell Mr Myatt Nov-13 Feb-14

Specialist Surgery

ENT



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Specialist Surgery

ENT National 1 National 1 Head and Neck Oncology (DAHNO) Mr England Ongoing Ongoing

Specialist Surgery

ENT National 1 National 1 Myringoplasty Audit Mr England Ongoing Ongoing

35

Division

Sp

ecia

lty

Rationale (e.g.

NICE, NSF,

CNST, risk, local

issue)

Pri

ori

ty

Evi

den

ce R

ef

Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Specialist Surgery

ENT Local 3 Local 3 Audit of Pharyngeal Pouch Management -

Surgical Outcomes Seb Wallis Mr England Apr-13 Mar-14

Specialist Surgery

ENT Local 3 Local 3 Audit of Thyroxine Replacement Post

Total Thyroidectomy Seb Wallis Mr England Apr-13 Dec-13

Specialist Surgery

GASTROENTEROLOGY & ENDOSCOPY



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Specialist Surgery


National 1 National 1 Inflammatory Bowel Disease (IBD) Dr Sebastian Ongoing Ongoing

Specialist Surgery


National 1 National 1 Audit of Blood Component Use in Patients

with Liver Cirrhosis Shairoz Samji

Dr Abouda Mar-13 Apr-13

Specialist Surgery

HEAD AND NECK MAX

FAX



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Specialist Surgery

HEAD AND NECK MAX

FAX Local 3 Local 3

Maxillofacial SHO Knowledge and Management of Dental Trauma in HRI

A&E Suresh Nayar May-13 May-13

Specialist Surgery

UPPER GI



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

Specialist Surgery

UPPER GI National 1 National 1 Oesophago-gastric Cancer (NAOGC) Mr Jain Ongoing Ongoing

Critical Care

ANAESTHETICS

Local 3 Local 3 Muscle Relaxant Audit J Biddulph Dr Lanka Apr-13 Aug-13

Critical Care

ANAESTHETICS

Local 3 Local 3 Cardiothoracic Theatre Start Times C Haworth Dr

Ananthasayanam

Apr-13 Jul-13

Critical ANAESTHET Local 3 Local 3 Vertebroplasty and Kyphoplasty: audit of Philip Apr-13 Jan-14

36

Division

Sp

ecia

lty

Rationale (e.g.

NICE, NSF,

CNST, risk, local

issue)

Pri

ori

ty

Evi

den

ce R

ef

Co

rpo

rate

Ob

ject

ive


Lead

Lead Clinician /

Project Sponsor

Proposed Start Date

Proposed Completion

Date

Care ICS Anaesthetic Service Provision Buckley Critical Care

ANAESTHETICS

Local 3 Local 3 An Audit of Rate of Dural Puncture After Epidural Insertion on the Labour Ward

Helen Doherty

Dan Mikl Apr-13 Aug-13

Critical Care

ICU AND HDU

National 1 National 1 Adult Critical Care (ICNARC) P Gray Ongoing Ongoing

Critical Care

ICU AND HDU

National 1 National 1 Potential Donor Audit T Heron Ongoing Ongoing

Critical Care

PAIN SERVICES



e 4.10

1,5


Quality and Safety

Managers

Eileen Henderson

Aug-13 Mar-14

37

APPENDIX II

PROPOSED ACTIONS FROM LOCAL CLINICAL AUDITS 2012/13

Local audit Specialty Actions the Trust intends to take to improve the

quality of healthcare provided

Clinical Support

Information Governance Audit for Clinical Support Health Group

Health Group (1) To continue with the current local process ensuring that all elements of Information Governance

are being addressed (2) To undertake a re-audit in October 2013

Comparison of the Labelling Efficiency of White Cells with In-oxine using (i) cell-free plasma and (ii) 0.9% Aqueous Solution of Sodium Chloride

Nuclear Medicine (1) Change protocol to use of 0.9% saline rather than CFP. (2) On-going review of labelling efficiency.

Endoscopic/floroscopic Stenting Versus Operative Gastrojejunostomy for Malignant Gastric Outlet Obstruction

Radiology (1) Consider duodenal stenting when suitable as first line in palliating malignant gastric outlet

obstruction

Quality of Posterior Anterior Chest X-Rays in CHH Match Up to the Standards Set Out by the European Guidelines

Radiology (1) Re-audit (2) Refresh technique (3) Review of exposure factors

38

An Audit to Assess the Accuracy of the Red Dot System on Paediatric X-rays Within A&E Radiology Dept

Radiology

(1) Re-audit (2) More application of the red dot system on paediatric radiographs from radiographers including

better understanding of paediatrics anatomy (3) Review of the red dot system throughout the radiography department with interest to paediatric

abnormality and normality of radiographs

The Effects of Collimation and Lead Rubber Equivalent on Doses to the Thyroid and Gonad in Relation to Chest Imaging

Radiology (1) To amend the paediatrician protection guideline protocol to reflect recommendation of the audit (2) Re-audit. (3) Staff training

Clinical Re-audit of the Use of CT Scanning for Head Injury Patients

Radiology (1) Education of referrers and NICE guidelines (CG56) resent to ED team

Professional Practice Self Audit of Clinical Reporting Skills 2012

Radiology (1) Re-audit to ensure standards are met

Consent Audit for Vascular Radiology

Radiology (1) Re-audit in 18 months, after the day case is well established.

A Retrospective Audit of Barium Swallow Examinations: Accuracy in Cancer Detection in Oesophagus and Pharynx

Radiology (1) Re-audit in 1 year to ensure the accuracy of detection of these cancers

Embolisation of Renal Angiomyolipoma: Complications, Short-Term and Long-Term

Radiology

(1) CT follow-up yearly post embolisation with discontinuation of follow-up if significant size reduction (>30%) has occurred after 3 year

(2) If minor reduction is observed continued follow-up to detect regrowth, repeat embolisation if regrowth occurs at any stage during follow-up

(3) Long-term follow-up for patients with tuberous sclerosis, with techniques not involving ionising

39

Outcomes and Patterns of Tumour Shrinkage

radiation (US or MRI)

Assessment of Image Quality of Supine Abdomen Radiograph using HEYRAD12 Examination Protocols

Radiology (1) Drive the strategy to follow the recommendations (2) Re-audit

Professional Practice - Self Audit or Clinical Reporting Standards

Radiology (1) Re-audit

Time Wasted in CT and MRI Scanners Due to Inadequately Prepared Patients

Radiology (1) No further actions needed

Consent Form Audit Clinical Haematology (1) No further action required

To Compare the Expected Date of Discharge to Actual Date of Discharge of Patients on Ward 33

Clinical Haematology

(1) Review EDD as part of the weekly ward round (2) Ensure all Consultants are involved (3) Audit current length of stay for different scenario's to estimate future EDD

Record Keeping Audit Clinical Oncology

(1) Re-audit on a monthly basis from April 2013 (2) Disseminate to staff groups and highlight areas for improvement (3) Implement stamps for all members of staff to support identification

Consent Form Audit Clinical Haematology (1) Re-audit

Audit of the Care of Oncology Patients Admitted in the Queens

Clinical Oncology

(1) To propose that further learning occurs through the appropriate Mortality meetings internal and external to the Trust

(2) Audit of patients with breast cancer undergoing chemotherapy with FEC-T to identify rate of NI as well as adherence to policy

40

Centre for Oncology and Haematology with Suspected Febrile Neutropenia

(3) Audit adherence to guidelines in the use of G-SCF for the management of NI (4) Continue with the rolling audit (5) Continue effective training of junior doctors in the management of neutropenic infections

Preferred Priorities/Place of Care - Point Prevalence Survey

Clinical Oncology

(1) Sharing of findings as those identified within the dissemination of results (2) Ward visits and planned teaching /awareness work plan programme incorporating the

recognition of Palliative End of life Care patients and the PPOC (3) Repeat Survey in 6 months’ time

Scoping Exercise to Measure the Awareness and Understanding of the Rapid Palliative Discharge Pathway Document

Clinical Oncology

(1) To share the findings of the exercise (2) To identify a link nurse for each of the top ten ward areas and to develop a two way

communication system to enable the cascading of information to support the safe and timely discharge of palliative end of life care patients

Assessment of the Completion of Immediate Discharge Letters Issued to Patients Discharge from the Queens Oncology Centre

Clinical Oncology (1) Re-audit 2014

Extravasation Audit 2012

Clinical Oncology (1) An extravasation form should be completed at time of any extravasation incident and kept with

chemotherapy documentation. To add the Datix number to allow future correlation and audit of data.

Audit to Assess the Indications for the Administration of Parenteral Nutrition (PN) to patients in the Queens Centre for Oncology and Haematology

Dietetics - Therapies

(1) Raise the profile of the nutrition team: Nutrition team to build relationships with ward staff at the Queens centre. Education of doctors around re-feeding syndrome PN, line care etc.

(2) Education of nurses - competency based training re line-care involving teacher practitioners, senior nurses (B6) and ward nutrition link nurses

(3) Repeat the audit using some of the NCEPOD data collection particularly around CVC access.

41

Could a New Approach to the Food Record Chart Help to Reduce Mortality in Hospital Inpatients?

Dietetics - Therapies (1) Training on nutrition screening tool and food chart (2) Re-audit of food charts to ensure compliance

Record Keeping Audit Infectious diseases (1) Re-audit

HIV testing in TB clinic Infectious Diseases (1) Re-audit in 6 months (2) To present the findings of the audit at the TB MDT and to discuss whether a clinic protocol is

needed

Virological/treatment Failure in HIV-infected Patients Established on ART (anti-rettoviral therapy)

Infectious Diseases

(1) Further study to look into other factors not identified such as naïve / experienced, adherence, individual factors and future viral local findings

(2) Closely monitor patients within the LLV group and assess virological and clinical progress and eventual prognosis

(3) Perform more resistance testing (although from real life experience it has invariably been technical limitation in processing the samples rather than requesting the test)

Venous Thromboembolism (VTE) Prophylaxis for Maternal Post Delivery

Pharmacy

(1) Pilot use of the new drug chart on postnatal wards (2) Revise and update TTO to include a space for documenting maternal weight. (3) Staff training on VTE risk assessment, VTE guideline and documentation of information

regarding VTE on drug chart, TTO and maternal record – to sign to confirm (4) Update VTE patient information leaflet regarding VTE prevention by early mobilisation and

hydration, and replace the previous version on the Trust intranet. (5) Update VTE guideline regarding the need to provide and discuss VTE leaflet to all postnatal

women on discharge at renewal date (6) Create and incorporate a discharge checklist for VTE into postnatal maternal records – staff to

sign to confirm information discussed with patients (7) Re-audit clinical compliance with VTE risk assessment.

Drug Policy: Do Doctors Prescribe According to the Prescribing Standards

Pharmacy (1) Further training to junior and senior doctors (2) Alterations to the drug chart (pre-printed amendments)

Appropriateness of Quinolone Prescribing at HEY

Pharmacy (1) Review of guidelines with consideration to making Ciprofloxacin an alert antibiotic (2) Encourage complete documentation, particularly with regards to outpatient prescriptions

Does PGP Affect Obstetric Outcome?

Physiotherapy - Therapies

(1) Staff training/monitoring of birth outcomes

42

Amputation to Cast Audit 2012


(1) Use results of the audit to inform patients of average amputation to cast time (2) Agree service to monitor the future service (3) Re-audit 2013

Physiotherapy Acute Respiratory COPD Service (PARCS) Outcomes Measures Audit.


(1) Research EQ-5D and begin trial of its use (2) Re-audit to reassess use of CCQ and to assess usefulness of EQ-5D

Is a Home Visit an Effective Use of Physiotherapy Time for Paediatric Cystic Fibrosis Patients Having Intravenous Antibiotics


(1) Feedback information to CF team and Physiotherapy manager

Physiotherapy Fracture Management Service


(1) Patient Satisfaction Survey for spinal # management pathway (2) Re-audit of Activity levels 2011-2012

An Audit of Physio Note keeping Standards


(1) Re-audit 2014

Rehabilitation Services Head and Neck Cancer Care Pathway Audit/ Service Education


(1) Larger scale audit of head and neck cancer rehabilitation pathway (2) Review of other cancer rehabilitation pathways

Re-audit- Neurosurgical Physio Phone Follow-up Service Activity 11-12 (previously 2430)


(1) Activity to be re-audited on a yearly basis (NB – unless discharge to Consultants increases significantly it is not thought appropriate to continue to audit outcomes from clinic reviews)

Physiotherapy Dept Activity Audit


(1) Review on duty activity and skill mix with Section heads at 1:1s, undertaking further audit as necessary (2) Re-audit annually to ensure clinical time is maximised (3) Development of band 2 physiotherapy helper role which will take on some of the non-clinical duties currently covered by band 3 and band 4 staff

43

A 6 Month Retrospective Analysis of the Neurosurgical Physiotherapy Service for Vertebroplasty Patients


(1) No actions

Audit of Bereavement Protocols in Women's and Children’s Services Against HTA (Human Tissue Authority)

Histopathology (1) Monitor through joint monthly meetings of bereavement services and W&C (2) Develop guidance for induction training in labour and delivery suite (3) Re-audit in early 2014 - now that the bereavement pathway booklet is fully rolled out

Re-audit of Time to Report of Respiratory Syncytial Virus Testing

Virology (1) Report to Microbiology Audit Group (2) Report to Sister 120, Matron Paediatrics (3) Report to Clinical Support Governance Committee

Audit of Compliance with the Trust Guidelines for Initial Investigations for Sepsis in Adults

Microbiology

(1) Review antimicrobial guidelines (2) Dissemination and education (likely most effective if co-indices with new guidelines launch or

junior doctor induction) (3) Re-audit to ensure compliance

44


quality of healthcare provided Family and Women’s Health

Information Governance Audit

Health Group Wide

(1) Audit findings to be discussed at each of the speciality audit meetings and speciality governance meetings

(2) Discuss audit findings at Senior Staff Meeting (3) Continue to monitor compliance with undertaking Information Governance training through

monitoring at Speciality Governance meetings (4) Shared folders to be established by each speciality and 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

(5) 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

Record Keeping Audit Neonates (1) Add GMC number (2) Repeat audit next financial year as per policy

Audit of Management of Preterm Infants Born Before 28 Weeks Gestation - Re-audit

Neonates (1) Add to admission sheet to collect information on thermoregulation measures (2) Use green sheets for parental communication for antenatal counselling

Use of Epidurals on the Neonatal Unit

Neonates (1) Re-audit in July 2015 (only 4 patients per year) (2) Feedback findings to Guideline Development Group

Surfactant Administration for Preterm Babies at 28 Weeks Gestation

Neonates (1) To consider including prophylactic surfactant administration in babies at 28 weeks of gestation

after further discussion in perinatal meeting

Neonatal Abstinence Syndrome Guideline Audit

Neonates (1) Review 5 sets of notes to cross check morphine given (2) Discuss results with Obstetrics and Midwifery

Management of Babies with Invasive Group B Streptococcus Disease

Neonates (1) Review practice of treatment of grunting babies on PNW/NICU - using specials system and

badger admissions

Audit of Babies at Risk of Neonatal Abstinence Syndrome Admitted to

Neonates (1) Presentation of the audit to midwifery and obstetrics - through NDT audit meeting in May. (2) Presentation of associated audit of management of babies with NAS on the NNU at same

meeting.

45

Transitional Care or Postnatal Wards

(3) Discussion about findings at TC planning meetings

Neonatal Intubation Audit

Neonates

(1) Investigate ways of recording intubation on Badger (2) Ensure sedation for intubation included in induction teaching (3) To trail shared skills development plan for trainees (4) Laminate list of times to be documented after intubation and attach to intubation trolley

NLS Guideline Implementation for Babies Born Through Meconium at the HRI

Neonates (1) Ensure that management of new-borns born through meconium stained liquor is included in

neonatal junior staff induction training.

Clinical Audit of Pre-assessment for Elective Paediatric Surgical Patients

Paediatric Medicine (1) Re-audit (2) Implement Checklist (3) Update other specialities - Mr Daniel to email orthopaedic, ENT & Plastics

Audit of Part C Initial and Review Health Assessments forms

Paediatric Medicine

(1) Development and writing of standards of completion for initial and review health assessments and the reporting documents. Presentation of the standards to managers in CHCP, HEY and the LA for agreement.

(2) Development of training package and then training offered to professionals in community medical, health visitors, school nurses and members of the LAC nursing Team.

(3) Re-audit of quality of documentation completion

Screening for Congenital Hypothyroidism - Are we following the guidance?

Paediatric Medicine (1) Improved documentation in notes about screening results and issue of leaflets by Consultant. (2) Copying the clinic letter to health visitor and screening lab.

Insulin Pumps (CSII) – Are we following NICE guidance?

Paediatric Medicine (1) Improve promotion of pump education (2) Urgent need for more diabetic nurses (3) Re-audit in 3 years

IDLs on Children Admitted to HRI with Diagnosis of Diabetes

Paediatric Medicine (1) Diabetes team to put appropriate information in notes. (2) Including IDL requirements relating to diabetes IDL in junior doctors induction. (3) Re-audit.

Paediatric IDL Coding Audit

Paediatric Medicine

(1) Re-audit (2) Guideline/Protocol for IDL content to be given and available for doctors on wards? ensure

template has relevant prompts

46

Non-operative Management of Blunt Spleen and Liver Trauma

Paediatric Surgery (1) Consider implementing APSA trauma committee guidelines for haemodynamically stable

children with blunt spleen and liver injury

Breast Care Follow up Patient Survey

Breast Screening and Surgery

(1) Outcome form 2 (2) Re-audit August 2014. (3) Education Sessions (4) Telephone assessment appointments (5) To ensure patients are receiving their management plans. Asl patients to complete repeat

survey once plan has been received. (6) To audit the appropriateness of referrals to medical staff. Discussion needs to take place as to

how this audit can be developed. (7) Develop patient survey for patients to complete on discharge.

Impact of Long Acting Reversible Contraception

Gynaecology

(1) Staff and patient education regarding the effectiveness of LARC in reducing unwanted pregnancy.

(2) Address medical and nursing staff training and availability for the MTOP service. (3) Repeat uptake of LARC at MTOP. (4) Audit under 25 year old subgroup for repeat abortion vs. national statistics and method of

contraception at termination.

Gynaecology Miscarriage Audit

Gynaecology (1) Disseminate through audit meeting (2) Disseminate to EPAU Lead. (3) Disseminate to EPAU Nurse lead.

Audit of Pregnancy Advisory Service Against RCOG Evidence Based Guidelines

Gynaecology

(1) Feedback to staff . Raise awareness of need for completion of all parts of pathway; the prompts are there but not used/completed.

(2) Add to STI risk assessment on pathway as prompt. (3) Review arrangements for chlamydia screening in the clinics/ notes completion on the ward. (4) Continue drive to skill medical and nursing staff in discussing and providing all possible methods

of contraception for MTOPs. (5) Highlight need for bridging contraception if immediate method not available/ patient unsure; pre-

assessment medic to do. An Audit to Assess What Percentage of Pregnant Women with a BMI over 30Kg/M2 Attends Healthy Lifestyles Clinics Throughout Their Pregnancy

Obstetrics (1) Implement texting service.

Support for Parents Obstetrics

(1) Education of midwives and nurses on how to access services to support women with communication and language support needs and the importance of documenting the services provided.

(2) Development of a care pack for parents whose baby is receiving palliative care.

47

Record Keeping Monthly Spot Checks

Obstetrics

(1) Maintain and improve general standards of record keeping (2) All midwives to undertake some self-audit of records as per this standard (3) Monthly random spot check of 10 sets of notes using devised tool (4) Revision of spot check audit tool ref: CNST standards

Record Keeping Audit Local Supervising Authority Supervisors of Midwives

Obstetrics

(1) Maintain and improve general standards of record keeping (2) All midwives to undertake some self-audit of records as per this standard (3) Re-audit records on annual basis (4) Revision of self-audit tool/record keeping audit ref: CNST standards (5) Monthly spot check of records to be undertaken to be reported to SoM meetings on a monthly

basis and findings disseminated to managers/midwives issues to be escalated as required number will remain at 10 per month

(6) For record keeping to be re-introduced to mandatory training from February 2013 and all outcomes from the audit to be communicated within the training

Care of Women in Labour

Obstetrics

(1) To research documentation in other Trusts and devise a new Labour Record for use within this Trust.

(2) To continue with education of staff regarding the information which must be completed for the care of women in labour.

(3) Circulate results of this audit through Labour Ward Practitioners Newsletter & Team Training sessions.

(4) Present audit results at Labour Ward Forum.

Continuous Electronic Fetal Monitoring (Quarterly)

Obstetrics (1) Disseminate results (2) Launch Fresh Eyes Approach (3) Update staff as to changes in new guideline

Use of Oxytocin (Bi Annual)

Obstetrics

(1) Results dissemination (2) Audit presentation (3) Change the local guidelines (4) Re-audit

Induction of Labour (Quarterly)

Obstetrics (1) Re-audit to report June 2013. (2) Increase compliance re maternal observations and fetal monitoring through a reminder system. (3) Monitor planning for failed IOL.

High Dependency Care (Bi Annual)

Obstetrics (1) Continue audit through MDT meetings. (2) Highlight new guidelines to staff.

Vaginal Birth After Caesarean Section (Annual)

Obstetrics (1) Raise the profile of use of the VBAC Sticker. (2) Ensure the VBAC leaflet being given at booking appointments. (3) Re-audit 2013/14 to ensure improvement in compliance.

48

Severe Pre-eclampsia (Quarterly)

Obstetrics

(1) Continue to audit all identified cases through MDT and address individuals where appropriate as part of the feedback

(2) Highlight the guideline through YMET training (3) Develop discharge letter

Eclampsia (Quarterly) Obstetrics

(1) Continue to audit all identified cases through MDT & address individuals where appropriate as part of the feedback.

(2) Highlight the guideline through YMET training. (3) Develop discharge letter.

Operative Vaginal Delivery (Quarterly)

Obstetrics (1) Continue to audit all identified cases through MDT and Address individuals where appropriate as

part of the feedback (2) Feedback results through LWP Newsletter

Multiple Pregnancy and Birth (Yearly)

Obstetrics

(1) Report current discrepancies between NICE and Trust Guideline. Provide report to Trust Board to acknowledge working outside NICE Guidance.

(2) Feedback at next Obstetric and Gynaecology Governance meeting that we are working outside NICE Guidance and the results.

(3) Re-audit within the financial year 2013 - 2014.

Perineal Trauma (Bi annual)

Obstetrics

(1) Education of staff regarding importance of documentation of consent, swab/sharp checking and advice.

(2) Education of staff regarding what advice should be given to women post-delivery with regard to perineal care.

(3) Education of staff of the importance of appropriate pain relief for women post birth. (4) Review of paperwork in use to support staff in documentation completion.

Shoulder Dystocia (Quarterly)

Obstetrics

(1) Continue audit through MDT meetings, individual staff members addressed through feedback from these meetings

(2) Highlight new guidelines to staff (3) Importance of completion of proforma through yearly obstetric emergencies training

Post Partum Haemorrhage (Quarterly)

Obstetrics

(1) Continue audit through MDT meetings (2) Explore the new Trust Fluid balance charts and teaching programme (3) Address with individuals where fluid balance has not been appropriately completed via feedback

from MDT case reviews

Venous Thromboembolism - Risk assessment and prophylaxis (Quarterly)

Obstetrics

(1) To introduce a maternity specific VTE risk assessment form for booking and inpatient stays. (2) To update the VTE Guideline against CNST Maternity Standards and the RCOG Green Top

Guideline No 37a (November 2009) Reducing the risk of thrombosis and embolism during pregnancy and the pueperium.

(3) To educate all staff in maternity services surrounding the completion of VTE risk assessment documentation

49

Pre-existing Diabetes (Yearly)

Obstetrics (1) Introduction of the new document to go in the notes.

Obesity (Yearly) Obstetrics (1) Raise awareness of importance of weight at 36 weeks. (2) VTE compliance.

Booking Appointments (Quarterly)

Obstetrics (1) Staff training and information sharing at managers and team meetings (2) Re-audit July 2013

Missed Appointments (Quarterly)

Obstetrics

(1) Staff awareness to changes to the original guideline (2) Discuss with Gynae Service possibility of women who have booked for maternity care to be

notified to maternity services to reduce repetitive appointments being generated (3) Discuss with AN Managers and Clerical Officers to enable copies of correspondence to GP and

Women if non attending for booking. (4) To re audit October 2013 then 6 monthly

Antenatal Clinical Risk Assessment (Quarterly)

Obstetrics

(1) Staff awareness of guideline and use of links to access relevant referral pathways to be discussion at community and hospital ward meetings

(2) Staff awareness to improve documentation within labour summary records (3) Agenda issues with antenatal checklist for next community meeting (4) Re-audit August 2013

Patient Information and Discussion (Bi annual)

Obstetrics (1) To discuss results at next unit meeting and managers meeting (2) Re-audit July 2013

Mental Health (Yearly) Obstetrics

(1) Disseminate recommendations of audit to midwives to aid improving practice, via community meetings and management.

(2) Contact SPA team and IAPT team regarding improving documentation between services. (3) To discuss results at next unit meeting and managers meeting (4) Re-audit July 2013

Handover of Care (Quarterly)

Obstetrics (1) Staff awareness (2) Review current documentation to ensure compliance (3) Re-audit May 2013

Maternal Transfer by Ambulance (now yearly because sample size too low)

Obstetrics (1) Establish log of transfers on L&D suite (2) Re-audit July 2013

50

Non-obstetric Maternity Care (Bi annual)

Obstetrics

(1) Send out copies of Guideline 59 and flowcharts from Guideline to Obstetric & Non Obstetric areas to inform of the process

(2) Establish system of labour/maple ward of where the information is to be recorded and investigate possibility of an Obstetric Communication Sheet

(3) Re-audit

Antenatal Screening Tests in Pregnancy (Quarterly)

Obstetrics

(1) Identify way in which maternity services can evidence review of infectious disease screening results within 10 days of them being taken

(2) Failsafe to be put in place in ANC/Community midwifery areas to ensure that all Downs Syndrome Screening tests taken can be accounted for within the required timeframe

(3) Audit proforma to be rewritten to also include requirement for screen positive test results to be audited

(4) Re-audit guideline quarterly

Referral When Fetal Abnormality Detected (Quarterly)

Obstetrics (1) Guideline change regarding ultrasound report

Immediate Care of the Newborn (Quarterly)

Obstetrics (1) Recommendations to be discussed at labour ward forum.

Examination of the Newborn (Quarterly)

Obstetrics (1) Complaint - no actions needed this quarter.

Bladder Care (Quarterly)

Obstetrics (1) 100% compliant - no actions (2) Full compliance positive feedback to be given via newsletter.

Recovery (Quarterly) Obstetrics

(1) To improve compliance with completion of fluid balance charts - actioned through spot check audits

(2) Compliance with discharge and transfer criteria from recovery (3) Compliance with completing set of observations on Recovery Chart (4) Fluid balance chart to be completed, staff to be informed. (5) Minimum observations to ensure staff compliant.

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Medicine

Information Governance Audit for Medicine Health Group

Health Group (1) If further audit is required, Central Governance team to consider production of a central audit tool

Consent Audit Health Group

(1) Healthcare professionals should be reminded about the importance of completing each section of the consent form correctly. Medicine Health Group will make results available through Governance Structure (2) Continue annual Audit (3) Consider merging Consent Audit with Patient Information Leaflet Audit (including review of cohort) as per actions from Audit 3306

Trust-wide Patient Information Audit

Health Group

(1) Data collection proforma should be revised (2) Amalgamate audit with other Trust-wide audits (ie consent)

Record Keeping Audit

Acute Assessment Unit

(AAU)

(1) New audit cycle (2) Introduction of new section about importance of accurate record keeping on the Trust intranet site (3) Provision of more posters in the department

An Examination of Hull Royal Infirmary's DVT Re-scanning Policy

Acute Assessment Unit (AAU)

(1) Standards met (97% compliance). Re-audit

Clinical Quality Indicators in AAU


(1) Re-audit

Management of Sepsis on AAU


(1) Re-audit (2) Improve training (3) Poster display

Intravenous Peripheral Cannula Audit


(1) Provide Targeted Training Programme (2) Review Emergency Department assessment documentation (3) Review location of patient information within AAU (4) Monitor staff compliance via HII 2 Cannula Care Bundle (5) Re-audit of practice

Record Keeping Audit Emergency Department

(1) Consideration of changes to A&E Documentation to be discussed at Governance Forum. (2) Re-audit

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Record Keeping Audit Chest Medicine (1) No actions specified - outcomes form needs re-doing

Clinical Re-audit on Performance and Interpretation of Spirometry

Chest Medicine (1) Spirometry training for junior doctors within first month of rotation

Clinical Audit on Performance and Interpretation of Spirometry (GICU2)

Chest Medicine (1) Spirometry teaching sessions for respiratory junior doctors 2. Re-audit

Clinical Re-audit on Performance and Interpretation of Spirometry (GICU2)

Chest Medicine (1) Spirometry training for junior doctors within first month of rotation

Record Keeping Audit Diabetes And Endocrinology

(1) Medical staff education to ensure proper medical note format including patient identifier, signature and staff designation

(2) Review requirement of bleep number to be recorded (3) Re-audit

Audit of Antibiotic Prescribing on Ward 10

Diabetes And Endocrinology

(1) Trust antibiotic guideline poster in ward - easy for all doctors to see (2) Regular consultants' review for prescribing antibiotics especially in AAU (3) Awareness of inappropriate use of co-amoxilar, to ensure consultants lead by example

Audit of Insulin Pump Service with Particular Focus on Emergency Admissions in Pump Patients and Pump Discontinuation Rates


(1) The pump team should identify early individuals with no improvement in HbA1c and a record of clinic DNA for discussion about underlying issues as a barrier to achieving poor glycaemic control.

(2) Re-audit in three years.

Audit of Bone Density (DXA) Requests Received


(1) Chief Technician to discuss implementation of electronic requesting with Clinical Lead (Dr Aye), and appropriate Trust staff.

(2) Re-audit once electronic requesting has been fully operational for at least 3 months

Accuracy of RadCentre Data Entry for Bone


(1) No actions - re-audit in 2013

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Density (DXA) Scans

The Use of Head CT Scans to Investigate Delirium in Older People

Medical Elderly

(1) Patients should be fully assessed neurologically for symptoms and signs of intracranial pathology (2) Posters showing the indications for head CT scans can be put up in acute assessment unit and

elderly wards (3) The physical examination page in the admission pathway can be divided into sections of all the

systems including neurological system to help remind doctors to do a full assessment Audit of the Use of Antibiotics for Treatment of Urinary Tract Infections

Medical Elderly (1) Re-audit to ensure improvements are continued

Re-audit of Antipsychotic Prescribing in Acute Hospitals for Patients with Dementia

Medical Elderly (1) Adhere to further National Audit Cycles through the National Audit of Dementia

Dementia Screening: Has the dementia diagnostic assessment tool improved patient care

Medical Elderly

(1) Redesign of DDA tool (2) Training (3) Re-audit (4) Arrange meeting with SPA to develop a referral form for referral of patient’s with a suspected dementia diagnosis to SPA

Record Keeping Audit Nephrology / Renal (1) Clear identification of person signing name (2) Two sided identification of patient 3. 24 hour clock

Recording of Transplant Status in Notes of new RRT Patients

Nephrology / Renal (1) Re-audit (2) Refer patients with type 1 diabetes for work-up with e-GFR = 20

Vascular Access -Patients Commencing HD via Catheters

Nephrology / Renal (1) Re-audit in six months

Record Keeping Audit Rheumatology (1) Record Keeping training for nursing and clerical staff (2) Review the guidelines for ward 1 as no bleep carried by junior staff and no procedures on ward

one

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EULAR Recommendations for Vaccinations in Adult Patient with Inflammatory Rheumatic Conditions

Rheumatology (1) GP awareness by incorporating a foot note in clinic letters (2) Re-audit

Use of Golimumab According to NICE Guidelines in Inflammatory Arthritis

Rheumatology (1) Ensure follow up appointments offered timely (2) Re-audit in 2015

Record Keeping Audit Dermatology

(1) Re-audit (2) Disseminate and discuss results of this audit with Dermatology Team and Service Managers (3) Ensure familiarity and compliance with the Trust “Patient Documentation Policy” and related

policies (4) Clinicians should be encouraged to use a stamp bearing their name and grade (5) Enhanced support should be made available to the non-clinical staff (6) Prepare a list of the documentation required, as an aide-memoire, for clinicians who perform

minor surgical procedures.

Consent Audit Dermatology

(1) Re-audit. (2) Disseminate and discuss results of this audit with Dermatology Team and Service Managers. (3) Ensure familiarity and compliance with the Trust “Policy on consent to examination or treatment”

and related policies. (4) All patients should receive verbal and written information about their minor surgical procedure

and it should be documented on the consent form that this has been done. (5) The Dermatology Patient Information Leaflet, “Minor Surgery”, should be reviewed and if

necessary updated. (6) Ideally, the clinician carrying out the minor procedure should complete the consent form. (7) Collate a register of those clinicians who:

a) Have been trained in each type of minor surgical procedure and are able to carry out consent for each type of procedure, or who b) are authorised to obtain consent for each type of minor surgical procedure but who are not capable of performing the procedure.

(8) Liaise with the clinicians on an individual basis who completed the consent forms used in this audit to discuss with them the areas where they need to meet the required standards.

(9) All patients should be given a telephone number to contact in the event of a problem post-operatively.

(10) Clinicians should be encouraged to use a stamp bearing their name and grade. (11) A list of abbreviations for use in Dermatology records should be drawn up and approved. (12) The first page of the Trust consent form could be re-designed so that the details of responsible

health professional are separate from the patient details.

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(13) The specific risks of the minor surgical procedures could be pre-printed on the consent form with adjacent tick boxes.

Isotretinoin Compliance Regional Audit

Dermatology

(1) Re-audit (February 2014) (2) Disseminate and discuss results of audit with Dermatology Team and Senior Managers (3) Ensure the clinicians who prescribe isotretinoin are familiar with the current BAD national

guideline and comply with this (4) Explore development of proformas based on the BAD guidelines 2010 which could be used pre-

treatment, at each follow up visit and at the patients’ final visit

Record Keeping Audit Cardiology (1) Clinicians to sign documentation with full name (not initials) (2) Patient ID on both sides of clinical document

Audit into the Use of Myocardial Perfusion Imaging in Patients Being Considered for Renal Transplantation

Cardiology (1) Complete analysis of data

Record Keeping Audit Cardiothoracic Surgery (1) Printing of name and designation (2) 24 hour clock time of entry (3) Importance of writing in tests requested and results

Record Keeping Audit Neurology

(1) Present the audit findings and recommendations at departmental Governance and educational meetings

(2) Consultant responsible for departmental induction to include record keeping in issues discussed with any new medical staff

(3) Re-audit Re-audit of compliance with NICE Guidelines for Natalizumab Treatment in Multiple Sclerosis

Neurology (1) All Neurology Consultants to be made aware of the recommendations

Record Keeping Audit Ophthalmology

(1) Patient admin to look at front sheet completion (2) Medical staff update on record keeping standards - results of audit and standards to be circulated

to medical staff. (3) Nursing staff update on record keeping standards - results of audit and standards to be circulated

to nursing staff.

Consent Audit Ophthalmology (1) Encourage clinicians and patients to print name, sign and date (2) Patient gender added to label

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(3) Contact number to be pre-printed on consent form

Screening Plus Pathway

Ophthalmology (1) Obtain DES Programme Board ratification to cease this pathway. (2) Cease entry of new patients into this pathway - HEY Trust agreement. (3) Phase out re-screening of existing Screening Plus patients as agreed with NDESP.

Record Keeping Audit Stroke (1) Improved results from initial audit. Re-audit at a later date

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Surgery

Audit of Day Case Procedures Being Done as In-Patient Procedures

Anaesthetics (1) Re-audit after service reconfiguration

Routine Coagulation Screening on the Intensive Care Unit

Anaesthetics

(1) Remove coagulation screen from Daily ICU bloods electronic request form. (2) Change blood test requesting on ICU to be medically led. (3) Introduce nursing / junior doctor teaching regarding requesting of blood tests. (4) Re-audit following above changes.

Follow-up Audit of Anaesthetic Chart Record Keeping

Anaesthetics (1) Improve standards of anaesthetic record keeping to meet national standards. Our CD sent out a

detailed email on anaesthetic record keeping in November 2012. (2) Continuing staff training.

Use of Non Luer Spinal Needles for Elective Lower Segment Caesarean Section

Anaesthetics (1) Multidisciplinary discussion. (2) Trial in emergency LSCS prior to implementation.

Frequency of Obstructive Sleep Apnoea in patients Undergoing Bariatric Surgery

Anaesthetics (1) Introduce STOPBang to pre-assessment

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Re-audit of Anaesthetic Documentation of Practice During Elective and Emergency Lower Segment Caesarean Section

Anaesthetics (1) Continue to raise awareness of new anaesthetists as to the importance of good documentation

Oxygen Prescription Audit

Critical Care (ICU/HDU)

(1) Amend oxygen prescription chart

Smoking Cessation Advice at Pre-assessment for Colorectal Surgical Patients

Colorectal Surgery (1) To incorporate NHS Stop Smoking services in Pre-assessment Booklet

Record Keeping Audit Colorectal Surgery (1) Introduce ward round pro-forma

Consent Audit Colorectal Surgery (1) Raise awareness at medical local induction

AAA Screening Programme Patient Satisfaction Survey

Vascular Surgery

(1) Ensure there is a chair or appropriate storage area for men’s possessions at Cromwell PCC venue.

(2) Present findings to the NEYNL AAA Screening Programme Director/Business Manager and Divisional General Manager.

(3) Present findings to the NEYNL AAA Screening Programme Team. (4) Present findings to the HEYHT Vascular Surgeons and registrars. (5) Disseminate the report to the NEYNL AAASP Project Board/ Steering Group. (6) Present findings to PCT Leads via project Board members. (7) Share with PCT audit departments and other key stakeholders. (8) Repeat survey bi-annually

Record Keeping Audit Vascular Surgery (1) Ensure all patients have case-note sheets.

Consent Audit Vascular Surgery (1) Minimise use of abbreviations.

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Consent Audit Urology (1) Encourage everyone to use BMA guidance

Audit to Assess the Efficacy of Management of Post-Operative Hypercalcaemia in Patients Undergoing Total Thyroidectomy

ENT - Head and Neck (1) Roll-out of hypoglycaemia management protocol

Record Keeping Audit ENT - Head and Neck (1) Ensure enough patient identifier labels are available and encourage their use on every sheet. (2) Adopt a consistent approach to documentation. (3) Stopping the use of abbreviations on consent forms

Consent Audit ENT – Head and Neck (1) Staff to write legibly. (2) There should be access to patient information leaflets. (3) Patients should be given copies of the forms (pink sheets).

Gastroenterology and Endoscopy

Record Keeping Audit (1) Education to junior doctors - add to induction for junior doctors.

Gastroenterology and Endoscopy

Consent Audit

(1) Raise awareness regarding lack of demographic information

Proportion of Radiographs Repeated When Original Supplied as Paper Printout of Digital Image

Oral Maxillofacial Surgery

(1) Local guidelines and cover letter to be sent to local practitioners (2) Contact Driffield re PACs image drop box precedent (3) Re-audit in 6 months

Consent Audit Oral Maxillofacial

Surgery (1) To look into the possibility of a dedicated Orthodontic treatment consent form

Mortality After Hip Fracture Surgery: Rates and Causes

Orthopaedics and Trauma

(1) Disseminate findings especially preventable causes of death to the staff caring for hip fracture patients.

(2) Plan re-audit for 2010-2011 fiscal year in order to see if mortality rate has improved. (3) Present findings of audit at international meeting in order to disseminate results to the wider

research community

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Audit on Delays and Theatre Time Loss for Elective Neurosurgical Cases

Orthopaedics and Trauma

(1) The first patient on the list should be admitted the night before and the pre-admission process to be completed at the latest by 8am on the day of surgery.

(2) Poster to highlight audit findings to be placed in neurosurgical theatres and wards. (3) Cranial cases to be scheduled second on the list where possible

Repatriation of Neurosurgical Patients

Neurosurgery (1) To escalate to senior management

Audit of Flexor Tendon Rupture Rates for 2011

Plastic Surgery (1) Increased consultant level input for tendon procedures

An Audit of Vaginal Melanomas Managed by Plastic Surgery

Plastic Surgery (1) Ensure new patients continue to be seen in a timely fashion

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APPENDIX III The reports of 33 national clinical audits were reviewed by the provider in 2012/13 and Hull and East Yorkshire Hospitals NHS Trust intends to take the following actions to improve the quality of healthcare provided:

National audits Proposed actions

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

Recommendations are being formulated by the Yorkshire Neonatal Network Board. These will be disseminated and implemented across all the networks within the Yorkshire region.

Paediatric pneumonia (British Thoracic Society)

To review the pneumonia guidelines to include: › Admission criteria › Investigations › Antibiotic choice › Management & investigation of complications › Follow-up

Paediatric asthma (British Thoracic Society)

To revise the current asthma pathway and documentation.

To ensure staff are aware of the new pathway and documentation to be completed.

To re-audit when asthma pathway has been adapted and fully implemented.

Paediatric intensive care Audit (Paediatric Intensive Care Audit Network - PICANet)

To develop written information for parents regarding the service.

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

To develop a system of automated text reminders 48 hrs prior to appointment.

The MDT and Retinal screening service to monitor and enrol in the screening programme.

To re-establish the 24 hour telephone support service for children and families.

To aim to extend current support to all children in the care of the Paediatric Diabetes team.

To develop collaborative networking with teams in Yorkshire and aim to attend 80% of meetings.

To establish regular education programme for children and parents.

To hold regular teaching / training sessions for ward staff and junior doctors.

A parent representative to attend MDT meetings. To collect information from 80% of service users

about the current provision of the service. Emergency use of oxygen (British Thoracic Society)

To change the position of the pre-printed oxygen prescription on the drug card

To ensure staff receive ongoing training To continue the Quality Monitoring Programme

which will look at the implementation of changes.

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Non invasive ventilation (NIV) – adults (British Thoracic Society)

To improve documentation around the mode of ventilation

To issue oxygen alert cards for patients with type 2 respiratory failure. This needs addressing to avoid over-oxygenation by ambulance crews

To look at levels of oxygen given to patients prior to hospital admission, excess oxygen being a contributory factor in respiratory failure

Adult critical care (Case Mix Programme) *No annual report - service receives quarterly reports per ward HICU GICU1, GICU2.

A local audit using CMPD data is proposed to identify management issues of Sepsis and Ventilator Associated Pneumonia in relation to the Standardised Mortality Ratio score for Hull Royal Infirmary and Castle Hill Hospital.

Feedback regarding the increasing figure of delayed discharges has been escalated to senior management and planners.

A local audit is currently underway to assess staff knowledge of Critical Care Minimum Data Set definitions in order to create an education programme to support achievement of maximum funding.

Potential donor audit (NHS Blood and Transplant)

To continue to address education needs, and disseminate guidance and policies, update hospital policies to achieve 100% referral rate and 100% Brain Stem death testing rate.

To update all guidance and policies relating to Organ and tissue donation.

Seizure management (National Audit of Seizure Management)

To produce a guideline and a proforma for patients presenting to the Acute Assessment Unit and Emergency Department with a seizure.

Diabetes (National Adult Diabetes Audit)

The diabetes specialist team will continue to work with commissioners both existing, and emerging CCGs, through the Hull & East Riding Diabetes Network to support commissioners in the planning of service design and delivery to meet the increasing prevalence recognising that over 90% of diabetes contacts for adult services occur within primary care

The diabetes specialist team will review the pathway for individuals with Type 1 diabetes who repeatedly fail to attend outpatient appointments and have not engaged with diabetes services as they are a group at very high risk of poor outcome.

To develop initiatives to investigate the high rate of amputations, understand the underlying causes and work to reduce amputations involve: - Root cause analysis of major amputations - Competency assessment of podiatry services - Launch of e-learning package on foot examination supported by Yorkshire & Humber SHA including risk assessment in accordance with NICE and appropriate referral to foot protection team launched April 2012 as joint work of specialist diabetes podiatrists employed by Humber Mental Health Trust and HEY diabetes team

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National Inpatient Diabetes Audit (NADIA)

To raise the profile of foot examinations in hospital To improve staff education in relation to the

management of inpatients with diabetes To develop an insulin prescription chart to be used

throughout the Trust

Heavy Menstrual Bleeding (HMB) (Royal College of Obstetrics and Gynaecologists - RCOG National Audit of Heavy Menstrual Bleeding)

To devise a guideline on menorrhagia in line with NICE guidance

To devise a patient information leaflet

Chronic pain (National Pain Audit)

There were no actions from the Phase 1 report required as the only recommendation was to continue with the national project which the Trust is still part of. The Phase 2 report is awaited.

Ulcerative colitis and Crohn’s disease (National Inflammatory Bowel Disease - IBD Audit)

To devise a business case to remedy the shortage of Inflammatory Bowel Disease Specialist Nurses provision

To get a dedicated pharmacy support which may help in streamlining use of drugs which will have potential cost savings.

To devise a business case to get a dietetic lead for the coeliac service.

Parkinson’s disease (National Parkinson’s Audit)

No actions have been identified to date.

Adult asthma (British Thoracic Society)

To improve documentation To improve the standard of record keeping

Bronchiectasis (British Thoracic Society)

To improve access to respiratory physiotherapy To implement annual spirometry

Dementia (National Audit of Dementia)

To develop a dementia care pathway To develop a policy relating to governing the use of

interventions for violent or challenging behaviour, aggression and extreme agitation which is suitable for use in patients with dementia who present with behavioural or psychological symptoms

To involve carers or relatives in the care of patients with dementia

To recommend additions and amendments to admission pack, which include recording information

To provide mandatory training of dementia awareness to doctors and all acute health care staffs involved in the care of people with dementia or who may have dementia

To include Structural imaging audit in the Medicine Health Group Audit Plan. Re-audit of organisational audit due to significant anecdotal evidence that current practice and organisational structure would provide increased compliance with standards

To ensure an assessment of functioning using a standardized assessment tool is carried out e.g. Barthel ADL Functioning Assessment Scale

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Hip, knee and ankle replacements (National Joint Registry)

Total Hip Replacements The Orthopaedic Surgeons no longer routinely

perform Hip Resurfacing Surgery or Metal on Metal Hip Replacements, as per report recommendations. The only cases performed within the Trust are on male patients who are requesting another Resurfacing Joint Replacement after a successful resurfacing on the other side. These patients are being warned of the potential problems and that the surgery is not to be undertaken lightly.

As per report recommendations the Trust is showing a growing trend within the Elective Orthopaedic Department for Cemented Hip Replacements being performed on men and women over 70 years of age. This will be discussed and encouraged further in Clinical Governance meetings.

Total Knee Replacements One of the main points discussed in this years report

appertaining to Total Knee Replacements is the use of Fixed Bearing Prosthesis. This Trust does not use any Mobile Bearing Prosthesis and uses fixed bearings for all Total Knee Replacements.

Data Inputting As per a new requirement of the National Joint

Registry, the Trust will begin to input all the Shoulder Replacements performed.

Carotid interventions (Carotid Intervention Audit)

A recent visit around the Stroke Service provided the following actions:-

The Trust will continue to provide acute stroke lysis/acute carotid surgery and image predominantly through duplex rather than MRA.

All patients will be seen by a dedicated stroke physician following pathways of care.

Dedicated daily sessions for duplex in lab will be provided for the TIA service.

QA process for imaging in place. Acute Myocardial Infarction and other Acute Coronary Syndrome (Myocardial Ischaemia National Audit Project – MINAP)

To review the management of patients with STEMI who initially present to HRI.

To develop a pathway with emergency medicine to ensure prompt management of patients with STEMI who are not directly transferred for primary angioplasty.

Heart failure (Heart Failure Audit)

The provision of the heart failure service will be reviewed as part of a strategic review of cardiac services.

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Acute stroke (Stroke Improvement National Audit Programme – SINAP)

To educate all staff, work on the Trust pathway and produce posters for awareness that all stroke patients should be directly admitted to a stroke unit equipped to manage acute stroke patients.

To ensure patients receive the same standard of care whether admission to hospital is in or out of hours. There is a 24/7 on call for stroke service and thrombolysis.

To improve co-ordination of care to reduce the delays within hospital control. On arrival, patients to be triaged rapidly to a specialist stroke team, undergo brain scanning, be thrombolysed where appropriate and be admitted to a stroke bed in a designated stroke unit.

To improve education across the Trust regarding stroke symptoms and how to contact the stroke team. This will reduce the current unacceptable delays.

To ensure that all stroke patients have access to a stroke service that can deliver thrombolysis safely and effectively. Any patients who are eligible for thrombolysis should receive it.

To place all incontinent patients onto a clear plan for continence management within 72 hours of admission.

To regularly maintain public awareness campaigns to reinforce the message that stroke needs to be treated as a medical emergency. The Act F.A.S.T campaign has been suggested to the commissioners

Stroke care (National Sentinel Stroke Audit)

The direct stroke unit admission policy has been extended to direct admissions 24/ 7. To ensure the RMO2 reviews the patients after midnight to ensure that transfers to the stroke unit are safe.

To produce a business case for dedicated in-reach neuropsychology support and a dedicated discharge liaison support worker

Nursing staff, occupational therapy assistants and physiotherapy assistants have been appointed and a business case will be put forward for further positions.

The Trust was accredited as a level one hyper acute stroke unit in September 2011. There will be another visit from the Peer Reviewers to monitor the process. Hull was the first Trust to be accredited in Humberside and Yorkshire region.

Renal replacement therapy (Renal Registry)

To continue to supply data on all Renal Replacement Therapy patients as per the Renal Registry

Lung cancer (National Lung Cancer Audit)

To ensure CT scan performed first/ pre-booking, to streamline diagnostic cancer pathway

To ensure specialist nurse is present at diagnosis To consolidate patient flow through specialist multi-

professional clinic

Bowel cancer (National Bowel Cancer Audit Programme)

This data will be looked at during our AGM in May 2012 but there are no current existing actions and mortality is in an acceptable range.

66

Head and neck cancer (Data for Head and Neck Oncology - DAHNO)

To increase input from allied specialties to the Somerset database and thus to DAHNO.

The MDT manager is to meet monthly with Consultants, Speech and Language Therapists and Dieticians to input patients into DAHNO.

To review whether additional resources are required to ensure the following national targets are met - 100% newly diagnosed patients should have been assessed by 1) Clinical Nurse Specialist 2) Dietician 3) Speech and Language Therapist before their treatment starts. Also, 85% of histopathology reports for suspected cancer should be reported within 7 days.

Hip fracture (National Hip Fracture Database)

Through discussion with the Yorkshire Ambulance Service, a protocol will be put in place to provide an early warning of hip fracture patients to ensure prioritisation of bed and theatre slots

To write a business case for the recruitment of a Nurse Practitioner to be prepared to early optimise patients for theatre

To increase investment to orthogeriatrician cover of wards, particularly at weekends and holiday periods

To increase flexibility of theatre sessions through peak times to ensure timely management of patients.

Falls and non-hip fractures (National Falls and Bone Health Audit)

To ensure orthogeriatricians undertake falls assessments and to treat underlying causes.

To ensure nurses, physiotherapists and occupational therapists undertake falls assessment.

For Osteoporosis assessments to be done by orthogeriatricians and to provide secondary prophylaxis of osteoporosis.

Bedside transfusion (National Comparative Audit of Blood Transfusion)

Provide results to Nurse Directors and Medical Directors with a requirement for each Nurse Director to provide reassurances to the Hospital Transfusion Committee as to how they will action the findings.

Transfusion Nurse Specialist to attend Nurse Directors meeting in March 2012, for feedback on Health Group response to the audit.

Recommend that each Health Group undertakes a 5 patient mini-audit to identify if compliance has improved.

Hospital Transfusion Committee to review the Transfusion policy in relation to the recording of observations for demonstrating compliance regarding forthcoming NHSLA assessment.

Re-audit as per national comparative audit plan.Care of dying in hospital (NCDAH)

To roll out training in care of the dying for all staff. To recruit an End of Life Facilitator to support

education and training.

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APPENDIX IV ANNUAL REPORT ACTION TRACKER

Action Lead Date to be completed by RAG Status

To transfer the audit plan and project documentation to Covalent to enable more efficient monitoring and reporting of the implementation of the plan

Clinical Audit and Effectiveness Manager

September 2013

To devise a new template to record the results of national audits, which includes the action plan


June 2013

To increase the number of outcomes forms for completed clinical audits

Health Group Medical Directors / Quality Facilitators / Quality and Safety Managers

March 2014

To improve the quality of outcome forms, including the requirement to state the reason for a re-audit being the only identified action

Health Group Medical Directors / Quality Facilitators / Quality and Safety Managers

March 2014

The effectiveness of the policy to be monitored via quarterly reports to the Clinical Audit and Effectiveness Committee.


Ongoing

To monitor the actions identified in relation to national audit reports via the corporate action tracking template.

Clinical Audit and Effectiveness Manager / project leads

Ongoing

To email the Clinical Leads the revised BCR form for the NICE


Ongoing

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guidelines to determine compliance

To monitor the identified actions from the NCEPOD studies via the corporate action tracking template and report to the Clinical Audit and Effectiveness Committee.


Ongoing

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