item 7 report to trust board 15 december 2016 7... · 2019-03-28 · report to trust board 15...

Report to Trust Board

15 December 2016

Report title Six monthly Clinical Quality and Safety Report Q1 & Q2

2016/17

Report from Declan Flanagan, Tracy Luckett, Ian Tombleson

Prepared by Editor: Ian Tombleson

Peter Addison, Trust Clinical Audit lead Kaajal Chotai, Head of Compliance Andy Dwyer, Head of Clinical Governance Declan Flanagan, Medical Director Tracey Foster, Children’s Safeguarding lead Niaz Islam, Trust Clinical Patient Safety Lead Carol Kibble, Clinical Audit Facilitator Tracy Luckett, Director of Nursing and Allied Health Professions Sumithra Maheswara, Associate Chief Pharmacist Julie Nott, Head of Risk and Safety Remi Ogbe, Head of Information Governance Sarah Philip, Adults Safeguarding lead Vanessa Sharman, Quality and Operations Manager, Moorfields Dubai Ian Tombleson, Director of Corporate Governance Catherine Wagland, Infection Control Matron

Tim Withers, Patient Experience Manager

Previously discussed

at

Management Executive and Trust Management Board

Brief summary of report

This report provides Trust Board with an overview of the clinical quality and safety activities and performance of Moorfields during Q1 and Q2 of 2016/17. The report is organised using the three Darzi headings of patient safety, patient experience and clinical effectiveness. There are new summary sections and sections setting out key areas of learning and improvement. Going forward the composition, structure and presentation of this report will be revised in line with the review of the performance assessment framework which is currently underway.

Action Required/Recommendation.

For discussion and comment.

For Assurance x For decision For discussion To note

Item 7

Clinical Quality and Safety Performance Report 2016/17

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Contents

1. Executive Summary……………………………………………………………. 3

2. Patient Safety………………………………………………………………….... 6

2.1 Incidents and duty of candour………………….……………………………..7

2.2 Claims and alerts ……….………………………………………………………18

2.3 Infection control….……………………………………………………………...20

2.4 Site and service safety………..……………………..………………………….23

2.5 Information Governance………………………………………………………..24

2.6 Medication safety………………………………………………………………...25

2.7 Safeguarding children…………………………………………………………..30

2.8 Safeguarding adults……………………………………………………………..32

3. Clinical effectiveness……………………………………………………………34

3.1 Policies, guidelines, protocols, standing operating procedures……….34

3.2 National Confidential Enquires………………………………………………..34

3.3 National Institute for Health and Care Excellence (NICE)………………...34

3.4 Clinical audit and outcomes…………………………………………………...35

4. Patient Experience………………………………………………………………38

4.1 NHS England Friends and Family Test results (FFT)……………………..38

4.2 Other sources of feedback…………………………………………………….40

4.3 Responses to patient feedback…………………………………………….....40

4.4 Complaints………………………………………………………………………..41

4.5 Patient Advice and Liaison Service (PALS)………………………………...43

4.6 Key learning and improvement actions……………………………………..44

5. Compliance……………………………………………………………………….46

6. Quality Reports from Moorfields United Arab Emirates (UAE)………….48


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1. Executive Summary

The quality and safety of our services is paramount at Moorfields. This report is a six

monthly (Q1 and Q2 2016/17) review of the quality and safety data and information

fundamental to care provision. It also includes the main learning and improvement actions.

This report is divided into five sections. Four are summarised below with the UAE (United

Arab Emirates) section included separately at the end.

Patient Safety

There have been 4 Serious Incidents (SIs). One was a Never Event due to

insertion of a wrong intraocular (IOL) lens (there was one wrong IOL insertion in

2015/16). The Trust has a very low rate of SIs compared to other Trusts. There is

an embedded governance process to learn from SIs. More work is taking place

trust-wide to improve and monitor the use of the WHO (world health organisation)

surgical safety checklist; improved use of the checklist is expected to reduce the

occurrence of wrong IOL implants.

There has been an increasing trend in the number of incidents reported over the

past 4 years. This is considered a positive sign of an open and learning culture.

The projected number of reported incidents this year (2016/17) is very likely to

exceed the total for last year (6224) and may reach 8000. In 2014/15 Moorfields

had the best reporting rate for Patient Safety Incidents of a peer group of 20

specialist Trusts.

Data is available per satellite. A significant percentage of incidents relate to clinical

documentation with the majority of those linked to health records unavailability.

Health record availability is not an issue at Croydon, because they have an

electronic medical record. It has not yet been possible to establish a benchmark for

incident reporting performance at the Trust’s satellite locations but this is being

developed.

The closure of incidents is often not timely (some incidents from 2014/15 have not

been closed) and this remains an area for improvement.

Reporting via the Duty of Candour (being open and transparent when things go

wrong) occurred 21 times. Although not yet benchmarked this number is expected

to become higher for two reasons: improved reporting and improving a ‘culture of

candour’ and the supporting processes.

The number of legal claims remains low, both in actual numbers and compared to

other Trusts.

Infection control rates for serious infections (for example MRSA) remains at zero.

Other infection rates are at, or better than benchmark performance.


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Clinical Effectiveness

Moorfields delivers good clinical outcomes. During this period a review took place

of service core clinical outcomes, resulting in paediatric, strabismus and neuro-

ophthalmology changing one of their outcomes. Full details of core outcome

performance will form part of the 2016/17 clinical quality and safety report. Trust

Management Board continues to receive regular updates about clinical audit

performance.

In relation to NICE (National Institute for Health and Care Excellence) guidelines,

the Trust is either fully compliant or progressing with compliance. At the time of

writing one deadline has breached: NG10 Violence and Aggression (deadline

October 2016). There are no regulatory consequences of this and actions are

taking place to meet the requirements.

Process changes have led to more clinical audit proposals commencing and more

completed reports being received, indicating better performance compared to

2015/16.

Patient Experience

Performance for the friends and family test (FFT) (about recommending Moorfields’

care to others) has been generally good for both quarters, in terms of a high

percentage of positive responses and benchmarked performance against 156 NHS

trusts.

The overwhelming number of FFT comments left by patients have been positive.

Action plans have been created to address many of the concerns or queries

highlighted by the patient feedback from FFT, focus groups, patient surveys; some

solutions require trust wide responses.

The number of complaints received was 57 in Q1 and 35 in Q2, similar to previous

quarters, with the predominant number being clinical complaints.

The rate of responding to complaints within a 25 working day period dropped

during Q2 and was attributed to some complaints requiring more involved

investigation and several being returned by the central team to ensure all questions

had been answered. Half the delayed responses were from Moorfields South. Also

75% of the delayed responses required medical staff input.

707 PALS enquiries (including compliments) were received in Q1 and 701 in Q2

which is up on the previous 2 quarters (Q3 2015/16 was 594 and Q4 was 614); this

increase is attributed to better promotion of the service earlier in the year.


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Compliance

The CQC inspected in May 2016 and has issued embargoed reports. The Trust

has responded with a number of factual accuracy queries. The Trust awaits a

further response from the CQC.

A phase 2 development of a quality scorecard is underway (first introduced in

August 2015). This will support operational analysis of quality and support

improvement and learning. This also meets the requirements of a Commissioning

for Quality and Innovation (CQUIN) framework work stream for 2016/17 worth up to

£300,000.

Work continues on the organisational journey of quality improvement and

additional activities have been described.


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2. Patient Safety

This section covers patient safety. The significant information points for Q1/Q2 are:

There have been 4 Serious Incidents (SIs). One was a Never Event due to

insertion of a wrong intraocular (IOL) lens (there was one wrong IOL insertion in

2015/16). The Trust has a very low rate of SIs compared to other Trusts. There is

an embedded governance process to learn from SIs. More work is taking place

trust-wide to improve and monitor the use of the WHO (world health organisation)

surgical safety checklist; improved use of the checklist is expected to reduce the

occurrence of wrong IOL implants.

There has been an increasing trend in the number of incidents reported over the

past 4 years. This is considered a positive sign of a better open and learning

culture. The projected number of reported incidents this year (2016/17) is very

likely to exceed the total for last year (6224) and may reach 8000. In 2014/15

Moorfields had the best reporting rate for Patient Safety Incidents of a peer group

of 20 specialist Trusts.

Data is available per satellite. A significant percentage of incidents relate to clinical

documentation with the majority of those linked to health records unavailability.


electronic medical record. It has not yet been possible to establish a benchmark for

incident reporting performance at the Trust’s satellite locations but this is being

worked on.

The closure of incidents is often not timely (some incidents from 2014/15 have not

been closed) and this remains an area for improvement.

Reporting via the Duty of Candour (being open and transparent when things go

wrong) occurred 21 times. Although not yet benchmarked this number is expected

to become higher for two reasons: improved reporting and improving a ‘culture of

candour’ and the supporting processes.

The number of legal claims remains low both in terms of actual numbers and

compared to other Trusts.

Infection control rates for serious infections (for example MRSA) remains at zero.

Other infection rates are at, or better than benchmark performance.


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2.1. Incidents and duty of candour

i. Serious Incidents (SIs), including Never Events (NEs)

Moorfields aims to minimise the number of SIs occurring. During Q1 and Q2 of 2016/17 a

total of 4 SIs were reported, 1 of which was a NE. This is similar to the first 6 months of

2015/16, when 4 SIs were also reported. The NE relates to the insertion of an incorrect

intraocular lens (IOL). A summary of each of the 4 SIs is provided below:

Q1 16/17

Delayed provision of a post-operative appointment (Glaucoma, Barking)

A patient underwent trabeculectomy surgery with Mitomycin C at City Road. She

attended a 1-day post-operative appointment at Barking Hospital. The next appointment

should have been booked for 1 week, but occurred at 6 weeks. This was due to multiple

administrative errors, such as a failure to complete a clinic outcome form and cancellation

of an outpatient appointment without input from a clinician. Contributory factors included

illegible handwriting of a doctor and a lack of documented processes to support the use

of PAS and the booking of post-operative appointments.

Discharge error (St George’s)

A patient was first registered on PAS in April 2009, following referral by her GP to the

Adnexal service. She continued to be seen by various healthcare professionals and

services over the next 5 years. In July 2014 the patient was discharged from the

strabismus service. Because appointments with a number of different services, including

the Glaucoma service, were all booked under the same episode the patient was also

discharged from these services. In March 2016 the patient was referred to the Glaucoma

service by her GP. When she was seen in May 2016, the error was detected and it was

identified that the visual field defects had progressed. The historic use of PAS, the


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variance of staff training, and the lack of associated supporting documentation provided to

clerical staff all contributed to this incident.

Q2 16/17

NEVER EVENT: Insertion of incorrect intraocular lens (IOL)(External Disease, St Ann’s)

A patient received the incorrect IOL power. The correct lens had been circled on the

biometry calculation page but had been written in an ambiguous way into the IOL power

box on the IOL selection sheet. This was later misread (27D rather than 22D which is a

different lens power) and the incorrect lens was inserted. Specifically the ‘collecting a

patient specific intraocular lens’ protocol, ‘guidelines for selection of intraocular lens power

in adults’ and ‘Surgical Safety Checklist Policy’ were not followed correctly and the

required checks were not performed.

PAS discharge codes (A&E, City Road)

In May 2015, a change to the discharge codes used in A&E was requested by clinicians in

the department. The reporting processes were not amended correctly resulting in 892

patients being identified as not having received a follow-up appointment. Following

review, an outcome remains unknown for only 8 of these patients and all of these are

believed to be low risk. No clinical harm has been identified.

ii. All incidents

The table below shows the increasing trend in the number of patient incidents (A patient

safety incident is any unintended or unexpected incident which could have or did lead to

harm for one or more patients receiving NHS care) reported over the past 4 years. This is

viewed as a positive sign of Moorfields being a learning organisation.The projected

number of reported incidents this year (2016/17) is very likely to exceed the total for last

year (6224) and may reach 8000.

Indicators 12/13 13/14 14/15 15/16 16/17

YTD Q1 Q2 Q3 Q4

Patient

Safety

Incident

(PSI)

1204 3446 6188 5504 1459 865 2324

Non-PSI 288 326 400 478 94 58 152

Incidents in

the web-

holding file1

0 0 4 242 674 1072 1746

1 A completed incident form is submitted to the web-holding file (WHF) where it remains until the

investigation is complete and the manager closes the incident. At the point at which it is merged into the ‘live’ file, the Risk & Safety department performs a data quality check. Incidents in the WHF have not been submitted to the National Reporting and Learning Service (NRLS) unless an SI/NE. The data in the table is correct as on 7

th November 2016


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Indicators 12/13 13/14 14/15 15/16 16/17

Q1

16/17

Q2 Q3 Q4 YTD

Total

incidents 1492 3772 6592 6224 2227 1995 4222

Serious

incidents

(SIs)

12 9 10 9 2 1 3

Never

events

(NEs)

2 2 6 1 0 1 1

The total number of incidents reported per quarter, including those in the web-holding file,

is shown graphically below. The accelerated increase in reporting (from Q3 2015/16 until

2016/17) can be attributed to an increase in the reporting of health records availability

incidents.

The incident data was extracted on 7 November 2016 and there were 1992 incidents in

the web-holding file (WHF). The directorates to which the incidents were assigned are

shown in the chart below, along with the number of incidents per year that remain open.

Incid

en

ts r

ep

ort

ed

per

qu

art

er


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Information of note is:

Clinical directorates, as expected, have the highest number of reported incidents in

the WHF (web-holding file). However, the North Directorate (including East, West

and Bedford) has an exceptionally low number, demonstrating good management of

the incident closure process;

88% (684/781) of the surgical services incidents that remain open are currently

recorded under the cause group ‘clinical documentation’. Of these 684 incidents,

629 relate to health record unavailability (missing/misfiled, delay in obtaining, unable

to retrieve);

53% (401/760) of the Outpatient and Diagnostic Services incidents that remain open

are currently recorded under the cause group ‘clinical documentation’. Of these 401

incidents, 258 are related to health record unavailability (missing/misfiled, delay in

obtaining, unable to retrieve). 24% (181/760) are recorded under the cause group

‘organisation of care’ and of these, 76% are related to appointments and referrals;

75% (554/737) of the Moorfields South incidents that remain open are currently

recorded under the cause group ‘clinical documentation’. Of these 554 incidents,

458 are related to health record unavailability (missing/misfiled, delay in obtaining,

unable to retrieve);


electronic medical record, therefore the incident profile looks very different. Of the

104 incidents in the WHF, 44% relate to a wide range of ‘clinical management’

issues’.

Incident reporting by site, for the 6-month period covered by this report (Q1 & Q2

2016/17) is shown in the chart below. Only incidents in the ‘live’ file are included within the


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chart (i.e. 1740 incidents in the WHF that relate to Q1 and Q2 2016/17 have been

excluded):

In its Annual Report 2015/16, Moorfields reported that for 2014/15 it had the highest

number of incidents of a benchmark group of 20 specialist Trusts (as published by the

National Reporting and Learning System – NRLS).

2015/16 incident reporting rates (per 1000 contacts) for each site are set out in the table

below. Where a reporting rate is zero this has not been included. Work continues to

understand the reporting variation between sites and the potential establishment of

benchmarks.


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Site Reporting rate

Q1 Q2

Barking 25.10 20.18

Bedford (North & South Wing) No data available

City Road 11.41 9.57

Croydon 5.36 6.72

Darent Valley 28.64 32.40

Ealing 12.67 11.43

Loxford 16.93 15.83

Ludwig Guttmann 28.49 17.22

Mile End 25.45 11.58

Nelson 4.78 5.66

Northwick Park 12.41 10.24

Potters Bar 7.99 4.61

Purley 2.05 0.00

QMR 9.04 1.49

St Ann’s 13.42 7.60

St Bart’s 12.82 0.00

St George’s 23.46 27.58

Teddington 0.00 2.50

Watford 9.80 0.00

High reporting rates are indicative of a mature reporting culture and staff are always encouraged to report incidents. The following points should be noted:

A reporting rate is not available for Bedford as the activity data is retained by

Bedford Trust. However, the number of reported incidents (32 in a 6-month period)

is very low compared to other sites who undertake surgery and offer an intravitreal

injection service;

Northwick Park and Ealing are broadly comparable in terms of surgical and

outpatient activity. Reporting rates for 2015/16, when compared with the same for

Northwick Park, suggested underreporting at Ealing; the reporting rates for the first 6

months of 2016/17 are broadly comparable;

The reporting rate at Croydon continues to be significantly lower than would be

expected compared to other satellites that offer similar services with complex

patients and surgery. There is evidence of reporting by multiple staff groups,

although review of the reporter names reveals that a relatively small number of staff

take responsibility for reporting incidents. This suggests either that staff are reliant

on specific people to report incidents and/or detected incidents are not being

reported;

If health records incidents were excluded from the City Road incidents this would

have a significant effect on the reporting rate. It is probable that the reporting rate

would fall to a level which would be low for a site that undertakes complex surgery,

offers outpatient care for all sub-specialities and has an A&E department;

With the exception of Potters Bar and Watford, reporting rates across all the North

sites are in excess of 10 incidents per 1000 contacts. This appears to demonstrate


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a good reporting culture, given the continued recognised success of the incident

management process in the North East;

The reporting rates for Mile End and QMR have fallen by more than 50% from Q1 to

Q2.

Review of the 2482 incidents in the live file gives the following headlines:

a) Of the incidents in the live file, 152 are non-PSIs and 2330 are PSIs.

b) Of the non-PSIs:

o 28 incidents record cases of verbal abuse towards staff and 23 of these are

abuse from patients. Over half of the cases were reported by staff working at

City Road;

o 81 of the 152 incidents were reported by staff working at City Road;

o With the exception of the RDCEC, who reported 11 non-PSIs, no other site has

reported more than 7 in the 6-month period;

o Only 4 near miss non-PSIs were reported. This is an area in which significant

improvement is required, across the whole of the organisation.

c) Of the PSIs in the live file:

o 1192 incidents (51%) are recorded under the cause group ‘clinical

documentation’. A comprehensive analysis of the total reveals the following:

Reports were received from 16 sites, including 528 (44%) – City Road,

202 (17%) – St George’s, 170 (14%) – Northwick Park, 78 (7%) – Ealing

and 72 (6%) – Barking;

Health record (missing/misfiled) remains the highest reason for reporting

a health record related incident, with a total of 572 reports having been

received. This accounts for 48% of all clinical documentation incidents.

Reports from City Road, that are in the live file, accounted for 57% of all

missing/misfiled records;

402 (34%) of reports are recorded under the cause ‘health record - delay

in obtaining’.

o 71 medical device incidents are present in the live file, which is lower pro-rata

than the 193 incidents reported included in the analysis for the previous 12

months:

28 (39%) reports of a ‘device failure’. All but 1 incident was assigned an

actual impact of no harm;

17 (24%) reports of ‘loss of device during procedure’. 1 of these

incidents, which occurred in Q2, was reported in Q3 as a Never Event

and remains under investigation. 14 of the incidents were reported

because a needle was lost during surgery; it is of note that one of the

claims received during the period covered by the report (CNST6) relates

to this issue. Of the 17 devices reported as having been lost, 12 of the


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reports originated from City Road which suggests underreporting at the

other sites where surgery is performed;

18 ‘medical device user error’ incidents were reported. The Trust

continues to record cases where a syringe and cannula have become

detached, having not been properly connected by the user, injuring the

patient and resulting in a need for further surgery to treat posterior

capsular rupture. There has been at least one previous claim in relation

to this type of incident; in one case a patient was awarded £20K

damages;

o 23 incidents were reported as a consequence of failures with the patient

transport system:

9 reports were made by staff at Ealing, to document that patients were

either not collected to attend an appointment or had to wait up to 3 hours

to be taken home. 5 of the incidents occurred at the end of May and the

delays were attributed to a higher than usual number of discharges prior

to the bank holiday weekend;

o Resuscitation incidents, including unplanned transfers, account for

approximately 5% (106) of the incidents in the live file;

o 42/60 (70%) of incidents related to staffing levels were reported by staff at

Darent Valley. Nursing support for the day care unit is supplied by Dartford

and Gravesham NHS Trust, as stipulated in the Service Level Agreement. A

band 5 nurse and a band 2 healthcare assistant should be provided, however

the band 2 is often not supplied and there is not always sufficient band 5 cover

(i.e. for the whole shift). Matrons for both the satellite service and host site day

care unit have met, and the requirements for day care staffing for the satellite

unit have again been clarified;

o Reported incidents continue to highlight weaknesses in processes associated

with the booking and management of outpatient and surgical appointments.

This was first highlighted in the Q4 2014/15 & Q1 2015/16 report and it was

referenced again in the 2015/16 report. Some of the more frequently reported

incidents are described below:

Appointments booked at the incorrect interval;

Appointments booked in the incorrect clinic;

Inadequate clinic organisation;

No appointment booked;

Patient attended cancelled appointment;

Overbooked outpatient clinic;

o Issues with referrals are a feature of the Q1 & Q2 2016/17 data, as they were in

2015/16. A number of issues were recognised, during Q2, in relation to the

processes that were being followed in the Booking Centre. An SI was declared in


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relation to referral management for in excess of 4000 patients in Q3, which

remains under investigation. Validation of episodes of all identified patients is

being undertaken by the RTT validation team. Health records are being reviewed,

where necessary by a consultant, where a specific need is identified;

o Medication incidents, recorded as both drug errors (i.e. those that are reported

locally by clinicians when an error has been detected) and pharmacy

interventions (i.e. those that are reported when a pharmacist intervenes and

prevents the incorrect dose from being dispensed, for example) are discussed

further in the ‘medicines management’ section of this report.

iii. Duty of Candour (DoC)

The aim of the DoC is to be transparent with patients in a clear and timely manner when

things go wrong. The e-reporting system incorporates functionality to record information

for the different stages of the DoC requirements. Reporters can record the following

information as part of the incident report:

That the relevant person has been contacted.

Whether a written explanation was given, and if no why not?

Whether a copy of the investigation report was sent, and if not why not?

Compliance for Q1 and Q2 2016/17 with DoC requirements, based on the date on which

an incident was reported, is as shown below:

o Data in relation to complications2 has not been included on this occasion as

further work is required to both understand and validate the data;

o The information is correct based on what is recorded in the incident reporting

system and/or information available on OpenEyes. A review of information

documented in the health record has not been undertaken on this occasion;

o Prolonged psychological harm and death have been excluded from the report

as neither has occurred during the reporting period.

2 Certain types of incident are nominally classified as ‘complications’ - there is also a requirement to

investigate these incidents to eliminate that no errors have occurred


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Incidents (excluding SIs & NEs and ‘complications’)

Initial "being open" disclosure* Moderate Major

Total number of patient safety incidents (excluding complications) reported during the reporting period

12 6

Stage

1a

Number of conversations informing family/carer that a patient safety incident has occurred within 10 working days of the incident being reported to local risk management systems

8 4

1b % of "being open" conversation taken place in time 67% 67%

1c

Number of conversations informing family/carer that a patient safety incident has occurred after 10 working days of the incident being reported to local risk management systems

- 1

1d Duty of candour status to be verified 4 1

1e % of "being open" conversation taken place in total 67% 83%

SIs/NEs (declared during Q1 & Q2 2016/17 – the incident date may be pre-April 2016)

Initial "being open" disclosure* Moderate Major

Total number of affected patients during the reporting period

3 -

Stage

1a

Number of conversations informing family/carer that a patient safety incident has occurred within 10 working days of the incident being reported to local risk management systems

3 -

1b % of "being open" conversation taken place in time 100% -

1c

Number of conversations informing family/carer that a patient safety incident has occurred after 10 working days of the incident being reported to local risk management systems

- -

1d Duty of candour status to be verified - -

1e % of "being open" conversation taken place in total 100% -

Compliance with DoC requirements remains challenging for the Risk & Safety department to verify. This is

a result of information being recorded in the paper health record and/or OpenEyes and incomplete or

inaccurate information being recorded on the incident reporting system.


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iv. Key learning points and improvement actions

1) Compliance with surgical safety checklist: Recent NE investigations and audits

have highlighted concerns regarding compliance with the WHO (WHO - world health

organisation) surgical safety checklist and this has been discussed by the Clinical

Governance Committee (CGC) in detail. The completion of the form is often treated as a

‘tick box’ exercise and sometimes behaviour of staff and the culture within the

organisation does not fully support the spirit of the checklist, which is to enhance

consistency in surgical team performance and foster good communication and teamwork.

At the CGC meeting in September, a revised checklist was reviewed and further

amendments, such as the removal of tick boxes and the need to record written answers to

questions were discussed. It was also noted that different sites have different

requirements and that a single form needs to satisfy the requirements of all sites and

services to be consistent across the organisation.

Completion of the revised form will be supported by a Standard Operating Procedure

(SOP) and there is a plan to put prompts on the walls of all theatres. The final revised

form will be implemented and trialled at City Road, in the first instance, and implemented

Trust wide once feedback has been obtained. The Theatre Management Group will be

responsible for ensuring that use of the revised checklist is fully embedded within all

theatres, at all sites, and that observational audits are conducted at an agreed frequency.

Further consideration regarding the need for human factors training (which relates to

human behaviour, its impact on patient and the application of that knowledge in clinical

settings) is being taken forward and was raised as a key area for progression at the Trust

wide clinical half-day on 15 November.

2) Use of PAS (patient administration system): Recent SIs, in addition to a number

of other incidents and reviews, have continued to highlight issues with the way in which

PAS is used by administrative staff. Poor practice has been exacerbated by the use of a

high proportion of bank staff in some areas (e.g. St George’s) and sharing of incorrect

processes amongst team members. The revised Patient Access Policy will be supported

by a new RTT (referral to treatment time) protocol. PAS training will be developed to

include scenarios to learn from errors that have previously occurred and PAS super-users

will be introduced to provide support. The information technology team have introduced a

change group to support the operational implementation of changes to PAS.

3) Duty of Candour requirements: The Trust continues to strive to fulfil the Duty of

Candour (DoC) requirements. The requirements are not yet fully embedded and further

work to achieve full compliance and more importantly a complete ‘culture of candour’ is

required. Mechanisms for improvement are being considered by the Head of Clinical

Governance and the Head of Risk & Safety. This is in addition to the supporting

functionality within the e-reporting system, which has already been implemented. A

formal audit of DoC compliance, to include a review of health records, has not yet been

undertaken and this is likely to identify a number of areas in which improvement is

required.


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4) Processes to support learning from incidents: The 2015/16 clinical and safety

annual report highlighted a number of mechanisms through which the Trust learns from

incidents and near misses. The following provides an update regarding the status of

some of the areas for improvement:

o Aggregate incident, complaints and claims data report: It is acknowledged that

the format of this report needs to change to reduce duplication with other

reports and to better highlight the improvements made in individual areas. It is

anticipated that, following analysis of incident data by the Head of Risk &

Safety, a pro-forma will be sent to directorates to request responses to areas of

concern and/or trends identified;

o Weekly incident meeting (SI panel): a formal review of this process, which will

identify strengths, weaknesses, limitations and areas for improvement, is

scheduled to commence during Q3 2016/17;

o Clinical governance half days: these are well-established and well attended,

however there is variability in the learning from incidents, complaints and

claims. Services are provided with a report which details all incidents,

complaints and claims in advance, but the analysis of key information and the

outcomes differ. Development and improvement will be further supported by

the production of a presentation template, the identification of champions within

services and further support by Quality Partners in the North and South;

o Feedback to individuals: the Risk & Safety department continues to work with

managers encouraging more timely closure of incidents, which in turn will result

in more timely provision of feedback to staff.

2.2. Claims and alerts i. Claims

The NHSLA was notified of claims relating to Moorfields as detailed below:

Claim type

Number of new claims advised

2013/14 2014/15 2015/16 2016/17

Q1 Q2 Q3 Q4

CNST

(clinical negligence) 7 12 11 4 3

Personal injury

(Liability to Third Parties Scheme – LTPS)

4 1 4 - 1

Total 11 13 15 4 4

An analysis of any trends will be considered in the annual clinical quality and safety report.

Unlike in previous quarters, all but one CNST claim was reported as an incident, and 3 of

the CNST claims have previously been reported and investigated as SIs. A further 2 of

the CNST claims have been reviewed at the weekly incident meeting (SI panel).


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ii. Alerts

Indicators 12/13 13/14 14/15 15/16

15/16

YTD

Q1 Q2 Q3 Q4

Number of alerts

received3 92 182 129 97 49 33 82

Acknowledged within

deadline 90 149 113 78 44 29

73

(89%)

Number of alerts

closed within

specified timescale

84 166 113 86 46 29 75

(91%)

Number of alerts

issued for which

action is

required/relevance is

being assessed

10 19 14 12 3 4 7

(9%)

Number of alerts not

signed off (no

breach)

7 2 5 1 1 3 4

(5%)

Number of alerts that

breached the

deadline

8 16 16 10 2 1 3

(4%)

Notable points from the data are:

It can be seen that the number of alerts received in the 6-month period (82) is

greater compared to 2015/16 (97 were received for the whole year);

The number of alerts for which action is required is less than 10% of the total

number of alerts received;

Of the 3 alerts that breached the deadline for completion, 2 breached by 5 days

and 1 breached by 3 days. Action was not required for any of the 3 alerts and the

breaches were a consequence of responses not being received from relevant

departments/specialist advisers;

11% of alerts were not acknowledged prior to the deadline of 2 working days from

receipt. The maximum breach was 5 working days; 8 of the 11 breaches coincided

with absences in the Risk & Safety department.

3 Only alerts for which a response is required have been included (i.e. drug alerts, MHRA Dear Doctor

Letters and CMO messaging alerts have been excluded)


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iii. Key learning points and improvement actions

Claims do not necessarily indicate poor practice or negligence. The analysis of

claims for learning and improvement is an area which we can continue to learn from.

An Interim Head of Legal Services has been engaged and a meeting with the Trust

legal team is planned to consider how best to do this. A detailed analysis of both

CNST and LTPS claims, as informed by both NHSLA claims scorecards, was

included within an aggregate data report covering the period 1 October 2015 to 30

September 2016;

1 alert from September 2015, ‘Supporting the Introduction of the National Safety

Standards for Invasive Procedures’ (NatSSIPs), has passed the completion deadline

of 14 September 2016. This breach has been escalated to the Medical Director and

the Director of Nursing and Allied Health Professions and has previously been

reported to the Clinical Governance Committee;

For alerts such as that which relates to NatSSIPs, a named individual needs to be

assigned as having responsibility for leading on implementation of the entire alert.

That same individual should be the person with responsibility for providing regular

and timely updates regarding progress with implementation to both the relevant

oversight committee (most likely to be CGC) and the Risk & Safety department.

2.3 Infection Control

i. Infection surveillance summary

¹Excludes Bedford cases and Ozurdex implant injections 2Incidence of presumed endophthalmitis per 1,000 cataract cases

3Incidence of presumed endophthalmitis per 1,000 intravitreal injections ( it is also for DMO and other

conditions)*CPE (a group of antibiotic resistant bacteria that can cause serious infections) screening began

in October 2014 following national guidelines. The Trust reports suspected (s) cases based on a history of

admission to hospitals abroad within the preceding 12 months with no notification of CPE carriage and

confirmed (c) cases where a patient reports medical notification.

Indicators 2015/16 Target

Q1

2016/17

Q2 YTD

2016/17

C.diff infection 0 0 0 0 0

MRSA bacteraemia 0 0 0 0 0

E.Coli bacteraemia 0 0 0 0 0

MSSA bacteraemia 0 0 0 0 0

MRSA Screening 100% 100% 100% 100% 100%

Endophthalmitis post cataract1,2

0.15 0.83 0.00 0.2 0.10

Endophthalmitis post intravitreal

Injection1,3

0.35 0.5 0.48 0.23 0.35

Adenovirus possible hospital

acquired 0.82% NA 0.00% 1.7% 0.78%

CPE screening* 23s

1c NA 11s 7s

18s


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ii. Endophthalmitis surveillance rates

Endophthalmitis surveillance detects patients diagnosed and treated for endophthalmitis

within six weeks of surgery or intraocular procedure. The following table accounts for all

cases of Trust endophthalmitis for Q1 and Q2 2016/17.

The total number of endophthalmitis cases reported for Q1 and Q2 2016/17 is 19.

Endophthalmitis per site

The above graph illustrates that for cataract endophthalmitis, Croydon has breached the

Trust benchmark, based on one case, due to the low number of overall procedures

undertaken, however the EMA score was assessed as ‘Green’ for continued service

provision.

Benchmarked

endophthalmitis (post

cataract surgery and

intravitreal injections)

Phaco and IOL City Road

Intravitreal Eylea Research Department City Road

Intravitreal Eylea Darent Valley

(this case has never been fully reported by Croydon, DIPC and

Chair of ICC aware)Intravitreal Eylea City Road x 4

Exception reported

cases (outside the six

week timeframe or

Bedford cases)

Intravitreal Lucentis Bedford North

Phaco and IOL Bedford South

Intravitreal implant Ozurdex Bedford North

Non-benchmark

endophthalmitis (all

other cases that fall

within the surveillance

definition)

Right PK x 2 City Road

Vitrectomy, Cryotherapy and Gas City Road

Vitrectomy and Peel City Road

Aqueous Shunt insertion City Road

Removal of suture post DSAEK St Georges Hospital

Injection of Provisc in AC City Road

Aspiration of Gas City Road


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The graph above illustrates that for intravitreal injection endophthalmitis, Darent Valley

breached the Trust benchmark, based on one case of endophthalmitis. The EMA

probability tool was used to assess this and was ‘Green’ for continued service provision.

iii. Infection surveillance summary

The Trust submits data to the national HCAI Data Capture System monthly as required.

There have been no identifiable cases of MRSA, MSSA, E.Coli or GRE bacteraemia at

the Trust for this year. Nor Clostridium difficile is also mandatory to report.

iv. Compliance

v. Key learning points and improvement actions

a) Endophthalmitis cases

Each diagnosed case of endophthalmitis is investigated and a root cause analysis is

undertaken by the Infection Control Team and the staff member who performed the

surgery. The aim is to try and identify the endophthalmitis source. A notification letter is

sent with the root cause analysis form which highlights preventative measures that need

to be followed by staff to minimise the risk of further cases. Each case is discussed at

the Infection Control Committee and shared with the Clinical Governance Committee. Any

learning points and actions required for each case are shared with clinical teams who are

responsible for ensuring actions are acted upon to minimise the risk of further cases of

the same nature.

Indicators 2015/16 Target Q1

Q2 Q3 Q4

YTD

2016/17

Hand hygiene compliance 97% 95% 98% 98 % 98%

Cleanliness inspections 98% 95% 98% 98% 98%

Slit lamp audit 93% 90% 92% 92%

Policy and Practice compliance 93% 90%


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b) Audit Compliance

Hand hygiene, cleanliness, and policy and practice audits that achieve an overall score of

partial or minimal compliance, are followed up by the Infection Control Nurses. Additional

training and re-audit is undertaken in an agreed timeframe if deemed necessary.

2.4 Site and service safety

i) Executive Mini Walkabouts Program

As reported in the 2015/16 Clinical Quality and Safety annual report, the Trust continues

to develop executive led quality and safety walkabouts and delivered a substantial

number leading to May’s CQC inspection. This was viewed as very useful from both an

Executive/team level and by frontline staff. Executives and teams were able to get insight

into frontline issues and speak with a number of staff. Staff were able to prepare

themselves for what it might feel like during inspection. Immediate feedback was provided

after inspections and short reports were produced which provided further feedback.

Escalations/assurances were provided to Management Executive, TMB and Board. A new

mini-walkabouts plan, based on the same methodology, will be put in place later in

2016/17.

ii) Use of the modified global trigger tool (mGTT)

The global trigger tool is a way of searching for adverse events by auditing a small

sample of patient notes regularly. 13 mGTT proposals were registered during Q1 & Q2,

(12 were registered for the whole of 2015/16); and 19 mGTT reports were received, (more

than the total of 15 reports received in 2015/16). The majority of reports received

however, included those proposed in 2014 but had not been submitted centrally.

Nearly all 19 mGTT reports approved identified some level of risk to patients, mostly

varying from category A risk (capacity to cause error) to category D risk (error reached

patient requiring additional visits, monitoring or treatment). One audit included a category

E risk (minor temporary harm to patient) for a patient referred for pseudostrabismus who

missed having a high refractive error on their first visit and delayed treatment. Actions

from the audits included reminders for staff groups regarding procedural compliance and

record keeping; a review of protocol/guideline; presentation at Alumni meeting and clinical

governance half days; the development of instruction sheets for staff groups and the

progression of a business case for more children’s vision clinic (CVC) trained staff.

Where issues are identified as having the potential to cause harm to patients, reviewers

are asked to complete incident reports to help triangulate data. Although the grading of

risk to patients is a little subjective, it allows the auditors and their services to reflect on

what makes good practice and encourages the drive to achieve this.


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Site/service Annual Target

Q1 & Q2 2016-17

Proposals Reports Site/service Target Proposals Reports

A&E 2 1 Bedford 2 1 1

Adnexal 2 City Road 2 10 7

Anaesthetics Croydon 2 1

Cataract 2 Dubai 1

Corneal / External 2 1 Ealing 2 1 1

General Ophthalmology / primary care

2 1 Harlow 1

Glaucoma 2 4 3 Homerton 1

Medical Retina 2 1 1 Loxford 1 1

Neuro, Strabs, Paeds (NSP)

2 3 1 Ludwig Gutmann

1

Optometry 6 Mile End 2

Orthoptics 1 7 NWP 2 2

Trust-wide (inc. Nursing) Potters Bar 2 2

Uveitis 1 1 St Ann’s 2

Vitreo Retinal 2 St Georges 2 1 2

Stratford 1

Upney Lane 1

2.5 Information governance (IG)

During the period April to September 2016, there were 67 IG related incidents. Most

involved disclosures made in error, where clinical correspondence was sent to a wrong

patient and paper-based information had been left in public areas. There were no

incidents which required reporting to the Information Commissioner’s Office. Between

June and September, a number of Information Governance training sessions were

delivered during Clinical Governance days at City Road and Northwick Park, and

at doctor’s induction and other clinical team meetings. The IG team continue to offer

training at clinical governance half day sessions. A new IG e-learning module has been

developed in collaboration with the learning and development team and will be available

soon on Trust systems. In addition, Information Governance remains a core part of the

Trust’s induction programme.

Following the publication of version 14 of the toolkit in July 2016, the team commenced a

detailed review of the IGT evidence base in preparation for an audit by KPMG in

December 2016. Good progress has been made; however, some of the previous scores

have been lowered where evidence is not available, or has not been provided.

The Trust received 290 Freedom of Information Act requests during this period,

responding to 288 within the statutory deadline of 20 working days. Requests came from

a wide variety of sources, including, journalists, solicitors, charities, students, private

companies, universities, and recruitment agencies. The requests received were very

varied in terms of content including: Trust financial position, waste contractors,

discharging patients, bank staff/agency spend, internal plans and strategies, ICT

contracts and sterilization equipment. An area of improvement continues to be

departments providing as much information as possible within the required timescales in


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order to deal with requests promptly. The annual data flow mapping exercise is underway.

75% of services have responded and provided their data flows, these will be analysed

and a report will be presented to the Information Governance Committee in December

2016.

In collaboration with the Chief Information Officer, the team have signed up to be an

earlier adopter for the NHS Digital’s Cyber Security CareCERT Assure programme. The

programme will include an onsite assessment of the Trust’s strategy for protecting IT

systems from cyber/security threats, and will support the improvement of data security

standards.

2.6 Medication safety

There were 374 medication related incidents reported in first 6 months FY15/16 and 389

in the same period for FY16/17 and the graph below shows the causes.

The actual impacts of incidents are shown below.


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Overall there was a modest increase in incidents reported for each category in the first 6

months of 2016/17 compared to 2015/16. Previously it was reported that due to

campaigning there had been an increase in reporting overall – it is possible that reporting

levels may have become more consistent as incident reporting is now embedded as part

of routine practice.

2.6.1 Incident reporting by pharmacy In July 2016, as a result of feedback, the way incidents are reported in pharmacy has

change slightly to improve reliability and improved clinical governance. This new process

ensures that the relevant medical specialties are alerted to issues.

i. Incident data presentation From September 2016 the data presented to the medication safety group is also being

presented by the following categories: overall (as per previous years), speciality, satellite

and common themes. Link pharmacists are taking the relevant information to service

meetings. The graphs below summarise the data.


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ii. Incorrect patient During the first 6 months of 2016/17, incidents in the category of ‘incorrect patient’

continued to decrease compared to the previous year. In 2015/16 the OpenEyes

prescribing module was modified to include a warning pop-up where a second

prescription event is created for a patient. A breakdown of the data for Q1 2016/17 shows


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that medical retinal had the greatest error rate in this category, but this is also reflected by

the large volume of prescriptions that are generated from this service.

Consistent with previous years, the majority of ‘near miss’ incidents were identified in

pharmacy at the screening process preventing prescriptions being handed out to patients.

The most significant change was a decrease to zero in the number of incidents reported

in the ‘moderate’ incidents were related to stock control or adverse drug reactions.

iii. Use of Mycophenolate and pregnancy Mycophenolate is teratrogenic. The MHRA (the medicines regulator) released a Drug

Safety Update in December 2015 emphasising the risks relating to the use of this drug

during pregnancy. The Trust has not yet fully implemented the requirements of this

update and because of the nature of this drug is reviewing whether this has had any

potential impact on patient safety.

iv. Eylea® vs Lucentis® There were a number of incidents involving Eylea® and Lucentis®, for example where the

wrong product had been administered. All cases resulted in either ‘near miss’ or ‘no

harm’. The medication safety group are reviewing the reasons for these errors. As part

of this review – it was clear that the appearance of both preparations was different and

there are two signatures prior to administration, therefore the process is still being clarified

to understand the reasons.

v. Acular® and Maxitrol® (dexamethasone and neomycin) As previously reported in FY15/16, Acular® and Maxitrol® combination has been

associated with corneal melts. The pharmacy department have continued to intervene on

prescriptions for these two medicines used in combination. All incidents so far in FY16/17

were ‘near miss’. An example of one such incident, involved a prescription for Maxidex®

where the EMIS (formerly known as Ascribe) system had a logged dispensing episode for

Acular® the week prior. This was checked with the prescriber and Maxidex® was

changed to an alternative product. Pharmacy have made recommendations for the EMR

system to include alerts for such interactions. Clinicians are continued to be reminded of

this and training is incorporated in medicines management induction programs.

vi. Temperature excursions Due to warm weather over the summer months there were 24 reported incidents where

temperatures exceeded the recommended range for storage of medicines at room

temperature and fridges. Incidents occurred across the Trust including satellite sites.

The pharmacy medicines information department answered enquiries related to ongoing

clinical usage of affected medicines. Air conditioning and temperature control storage

units have been recommended, and discussions are ongoing as to feasibility of this

across the main site and satellites.


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vii. Accessible Information Standard From 31 July 2016, it became a legal requirement that Trust follows the Accessible

Information Standard. The standard ensures that individuals who have a disability,

impairment or sensory loss are provided with information that they can easily read or

understand with support so they can communicate effectively with health and social care

services.

There are several aspects to be considered from a medication safety perspective,

particularly with regards to the provision of medication labels in a variety of formats for

immediate need, for example prednisolone prescriptions. The pharmacy department are

working with the Trust’s working group and seeking advice from the Royal Pharmaceutical

Society regarding implementing this standard in practice.

viii. Non- medical supply of medicines committee This was a new Trust committee that commenced in July 2016 in accordance with NICE

recommendations to discuss action plans, protocols, processes and issues with Patient

Group Directions and Non-medical prescribing. It was determined that medical

representation would be required for the group to be quorate. The committee acts as a

subcommittee of the DTMMC with responsibility for ensuring compliance with NMP and

PGD policies.

2.6.2 Medicines Alerts

There were eleven drug alerts via the central alerting system over this period, three of

which involved a medicine brand used at Moorfields. All actions were completed within

the time frame.

2.6.3 Key learning points and improvement actions

As referred to above, the introduction of an MHRA Drug Safety Update in relation

to Mycophenolate will result in lessons for distribution of future drug updates.

Many of the interventions have been linked with the necessity for an improved

EMR system, however this is not the only component integral to medication safety,

this was recognised by the pharmacy department. Therefore key advice that is

being delivered in service meetings is a reminder to take extra time to read

prescriptions and documents carefully.

As previously discussed the way data is summarised for medication safety

incidents has changed. This change has enabled tailor made data to be presented

to services and satellites, thus in line with the Moorfield’s way – is more inclusive

and helps to engage staff in addressing medication safety incidents at a more local

level.


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2.7. Safeguarding children

2.7.1 Safeguarding children and young people (0-18years)

Safeguarding Children and Young People remains a high priority within the Trust through

a continued and consistent commitment to ensuring the Trust’s responsibilities are fulfilled

under Section 11 (Children’s Act) duties.

i) Key Messages and Quality Assurance

The Trust has systems, policies and processes to safeguard and promote the

welfare of children and young people which are constantly reviewed to ensure that

they comply with national and local guidance.

Risks are managed and monitored by the Safeguarding Children Group.

A safeguarding children and young people’s work plan is in place and is regularly

monitored by the Safeguarding Children Group. Progress against the work plan

has been made with 34 actions achieved.

There has been a total of 16 Section 17 Child In Need referrals made to Children’s

Social Care and no Section 47 Child Protection referrals. A total of 23 incidents

included effective liaison and referral to early intervention and universal health

services with no omissions of care identified.

Training compliance for safeguarding children (Level 1, 2 and 3) has remained

above the target 80% compliance level throughout this period and Level 4

specialist safeguarding children training 100% compliance.

There have been no Serious Incidents declared involving child protection/

safeguarding children that involve the Trust. One complaint with a safeguarding

child element was reviewed by the safeguarding children’s lead and children’s

social care were already involved.

There were no Serious Case Reviews convened during this reporting period that

involved the Trust.

Effective partnership working arrangements are in place with key agencies

including the Islington Safeguarding Children Board and relevant subgroups.

The Safeguarding Children and Young People Annual Report 2015 – 2016 was

presented to the Clinical Quality Review (CQR) Group in August 2016.

The safeguarding children and adult agenda across the organisation continues to

be strengthened through the recognition that children and adults do not exist in

isolation. The agenda is immense and responsibilities broad and far reaching.

ii) Key Achievements April to September 2016

Continued collaborative working with the Trust Safeguarding Adult Lead in relation

to aspects of the safeguarding agendas which straddle adults and children

including Learning Disabilities, Mental Capacity and PREVENT.

Key Safeguarding Children and Young People Performance Indicators, Metrics and

Reporting were submitted to Islington CCG, Islington Safeguarding Children Board,

NHS England and the HSCIC.


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The key priorities set by Islington Safeguarding Children Board 2016 – 2017 were

addressed by the Trust including addressing child sexual exploitation (CSE),

domestic abuse and violence and neglect and promoting resilience.

Safeguarding Children Presentations were delivered at the Clinical Governance

Half Day, the Paediatric Ophthalmology Study Day and the Oculoplastic Allied

Health Professionals Study day.

Additional policies and procedures were developed including Clinical Holding and

DNA Policies.

iii) Priorities October 2016 to March 2017

To review safeguarding children procedures and processes to ensure they are

robust.

To complete remaining Section 11 audit actions.

To strengthen reporting from Moorfields into the statutory Child Death Reporting

process.

To prepare for the Islington Safeguarding Joint Area Targeted Review (JTAI).

To recruit additional safeguarding personnel and designated safeguarding

administrator.

To explore the development of a Safeguarding Champions Model across the Trust.

iv) Key learning and improvement actions

A key learning point arises from the national “Seriously Awkward” Report which

highlighted the need to recognise and understand vulnerabilities of 16 and 17 year

old patients under the care of adult services. Scenario based learning has already

been introduced within safeguarding training, as have sessions to strengthen staff

awareness of the need to respond to concerns in this age group.

A key learning point is to continually review the denominator / cohort of clinical staff

who require Level 3 training. This review is overseen by the Safeguarding Group

which meets bimonthly. Moorfields has developed and will deliver Level 3

Safeguarding Children Multi-agency in house training to include a Workshop to

Raise Awareness of Prevent (WRAP).

A key learning point arises from the national Jay Report into Child Sexual

Exploitation (CSE) which identified the underreporting of CSE. How CSE might

present in an ophthalmic setting has been introduced. CSE training and resource

learning outcomes will be monitored via referrals to children’s social care and

incident reporting.


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2.8 Safeguarding adults

Safeguarding adults remains a high priority within the trust through a continued

commitment to ensuring the trust meets its duties and responsibilities under the Care Act

2014, the care and support statutory guidance 2016, the Mental Capacity Act 2005 and

the Code of Practice.

i) Key Messages and Quality Assurance

The trust systems, policies and procedures to safeguard adults at risk and to

ensure lawful practice are constantly reviewed to ensure compliance with local and

national guidance.

Risks identified are managed and monitored by the Safeguarding Adults At Risk

Group.

The safeguarding adults at risk work plan was reviewed in August 2016, and is

monitored by the Safeguarding Adults At Risk Group. Progress against the work

plan has been achieved with 56 actions completed.

The substantive safeguarding adults lead commenced working at the trust in May

2016.

Training compliance for safeguarding adults (Level 1 and 2) has remained above

the target 80% compliance level throughout this period.

Training compliance for Mental Capacity Act has remained above the target 30%

compliance level throughout this period.

There has been an increase in mental capacity act queries to the safeguarding

adults lead demonstrating increased awareness of legal duties.

There have been no Serious Incidents declared involving safeguarding adults. One

complaint involving an adult at risk was reviewed by the safeguarding adults lead

and a concern was raised with adult social care.

There have been no Safeguarding Adults Reviews convened during this reporting

period that involved the trust.

The Ealing Domestic Homicide Review which the trust has had involvement with

signed off the overview report. Awaiting publication by the Home Office.

Effective partnership working with key agencies including Islington Safeguarding

Adults Board and its subgroups has been consolidated.

The Safeguarding Adults Annual Report 2015 – 2016 was presented to the Clinical

Quality Review (CQR) Group in October 2016.

The safeguarding adults agenda across the trust continues to be strengthened

through recognition that the scope of the agenda has expanded and it is broad and

far reaching.

ii) Key Achievements April to September 2016

Level 2 safeguarding adults training was developed to include basic awareness on

Mental Capacity Act and Prevent, and Making Safeguarding Personal approach.

Training was reviewed to be Care Act compliant.

Comprehensive Mental Capacity Act training was provided to all medical staff.

Mental Capacity Act briefings were delivered at the Clinical Governance Half Day.


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Mental Capacity Act templates were produced to support staff.

Partnership working with Dementia Action Alliance and MEH committed to being a

Dementia-Friendly Hospital.

Dementia & Learning Disability flags were introduced on OpenEyes.

Preventative work with London Fire Brigade.

Key Safeguarding Adults Performance Indicators, metrics and reporting were

submitted to Islington CCG and Islington Safeguarding Adults Board.

Policies and procedures were developed or reviewed to be Care Act and Mental

Capacity Act compliant including Restraint Policy, Domestic Violence Policy,

Complaints Policy, and Learning Disabilities Policy.

iii) Priorities October 2016 to March 2017

Review and develop safeguarding adults and mental capacity act policies, policy

summaries, infographics, flowcharts and staff leaflets.

Strengthen the support to Carers across the Trust

Establish a Champions Model focusing on safeguarding, dementia & learning

disability.

Deliver Mental Capacity Act training to clinical staff and embed learning in practice

across the trust.

Deliver Tier 2 Dementia training to a target of 300 staff with UCLP

Deliver Tier 2 Learning Disability training to a target of 40 staff with Mencap.

Deliver WRAP (Workshop to Raise Awareness of Prevent) training.

Address key priorities set by Islington Safeguarding Adults Board focusing on safe

discharge and improved information sharing with Adult Social Care.

Review incident reporting system to provide robust accurate data.

Recruit additional safeguarding personnel and designated safeguarding

administrator.

iv) Key Learning & Improvement Actions

A key learning point arises from the Islington Safeguarding Adults Board’s focus on

improving the Making Safeguarding Personal (MSP) approach across NHS Trusts.

MSP has been introduced into Safeguarding Adults training & a person-centred &

‘outcome’ focus is emphasised during advice to staff.

A key learning point arises from the outcome of MEH Mental Capacity Act audit

which highlighted a lack of implementation in practice. MCA training has been

introduced as mandatory for clinical staff, bespoke briefing sessions are offered to

departments, briefing sessions have been delivered at clinical governance half

days and user friendly templates have been produced.


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3. Clinical effectiveness

This section covers clinical effectiveness. The significant points for Q1/Q2 are:

Moorfields delivers good clinical outcomes. During this period a review took place

of service core clinical outcomes, resulting in paediatric, strabismus and neuro-

ophthalmology changing one of their outcomes. Full details of core outcome

performance will form part of the 2016/17 clinical quality and safety report. Trust

Management Board continues to receive regular updates about clinical audit

performance.

In relation to NICE guidelines, the Trust is either fully compliant or progressing with

compliance. At the time of writing one deadline has breached: NG10 Violence and

Aggression (deadline October 2016). There are no regulatory consequences of this

and actions are taking place to meet the requirements.

Process changes have led to more clinical audit proposals commencing and more

completed reports being received, indicating better performance compared to

2015/16.

3.1. Policies, Guidelines, Protocols, Standard Operating Procedures

70 clinical documents were approved at Clinical Governance Committee (CGC); 43

clinical documents were approved at Clinical Audit and Effectiveness Committee (CAEC).

3.2. National Confidential Enquiries (NCE)

There were no NCE guidelines applicable to Moorfields identified during Q1 and Q2 of

2016-17. The Trust is fully compliant with any NCE guidelines.

3.3 National Institute for Health and Care Excellence (NICE)

The CAEC reviews newly developed NICE advice and quality standards as well as NICE

guidelines and NICE projects in development. The following NICE guidance has been

considered and accepted as relevant to Moorfields during Q1 & Q2 of 2016-17. The table

below shows a summary of the compliance status.

0

5

10

15

20

Applicable to MEH Fully Compliant Partially Compliant Awaiting Response

MEH Compliance with Q1 & Q2 2016-17 NICE Guidelines


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NICE guidelines in development During this time there were 4 NICE guidelines in development that were considered

potentially relevant and were sent to Trust leads for information. This allows staff to be

better prepared for when the guidelines are published.

Antimicrobial stewardship - in development

Diabetes (type 2) - Canagliflozin, Dapagliflozin and Empagliflozin (monotherapy)

(ID756) - in development (for information only)

Sepsis Guideline

Diabetes in children and young people in development.

Outstanding NICE Guidelines The Trust is now able to analyse NICE guidelines to a greater degree of accuracy. Our

compliance percentage is 82.5%, measured as a sum of all NICE guidelines relevant to

the Trust since 2013 where a response has been provided by the lead. At the time of

writing only one guideline deadline has breached its timescales for completion, NG 10:

Violence and Aggression (see below for more details).

The CAEC also monitor those NICE guidelines that require further work to achieve ‘full

compliance’ for aspects relating to Moorfields prior to April 2016, currently recorded as

‘partially compliant.’ These include:

MPG2 Patient Group Directives

NG5 Medicines Optimisation

NG10 Violence and Aggression (deadline October 2016)

QS92 Smoking cessation

NG15 Antimicrobial Stewardship

QS113 Healthcare Associated Infections

QS120 Medicines Optimisation

NG13 Workplace Health

3.4. Clinical audit and outcomes

During Q1 the Trust reviewed its processes for the approval of clinical audit proposals and

reports. The outcome was that two-weekly Clinical Audit and Assessment Committee

(CAAC) where proposals and reports were previously discussed should no longer take

place and no further meetings took place after 17 May 2016. A new process was

introduced consisting of a review by the Clinical Audit Facilitator with support from the

Head of Clinical Governance and Clinical Lead for Audit and Effectiveness. This change

has increased throughput during Q1 and Q2, with 128 proposals for clinical audit activity

being approved. This compares to 207 proposals approved during the entire year of

2015/16.


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Reasons for Clinical Audit Proposals in Q1 & Q2 2016-17

Reason for audit Q1 & Q2 16-17

Clinical Interest 3

Complaints, claims and litigation 1

Core Outcome audit 5

CQUINS / commissioners 2

Incidents 3

Local Guidelines 20

Nationally Audits (not part of NCAPOP – national clinical audit and patient outcomes programme)

1

NICE 4

National Service Framework (NSF) 1

Patient Feedback 1

Patient Safety First 2

Royal College of Ophthalmologists (RCO) 2

Royal Colleges Other (Anaesthetics, Physicians) 1

Royal College of Ophthalmologists mGTT (RCOmGTT) 13

Re-audit 9

Revalidation 16

Service Evaluation 33

Survey 11

Total 128

144 clinical audit reports were received and signed off centrally by the Clinical Audit

Facilitator in Q1 and Q2. More than the 128 reports received for the entire year of 2015/16

and 62 received for 2014/15.


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3.4.1 Core Outcomes

Core outcomes data is gathered annually to measure against defined standards and data

from previous years. The Trust aspires to link as much of the core outcome data to the

electronic patient record (EPR) systems to obtain live figures throughout the year. This is

work in progress with the EPR leads. During Q1 and Q2, all services have been reviewing

their core outcomes for appropriateness and the abilities to capture the accurate data.

This has been driven by the Clinical Lead for Audit and Effectiveness and discussed at

service clinical governance half days. These discussions have resulted in the Paediatric,

Strabismus and Neuro-ophthalmology services changing one of their outcomes. Final

clarification of this amendment will be made and results will be included in the report

findings at the end of the year.


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4. Patient Experience This section covers patient experience. The significant points for Q1/Q2 are:

Performance for the friends and family test (FFT) (about recommending Moorfields’

care to others) has been generally good for both quarters, in terms of a high

percentage of positive responses and benchmarked performance against 156 NHS

trusts.

The overwhelming number of FFT comments left by patients have been positive.

Action plans have been created to address many of the concerns or queries

highlighted by the patient feedback from FFT, focus groups, patient surveys; some

solutions require trust wide responses.

The number of complaints received was 57 in Q1 and 35 in Q2, similar to previous

quarters, with the predominant number being clinical complaints.

The rate of responding to complaints within a 25 working day period dropped

during Q2 and was attributed to some complaints requiring more involved

investigation and several being returned by the central team to ensure all questions

had been answered. Half the delayed responses were from Moorfields South. Also

75% of the delayed responses required medical staff input.

707 PALS enquiries (including compliments) were received in Q1 and 701 in Q2

which is up on the previous 2 quarters (Q3 2015/16 was 594 and Q4 was 614); this

increase is attributed to better promotion of the service earlier in the year.

4.1 NHS England Friends and Family Test results (FFT) The FFT allows patients to not only ‘score’ the Trust on their visit, but also to comment on

their experience in real time, allowing the opportunity to thank the staff in writing or to

raise concerns they might previously have let pass.

4.1.1 Results Quarter one:

27,507 patients (15.5% of patients seen) completed the FFT. 99.1% of Day Care, 98.8%

of Outpatients and 92.1% of Accident and Emergency patients responded as extremely

likely or likely to recommend the Trust, whilst only 0.4%, 1.3% and 2.0% respectively

recording that they would not.

Quarter two:

30,992 patients (16.8% of patients seen) completed the FFT. 99.3% of Day Care, 96.5%

of Outpatients and 94.1% of Accident and Emergency patients responded as extremely

likely or likely to recommend the Trust, whilst only 0.3%, 1.6% and 2.0% respectively

recording that they would not.


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FFT respondents and scores Q1 and Q2 2016/17

Quarter 1 Apr-16 May-16 Jun-16

Respondents 8,671 9,951 8,885

Pts seen 58,116 55,893 63,135

% of patients 14.9% 17.8% 14.1%

Score 96.1% 1.4% 96.9% 1.4% 97.2% 1.2%

Quarter 2 Jul-16 Aug-16 Sep-16

Respondents 10,350 10,331 10,311

Pts seen 60,656 61,200 62,227

% of patients 17.1% 16.8% 16.6%

Score 96.6% 1.4% 96.7% 1.3% 96.7% 1.4%

Benchmarking Moorfields against the other 156 NHS Trusts undertaking the survey in a

snap shot each quarter shows:

For Day Care, Moorfields was among the top 3% for both quarters.

For Outpatients, Moorfields was in the top 22% in April and in the top 15% in

September 2016.

4.1.2 FFT Comments As previously, the overwhelming number of comments left by patients were positive.

Throughout both quarters, the most commonly used adjectives were; good, friendly,

helpful and caring, excellent, and many cited efficient organisation, the professionalism of

staff and clinical outcomes as reasons for recommending the service. For Q1, 551

patients left comments citing individuals by name and for Q2 there were 638 (by

comparison for Q3 and Q4 the previous year the numbers were 314 and 500 respectively.

Though only a general measure, there is consistency with regards to what patients feel

would have improved their visit, waiting times in clinics remains the main issue, with

around 15% of those who commented (mostly those who would also recommend the

service, regardless), raising it. Of those who would not recommend the service, waiting

and delays was cited by around 54% as the reason.

Each month between 500 and 600 patients leave comments that suggest or imply

improvements that would have made their visit better, (other than improved waiting times).

The majority of these concerned the experience of waiting with the main three being:

Being informed of the length of expected delays in clinic and day care and not

being able to hear their name called in clinic along with other communication

issues (e.g. letters not received, calls not answered).

Availability of provision and type of refreshments available

Entertainment whilst waiting- reading matter, television, background music or radio

and availability of Wi-Fi.

To a lesser extent, but still notable where issues around

Parking and transport


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Appointments management

Poor staff attitude.

4.2 Other sources of feedback 4.2.1 Social Media The Trust continues to monitor and receive comments from social media. Where

comments are received from sites such as twitter and Facebook, they are passed to the

appropriate management team so that issues can be resolved, on occasion whilst the

patient is still in the department. Where comments are left on patient feedback sites such

as NHS Choices or Patient Opinion, which tend to be more detailed, these are responded

to and shared with operational management teams. Of the 25 comments posted, 20 were

positive and 5 were less so, though there were no specific themes identified from those

who felt their experience could have been improved.

4.2.2 Patient Surveys / Audit There were no CQC or Trust wide patient experience surveys during Q1 and Q2 (A&E

and Paediatrics are being undertaken in Q3&4) however there were several local audits

undertaken with a patient experience element and these are included in section 3.4 of this

report.

4.2.3 Patient Engagement Patient engagement activities during Q1 and Q2 have included patient focus groups at

Bedford, Pharmacy led ‘Know your drops’ days at the satellite sites and City road, support

and education sessions for AMD and Glaucoma patients bringing patient support groups

and patients together. World Sight day brought patients and groups such as the IGA, the

Macular Society, the Retinitis Pigmentosa Society, the Keratoconus Society and the RNIB

(assisted technology) together. A medical led pre-surgery Glaucoma patient education

seminar began at St Ann’s and the Accessible Information Standard Patient engagement

group as noted above, which will hopefully act as a model when future service change is

being undertaken. There were also two patients invited to address the Trust board with

their experiences of the service at Moorfields. Both patient stories were to do with

different aspects of communication around surgery and were well received. PALS and

complaints are also a useful source of patient experience feedback and these are

discussed below.

4.3 Response to patient feedback

Action plans have been created to address many of the elements highlighted by the

patient feedback from FFT, Focus groups, patient surveys etc. received in quarters one

and two. These are overseen by the Patient Experience Committee. However, many of

the systemic issues raised are being addressed by Trust wide responses such as the

Accessible Information standard implementation, staff behaviours though the Moorfields

Way training sessions and appraisal and recruitment documentation, and the work being

undertaken by the Service Improvement and Sustainability group in regards to

appointments management and clinic waiting times. Some examples on learning and

improvement from this above feedback are:


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FFT (waiting experience) Staff are encouraged to provide read magazines which

are collected centrally and distributed throughout the City Road clinics. Wi-Fi

connections are also being promoted on the patient information screens.

Following an expression of need from patients, funding has been secured from

Friends of Moorfields for a two year pilot for a children’s and Young Persons

counsellor. This involved joint working with Family Support and the adult

counselling team.

FFT (staff behaviour) In response to several comments about staff not introducing

themselves, the national ‘Hello, my name is’ campaign is being promoted across

the Trust.

Following a focus group meeting at Bedford, patients said they would like details of

who to contact if there were problems between appointments and following surgery

that can be carried in a convenient way, so the options of business cards or wrist

bands are being explored.

FFT (refreshments) A review of vending machine provision at the City road site and

the better sign posting of patients to local refreshments at the satellite sites has

been undertaken.

CQC patient survey suggested that patients in A&E might be better assessed for

pain. This question is now included as part of the triage documentation and

analgesia is kept at the triage station. Patient in pain are also given appropriate

priority.

4.4 Complaints 4.4.1 Complaints received Q1 and Q2 2016/17

Complaints received by quarter Q3 2015/16 to Q2 2016/17

Q3 2015/16

Q4 2015/16

Q1 2016/17

Q2 2016/17

49 (47 complainants)




Percentage of patients seen who went on to complain

0.02% (166,672 patients

0.02% 168,056 patients

0.03% 174,485 patients

0.02% 175,481 patients

Complainants per 10,000 patient contacts

2.9 2.9 3.2 1.9

An average of 19 complaints a month were received by the Trust during Q1, the

total number of complaints received being 57 from 56 complainants.

An average of 12 complaints a month were received by the Trust during Q2, the

total number of complaints received being 33 from 35 complainants.

The number of clinical complaints was 30 and 17, proportionately the same as

previous quarters. All complaints and PALS enquiries are reviewed with the risk

and safety team and adult safeguarding lead (and where appropriate the Named

Nurse for child safeguarding).


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4.4.2 Complaints by type

Complaints received by type Q3 2015/16 to Q2 2016/17

Clinical issues continue to dominate making up around half of the complaints received. Of

these the majority (24) questioned the treatment they had received with a further ten

feeling the outcome of treatment or surgery was not as had been expected. Of the others,

five questioned the level of care received, both medical and nursing, four felt that the

incorrect diagnosis had been made and two felt that they had been inappropriately

discharged and two had issues with communication around their care. Of the 47 clinical

complaints, 13 were partially or fully upheld.

All responses to patients who make clinical complaints are reviewed by the Medical

Director to ensure all points have been addressed accurately and honestly. The nature of

these complaints are specific to the individual complainant and there does not appear to

be any correlation between specialty, site, clinician, type or date that indicates inherent

problems. Other complaints focused on staff attitude and administrative issues and

appointments. Of the complaints received in Q1: 12 were upheld and 11 were partially

upheld (40%) and in Q2: 10 were upheld and 7 were partially upheld (40%).

4.4.3. Complaints response time The response target of responding within a 25 working day period dropped noticeably

during Q2. This was due to several factors; a number of complaints requiring more

involved investigation and several being returned to ensure all questions had been

answered. Notably however, half of the delayed responses were from Moorfields South,

where staffing problems (now resolved) might have contributed. Also 75% of the delayed

responses required medical staff input, which tend to take longer and summer leave may

have also contributed. During Q1 and Q2 96.5% and 91% of complainants respectively,

were acknowledged within the three day target.


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25 day response rate Q3 2015/16 to Q2 2016/17

4.4.4 Analysis of complaints by site Complaints by site and type: Quarters 1 and 2, 2016/17

City Road is shown in the chart above as outpatients and diagnostics. Complaints taken

by site and type are relative to the volume of patients seen in those areas. Otherwise, no

discernible themes by site, type or persons involved can be seen. Those sites not

mentioned have received no complaints.

4.5 Patient Advice and Liaison Service (PALS) PALS enquires are classified as one of three types: compliments, general enquiries for

information or advice, and concerns or informal complaints. The latter two are similar as

most of the concerns and informal complaints are requests for information or a resolution

of an issue. The category these are recorded under is left to the discretion of the PALS

officer taking the call or enquiry and the degree of frustration exhibited by the patient. 707

PALS enquiries, including compliments, were received during Q1and 701 during Q2. This

compares with 594 and 614 for Q3 and Q4 2015/16.

Complaints answered within 25 days

Q3 15/16 78%

Q4 15/16 73%

Q1 16/17 78%

Q2 16/17 46%


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As can be seen from the graphs below, although the general number of enquiries is going

up (possibly in light of better promotion of the service prior to the CQC inspection

including an increase of 50% at Satellite locations), classification is relatively stable. One

exception is the increase in concerns about appointments.

PALS Information and enquiries Q1 2015/16 to Q4 2015/16 by number and percentage

PALS Concerns and informal complaints Q1 2015/16 to Q4 2015/16 by number and percentage

4.6 Key learning and improvement actions As in previous quarters, the majority of PALS enquiries are resolved to the patients

satisfaction within 24-48 hours, and the concerns raised and their resolution are circulated

to Directorate management teams on a weekly basis to assist in Trust wide learning.

Issues around appointment management and communication between the Trust and

patients remain the greatest source of concern.


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Formal complaints tend to be specific and responses to most clinical ones clarify the

patient’s care pathway, explain the reasons for treatment decisions and why the clinical

outcome was as it was. Other ‘non-specific’ responses to complaints include resolving

appointment issues, arranging meetings between Trust staff (commonly the Medical

Director) and complainants, encouraging staff to reflect on their behaviour or be reminded

of processes and procedures not followed, and addressing the underlying organisational

flaws that lead to complaints through Trust wide projects.

However, specific service changes are made as a direct result of complaints, include:

In response to poor staff attitude, the Fellow concerned has been interviewed

by their consultant and future attitude monitored.

Following the difficulty for one patient in managing an appointment change over

the telephone, the Service Managers of the area have revised the process that

patients are called back appropriately.

An assessment of how patients wear contact lenses has been shared at clinical

governance sessions.

Following a patient wanting to change their appointment by text, they were

advised that the trust is reviewing more use of texts but they can currently

change appointments on line.

Following a patient not being assessed or treated as appropriate, the pathway

has been clarified and explained to staff.

Following a patient misunderstanding a procedure in phlebotomy, the signage

has been changed and staff strongly reminded to check medical forms before

accepting patients.

Following confusion about an appointment booking, the Booking Centre is to

issue generic email address which should prevent a re-occurrence.


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5. Compliance

The CQC inspected in May 2016 and has issued their embargoed reports. The

Trust has responded with a number of factual accuracy queries. The Trust awaits a

further response from the CQC.

A phase 2 development of a quality scorecard is underway (first introduced in

August 2015). This will support operational analysis of quality and support

improvement and learning. This also meets the requirements of a Commissioning

for Quality and Innovation (CQUIN) framework work stream for 2016/17 worth up to

£300,000.

Work continues on the journey of quality improvement and additional acitivities

have been described.

5.1 CQC inspection

In May 2016, the Trust was inspected by the CQC. This section summarises the further

work following inspection:

a. On-going information requests by CQC through to early September

100+ data requests have been received and responded to.

b. Preparation for receipt of and responding to the CQC’s draft reports

The CQC issued embargoed reports (location/service specific inspection

reports and an overall Trust report) and the Trust responded with

required timescales.

The Trust awaits a further response from the CQC.

c. Preparation for inspection outcomes

Once the inspection outcome is final and a rating has been provided, a

number of actions will be required, (including publishing our rating at our

sites within five days of the rating being announced). A quality summit

with the CQC, NHS Improvement and possibly the CCG will take place

soon after to agree the next steps in terms of “must do” actions.

5.2 Quality dashboard

The Quality dashboard is a phased development of a quality scorecard introduced

in August 2015. As well as supporting a number of quality improvements, the

dashboard will also satisfy our Commissioning for Quality and Innovation (CQUIN)

framework for 2016/17 requirements up to a value of £300,000.

5.3 The Quality Assurance Framework (QAF)

The Quality Assurance Framework is a mechanism to assess the compliance and

safety culture of the organisation; identifying areas of concern, review and

improvement, informing assurance activity, and to provide an early warning system

for potential serious failures in quality and safety. The model works by bringing

together and triangulating data from a variety of sources both quantitative and

qualitative.


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5.4 From Compliance to Commitment: the journey

The Trust has embarked upon a journey to move from a compliant organisation to

a more committed one where it is less driven by compliance. This will

progressively develop through the introduction of a Quality Improvement

Programme.

5.5 Policy management

A significant activity of the compliance function is the management of the Trust’s

197 (as at 30 September 2016) policies. In the previous 2 Qs this included:

Policy publication:

64 policies reviewed, updated and published during the period

01/04/2016 – 31/05/2016

A further 10 policies were reviewed, updated and published during the

period 01/06/2016 – 30/09/2016

As at 30 September 2016, 93% (i.e. 184 out of a total of 197) of the

Trust’s policies were in date.

Revised policy on policies published in early May. This included:

A new infographic on how to develop a new policy or review an existing

policy.

A new process which sends a calendar reminder for the next review of

the policy.

An extract from the policy register is sent to responsible EDs every

month.

Work is underway to move the existing policy register spreadsheet to a new database.


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Clinical Quality and Safety Performance Report Moorfields United Arab Emirates

(UAE), Dubai (MEHD)

Quarter 1&2 2016/7 (1st April – 30th September 2016)

1. PATIENT SAFETY

1.1 Incident Reporting

Incident reporting at MEHD is a paper-based reporting system. When an incident occurs, each

staff member should report it immediately (within 24 hours) to their line manager and together

complete an Incident Report form. The line manager will inform the Quality Manager. Once the

Incident Report is completed with actions, this should be handed to the Quality Manager for

analysis of incidents and to provide an update on progress and challenges faced during the

reporting period. The actions must be communicated to the relevant staff involved.

Summary of Incidents;

Indicators

2016/17

Q1 Q2 Q3 Q4 YTD

Patient Safety Incident (PSI) 30 21

All other incidents 4 21

Total incidents 34 42

Sentinel Events 0 0

Q1

There were 34 incidents reported during quarter 1. This involves a number of patient safety

incidents, including 12 relating to similar administration patient documentation issues. A number of

these incidents relate to simple mismanagement of patient records administration, including

duplicate or incorrect patient records being transferred to the clinical areas. There seems to be a

pattern with the paediatric department. This could possibly be due to the construction work in the

paediatric area. The HR/Administrative Director has been informed of each incident and has

communicated to her team.

There was a serious incident raised regarding incorrect follow-up appointment booking. A patient

was requested by the doctor to have a follow up booked after 4 weeks. The appointment was

booked at 6 weeks, rather than 4 weeks despite clinic availability. The patient experienced some

side effects possibly linked to stopping the medication for 2 weeks and not being reviewed in the

correct time frame. This was shared with the Medical Director and Administrative Director for their

review and management of the situation to ensure this is not repeated. The patient has been

followed up more closely by the treating physician and is doing well, with no further side effects.

We had a number of incidents relating to equipment failure. The majority of these were fixed in a

short time frame causing minimal, if any disruption to patient care. However there was an incident

noted of issues with the vitrectomy machine in theatre. This has a serious impact on Moorfields

from a patient care and safety point of view plus also financial. The engineers were called to

attend MEHD but there was a delay in the response and time to repair the equipment. In this


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instance, in order to maintain patient safety, the Theatre Manager, Operating Doctor and Medical

Director made the decision to use facilities equipment.

There was a 16 year old patient who attended MEHD without a parent or guardian. A 16 year old

patient cannot give their consent legally. We must have a parent or guardian to sign the initial

Patient Information Form Consent plus also be present during the appointment for consent to use

drops, etc. All staff have been informed of this incident and the Informed Consent policy shared.

The patient was contacted to inform him to bring an adult relative to his next appointment.

Q2 There have been 42 incidents reported during quarter 2 (including 21 issues with equipment). The

equipment issues are recorded as incidents as this will impact what investigations are available to

the patient and therefore could impact ability for doctor to diagnose fully.

There have been 8 clinical incidents reported this quarter. These include a number of incidents

relating to use of the new Constellation equipment. These issues have been highlighted by the

Theatre Manager to the Medical Director who has communicated with the equipment company

representative. Furthermore, the Medical Director has discussed with the doctors during the

weekly doctors meeting. All procedures with this equipment will be supported by the equipment

representatives and monitored by the Theatre Manager and Medical Director.

There have been 6 incidents regarding patient documentation this quarter. This has been shared

with the team by the Administration Director, Nurse and Medical Director to ensure all staff are

informed and each issue will not be repeated. All staff have been reminded to use 2 patient

identifiers. Again, this will be monitored closely by the department managers/directors.

One other clinical incident that occurred was during a surgery involving a visiting doctor from MEH.

The patient was from the GCC region and advised to be seen in Dubai rather than travelling to

London. Surgery was attempted but due to patient general health, the procedure was cancelled

and rebooked in a general hospital to ensure the correct anaesthetic and follow up support was

available. The learning from this incident was to ensure the full patient history is shared and

obtained from the visiting doctor by the Theatre Manager, Anaesthetist and supporting local

doctor or Medical Director before booking/confirming surgery.

There was a hospital evacuation due to a fire in the food court area of the building. The

evacuation was handled extremely well by the fire warden and fire marshall team with all staff and

patients were escorted safely and smoothly out of the building. There were a number of

vulnerable patients in the hospital at this time including babies and children, a pregnant lady and

elderly. We also had a number of surgical patients who were also evacuated. Due to the high

temperature and lack of shade in the designated evacuation area, staff provided the vulnerable

patients water and comfort in air conditioned cars. In terms of learning, all staff are advised to

remain in the evacuation area until advised by the Head Fire Warden.

There was a complete power failure of the building, including the hospital. The back-up generator

was also affected. This was reported to DHCC due to system electrical fault. This was followed up

and managed by the Operations Director and maintenance company (Interact) were also on hold

to support the building maintenance by providing a report on the exact issue and how to rectify the

problem.


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C.

Diffi

cile

and

E.

Coli screening is not applicable at MEHD as the patients are out-patients/day case surgeries only.

* No cases of previous MRSA were identified. The theatre manager is ensuring that all patients

are asked of their MRSA history in the surgical pre-assessment appointment.

The infection control audit results have been consistently good this year to date. The Infection

Control team is headed up by the Senior Nurse and a number of nurses have been appointed and

trained to support carrying out the audits and supporting the staff in Infection Control measures.

During October, the senior nurse reviewed all IC measures with respect to the new Moorfields

London standards, Moorfields Dubai (DHCC guidelines), UEMS (HAAD guidelines) and Al Jalila

(JCI guidelines) to ensure that one audit is created to ensure we meet all standards.

2. CLINICAL EFFECTIVENESS

2.1 Guidelines and Policies

Title Department SOP, Protocol,

Policy, Clinical Guidelines

New/ Update

Helping Hand Policy OPD Clinical Policy New

Following an idea from the paediatric team, we have created a policy in order to support

vulnerable patients in the patient pathway process at Moorfields Eye Hospital Dubai. This idea

and policy is based on the Helping hand process and policy from Moorfields London but has been

modified for the UAE. The idea was shared with the PPC team and presented and approved by

the SMM with final sign off from Medical Director, Professor Scott who will be responsible for the

policy. This is a positive example of the newly structured PPC.

Indicators Target Q1

16/17 Q2 Q3 Q4 YTD

MRSA Screening 100% N/A* N/A*

%Endophthalmitis post

cataract 0.08% 0% 0%

%Endophthalmitis post

AMD/DR 0.05% 0% 0%


acquired NA 0 0

Indicators Target Q1 Q2 Q3 Q4 YTD

Hand hygiene compliance 95% 93 94

Cleanliness inspections 95% 98 96

Medical Equipment audit 90% 88 89

Sharps Audit 94 90


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This quarter, regular quality meetings have been setup on a monthly basis. This will include the

Medical Director, Quality Manager, Senior Nurse and Theatre Manager. Other staff will be invited

depending on agenda set for the meeting and may also involve skyping in from London.

All policies are in the process of being reviewed in line with review date and CPQ audit in January

2017.

2.2 Clinical Audit and Outcomes

Core Outcomes results

Specialty Metric Standard Q1 Q2

Cataract Posterior capsular rupture (PCR) in cataract surgery

<1.8% 0% 0.95%

Cataract Endophthalmitis after

cataract surgery <0.08% 0% 0%

Cataract Biometry accuracy in

cataract surgery >85% 90% 85.27%

Glaucoma Trabeculectomy (glaucoma

drainage surgery) failure <15%

N/A – no

surgery

N/A – no surgery

Glaucoma PCR in glaucoma patients <NOD 0% 0%

Glaucoma Glaucoma tube drainage

surgery failure <10% 6.25% 4%

MR Endophthalmitis after

injections for DR <0.05% 0% 0%

VR Success of primary RD

surgery >75%

88.24%

90%

VR Success of macular hole

surgery >80% 100% 100%

VR PCR in cataract surgery in

vitrectomised eyes <NOD 0% 0%

NSP Serious complications

strabismus surgery <2.2% 0% 0%

NSP Success of probing for congenital tear duct

blockage > 85%

85.71%

81.82%

Ext Dis DSAEK corneal graft failure

rate ≤12% 0% 0%

Ext Dis PK corneal graft failure rate UKTS 0% 0%

Ext Dis DALK corneal graft failure

rate UKTS 0% 0%

Refractive Accuracy LASIK (laser for >85% 93% 90%


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refractive error) in short sight

Refractive Loss of vision after LASIK <1% 0% 0%

Refractive Good vision without lenses

after LASIK ≥80% 92% 96.3%

Adnexal Ptosis surgery failure <15% 0% 8.3%

Adnexal Entropion surgery success >95%

75%

(2 patien

ts)

67%

(2 patients)

Adnexal Ectropion surgery success >80% 100% 100%

Anaesthetic On the day transfers

0.22%

1 patien

t

0%

(0.12% cumulative)

Serious Incidents, Never Events and Incidents

Type Metric Q1 Q2

Incident Wrong patient 0% 0%

Incident Wrong side 0% 0%

Incident Wrong IOL 0% 0%

Incident Unplanned 2nd surgery < 30days 0.66% 0.79%

All unplanned surgeries are communicated to the Medical Director and investigated. These

patients are identified monthly and reported in a similar format to MEH to ensure clinical quality

and learning. During Q2 there were 2 patients who repeat surgery within 1 month. These cases

were complex retinal detachment patients and the records have been reviewed by the Medical

Director.

3. PATIENT EXPERIENCE

3.1 Patient’s Satisfaction Survey

Patient experience is captured using an ipad survey. A new survey was introduced last quarter

and this is continuing to provide a much greater number of results. Paper based surveys are also

available at reception desks if required and the results are collated with the electronic results.

There are 5 ipads located in MEHD; 3 in the check-out administrative reception area, 1 in theatre

and 1 in the surgical booking area. The results are reviewed daily and discussed weekly at the

Performance Improvement Committee meetings and shared with all staff on a monthly basis.

Number of Surveys in Q1&Q2: 1271 Question 14: Would you recommend this Hospital to a family member/friend? Yes 96%


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We have met our target of 15% of patients to share their feedback, in order to make the results

statistically significant. As we now have a more user friendly survey, a target will be set by the SM

in order to obtain more patient feedback and provide better services to our patients and help

attract new patients to the hospital.

Consistently excellent results each month this quarter, all above 90%. In addition, over target for

MEH Benchmarking/Average of 79% and we have met the minimum response rate of 15%.

During Q1 there were 28 complaints recorded on the feedback survey. Complaints by type;

The main patient complaints are waiting times (8), costs (7) and appointment scheduling (6). All

comments are followed up to understand the feedback and ensure we can implement the right

actions for improvement.

A number of measures have been taken to combat the waiting time complaint in OPD. There has

been an increase in patient communication about the appointment process itself to ensure

patients understand the clinical pathway and awareness of dilation drops. There has been an

improvement in the information available on the website, training to the call center regarding

information shared with patients when booking appointments, increased and improved

communication from clinical team in OPD. There is an ongoing project to allocate a nurse to each

doctor’s clinic. The initial stages have been implemented with further changes and improves to be

made in due course.

There were a significant number of complaints regarding costs of appointments, surgery,

laboratory tests and parking. This is discussed at the PPC which involves the Administrative and

Financial Director. The costs are regularly reviewed with relation to Moorfields London and local

market trends.

There were also a number of complaints regarding appointment scheduling, including suggestions

for after school/evening clinics, problems with booking and connecting to the call center and

communication regarding appointments. These concerns were shared with the Medical Director

and Administrative Director.


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3.2 Patient Complaints

In order to capture patient complaints we have two measures of recording, firstly through the

verbal feedback log and secondly communication (in person, telephone, email) with the Quality

Manager or a Director of service. The concerns raised on the feedback log are resolved during the

patient’s visit but we have it important to capture this information to gather a true reflection of how

the hospital is running. The more serious complaints or those that cannot be resolved by the line

manager are passed to the Quality Manager or Director for investigation, action and feedback to

the patient. A complaint form is available but is not readily used. This complaint form will be

reviewed during Q3 and made available to staff to share with patients in order to have a clear,

trackable process.

Q1

There were 30 complaints recorded from the OPD manager this quarter. The majority involving

patient waiting times for doctor. It is worth noting the number of waiting times for optometrist is

significantly reduced from the last few quarters. There is a number of complaints regarding

communication to patients before they attend the hospital and during the visit regarding the

patient pathway.

There were 10 waiting time complaints in the theatre department. This involves delays to doctor

delays due to complicated surgeries, staff arrival times to theatre list (OPD delays and staff

morning attendance) and translator availability. This is being closely monitored by the theatre

manager in order to improve patient experience and theatre utilization.

It is key that all departments use this complaints/comments log to capture this important

information. This quarter it has only been used by the OPD Manager and OT Manager. The

administrative team leaders have been asked to record their findings so the complete patient

experience can be reviewed.

Q2

From the verbal feedback tracker, there are 14 patient concerns raised in the theatre department

regarding waiting times for surgery. This has been recorded by the Theatre Manager and team

and managed immediately on the day. Along with these complaints, the Operations Director and

Medical Director have highlighted the inefficiency of theatre and the need to improve the theatre

utilization and reduce unnecessary staff overtime. An improvement plan to improve the theatre


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utilization and patient satisfaction has been started by the Operations Director with support from

the medical Director and Theatre Manager. In addition to this, a specific theatre feedback survey

has been developed in order to get more detailed feedback to ensure we improve for our patients.

There have been 14 waiting time complaints from the OPD department, 10 relating to waiting for

the doctor, 3 for optometrist and 1 for orthoptist. There have been 2 clinical outcome complaints

that relate to surgical outcome (Medical Director MEH involved with patient communication) and

incorrect glasses prescription. A complaint was made regarding communication of laboratory

results. In response to this the Senior Nurse has reviewed the process and policy and assigned a

nurse to monitor. The Senior Nurse will be monitoring this process to ensure full compliance and

better patient satisfaction.

There were 2 complaints regarding clinical staff attitude. One of the staff has left the business,

however the situation has been managed well by the head of department and quality manager,

leaving the patient is satisfied. The second complaint relates to a busy clinic and attention from

the member of staff. This feedback was shared with the individual staff member, who has spoken

to the patient directly. The patient was contacted for further feedback and found to be satisfied

(has been seen multiple times since complaint made).

3.3 Formal DHCC Complaints

A formal, written complaint was received regarding a patient’s clinical outcome of cataract surgery.

This has been ongoing for a number of months with communications from 3 different legal entities

and a formal DHCC complaint raised. DHCC reviewed, investigated and gave the decision that

there was no evidence for the complaint. This complaint is now closed.

Learning and Improvement

MEHD has had consistent incident reporting throughout the year to date and there is a better

awareness amongst all staff about the iR process. There is a significant improvement from the

theatre department. At the beginning of the year a number of incidents were not reported due to

lack of knowledge or staff taking individual responsibility. This was addressed with the Theatre

Manager and has improved in the last quarter. The Senior Nurse and Medical Director roles are

key to supporting the theatre team with the process.

Although an incident was reported regarding a Moorfields London patient, this was a great

learning experience for ensuring all of the information is shared and obtained when patients are

seen across all sites. If (and when) other patients from the GCC region need to be seen in MEHD,

rather than London, there is now a clear process an better understanding of how to safely manage

this type of patient. This is crucial for patient access and maintaining good business in Dubai.

Further improvement is expected with the IR process once the sytem can be moved from a paper

based system to an online software. This is expected in October 2016.

A Senior Nurse was appointed from Moorfields London at the beginning of this year. This has

provided support to the nursing team and clinical team on infection control measures. The Senior

Nurse is in the process of reviewing all Infection Control audits and processes to ensure they are

in line with Moorfields London and meet our standards and targets with our local partners, UEMS

and AJCH. Part of this role is also to setup a clear infection control nursing team and structure to


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implement regular IC review and clear action plans to improve and ensure consistent IC practice

across all Moorfields sites.

There has been significant improvement in the amount of patient feedback obtain during the last 6

months. MEHD is now meeting the 15% target. This has been achieved by using a new software

company with a more user friendly survey, increasing the number and the relocation of outlets

(ipads) for patients to leave their feedback; 3 to 5 ipads located at administrative (check-out) desk

for use at the end of visit while waiting for insurance approval/billing. A new process for following

up patients has also been implemented. Patients are asked if they would like to be contacted to

discuss their feedback/experience, thus allowing us an opportunity to gather more patient

feedback but also manage any unresolved issues/complaints and improve retention. All patients

are contacted by the administrative team for screening, if further assistance/management is

needed, the patient is contacted by the Quality Manager for further investigation and management.

If the patient cannot be contacted an email is sent.

A new question has also been added to the survey to obtain patient feedback on appoinment

timings. This information has already been reviewed and an increase to the opening hours on a

Saturday is in the process of being trialled.


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Clinical Quality and Safety Performance Report Moorfields United Arab Emirates (Abu Dhabi - MEHCAD)

Q1 & Q2 2016/17 (1st April – 30th September 2016)

1. Patient Safety 1.1 Incidents

Indicators 2016/17

Q1 Q2 Q3 Q4 YTD

Incidents 33 7

Sentinel Events 0 0

Total incidents 33 7

In Q1 there were 33 incidents reported. The majority of those (31) are due to maintenance issues.

These have been recorded as incidents as they involve a number of issues that are continually

not functioning and could potentially impact the hospital’s ability to provide a safe environment for

patients and staff and impact the efficiency of patient experience (delay to theatre opening), e.g.

power failure, air conditioning system, water pressure.

There was also an incident regarding availability of equipment/consumables for an Outpatient

procedure. When investigated by the Head Nurse, it was noted that the staff did not know the

doctors preference for the procedure. Training has been carried out by the Head Nurse, to all

nursing staff to ensure this incident is not repeated.

It important to note that the incidents reported during Q1 (33 incidents) were not reported correctly

on IR forms, but compiled at the end of the month by one or two staff members. A significant

number of these incidents were related to equipment and maintenance of the new facility. There is

now a clear process in place for reporting maintenance issues (staff have been retrained on

process) in order to ensure these issues are not confused with incidents.

The 7 incidents reported in Q2 were reported on the correct incident report form and sent in a

timely manner to the Quality Manager.

There has been a lack of incidents being reported or following the correct process. After the

Quality team was made aware that there were a number of issues that had occurred but had not

been reported, a refresher training session was arranged in September. All staff attended the 4

sessions that ran throughout the day in order for all staff to have access to the training session.

The purpose of the training session was to clarify the definition of an incident, understand exactly

how to report and the importance of reporting. All staff were reassured that incident reporting is a

positive exercise and given the confidence to report without fear. It was highlighted that the

responsibility for reporting is applicable to each and every member of staff, not just supervisors or

managers. It was a positive session and following the training, 6 incidents were reported during

the last 3 weeks of the month.

The incidents this Q included 2 leaks in the theatre area (OT and medication room), the fire alarm

being activated without cause and a power trip affecting the facility during operating hours. All of

these issues were reported in a timely manner and have been resolved.


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There was an incident that occurred in UAE involving MEHCAD clinical team and equipment.

MEHCAD are providing RoP screening services to DAE patients. Currently, DAE does not have

any equipment for this service and MEHCAD transports the equipment from MEHCAD to DAE on

a weekly basis for the clinic. The equipment was damaged during the transfer process and

treatment was unable to be carried out. There was no clinical harm to the patient but the patient

and family were put through undue stress in preparation for the failed treatment. In terms of

learning, a new checklist was produced for checking equipment function, equipment is not to be

transported unless in emergency cases and is to be transported by equipment representatives.

This has been communicated to all parties involved.

There was an incident relating to malfunctioning of a piece of clinical diagnostic equipment,

involving patient’s clinical diagnostic information not being saved correctly (Optos fundus

photography). This affected a number of patients but the nursing team insured all data obtained

was managed correctly and the company representative was contacted to fix the problem. This

issue has now been resolved.


C. Difficile and E. Coli screening is not applicable at MEHD as the patients are out-patients/day

case surgeries only. Surgical procedures started during the month of September. No MRSA

screenings were identified.

The Hand hygiene results have improved slightly over the course of the year but are still

significantly below the target of 95%. The Infection Control team is led by Senior Nurse and

supported by the Medical Director. At MEHC, the Head nurse is responsible for ensuring IC

practices are followed. In order to support the Head Nurse to ensure all audits are completed and


2016/17

MRSA Screening 100% N/A N/A

% Endophthalmitis post

cataract 0.08% N/A 0%

% Endophthalmitis post

intravitreal injection 0.05% 0% 0%


acquired 0 0


2016/17

Hand hygiene compliance 95% 65 78

Cleanliness inspections (EOC) 95% N/A 91

Medical Equipment audit 90% NOT

DONE

NOT

DONE

Sharps Audit NOT

DONE

NOT

DONE


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improve the results, 2 nurses have been identified to be trained as IC nurses to ensure best

practice in the facility. These nurses will undergo formal IC training by the end of Q2.

1.3 Environment of Care Audit

The first Environment of Care Audit was carried out on 22/8/2016. MEHCAD achieved a score of

74%. This was below the target. An action plan was created and the facility was re-audited on

19/09/2016 and met the target, achieving a score of 91%.

1.4 Medication Audit Report

The first Medication Audit Report was carried out on 21/08/2016 and MEHC achieved a score of

78%. This was below the target. An action plan has been created to improve this score and the

Head of Pharmacy at Healthplus will support. This is a new audit for Healthplus and has not been

re-audited to date.

2. Clinical effectiveness

2.1. Guidelines and policies

Title

Standard Operating

Procedure/protocol/policy/clinical

guidelines

New/Update

Access to theatre

department

SOP/Policy New for MEHCAD

(Moorfields policy)

The Role of the

Admission (Pre-op)

Nurse Policy


(Moorfields policy)

Aseptic Technique Policy


(Moorfields policy)

Body fluid spillage policy


(Moorfields policy)

Care of Surgical

Specimens


(Moorfields policy)

Child Protection Policy


(Moorfields policy)

The Role of Circulating

Nurse in OR


(Moorfields policy)

Collagen Cross Linking

Policy


(Moorfields policy)

Discharge Criteria


(Moorfields policy)

Disposal of needles,

syringes and sharp

instruments Policy


(Moorfields policy)


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Gloving Policy


(Moorfields policy)

Gowning Policy


(Moorfields policy)

Intra-operative Record

Policy


(Moorfields policy)

Laser Safety Policy


(Moorfields policy)

Latex Sensitivity Policy -

This needs to revised -

allocated to CL, GDV &

RD


(Moorfields policy)

Policy for monitoring

patients under sedation

or general anaesthetic


(Moorfields policy)

Management of

operating suite attire

policy


(Moorfields policy)

Pain Assessment in

recovery Policy


(Moorfields policy)

Peri-operative

Documentation


(Moorfields policy)

Policy for Intravitreal

Injections


(Moorfields policy)

Care of the post

operative patient in

recovery


(Moorfields policy)

Policy for Pre Assessing

patients - This needs to

be revised by SM/CL and

Anaesthetist


(Moorfields policy)

Pre-operative

Handwashing


(Moorfields policy)

Role of the Recovery

Nurse


(Moorfields policy)

Surgical Count Policy


(Moorfields policy)


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Surgical Marking Policy


(Moorfields policy)

The role of the

instrument (scrub) in OR


(Moorfields policy)

Theatre Preparation

Policy


(Moorfields policy)

Theatre staff Orientation

Policy


(Moorfields policy)

Time Out Policy


(Moorfields policy)

The policies listed above, have been modified from Moorfields guidelines for MEHCAD by the Senior Nurse. The Senior Nurse and Head Nurse will ensure all necessary staff (nurses and doctors) are trained on these policies. This is to be arranged before the opening of OT to ensure all staff fully understand the process and policy. The Medical Director is in the process of reviewing the clinical guidelines for the following sub-speciality areas; cataract, paediatrics, VR, MR, cornea, oculo-plastics (DR completed). Expected Q3. A number of additional policies are under review by the Quality Manager and team, these are to be expected during Q3. 2.2 Clinical audit and outcomes

Core outcomes results

Year to date, we have performed 23 intravitreal injections. There have been no cases reported of endophthalmitis from any of these procedures. The visual outcomes and stability will be reviewed after 12 months. A number of these patients started the course of injections in Dubai but now will be seen in Abu Dhabi. The data for these patients has been transferred to the clinical outcome audits for MEHCAD. This data will be assessed by the Head Nurse, Quality Manager and Medical Director.

Operating Theatres were commissioned in September 2016. There have been 7 surgical procedures carried out to date in MEHCAD Q2. These procedures include 5 cataracts, a steroid injection and an oculo-plastic procedure. The cataract surgeries will be audited in line with Moorfields London criteria approximately 6-8 weeks post operatively.

Specialty Metric Standard 2016/17 Q1&2

MR Endophthalmitis after injections <0.05% 0%

MR Visual improvement after injections >20% N/A

MR Visual stability after injections >80% N/A

NSP Serious complications strabismus surgery <2.2% 0%

Cataract Posterior capsular rupture (PCR) in cataract surgery

<1.8% 0%

Cataract Endophthalmitis after cataract surgery <0.08% 0%


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Serious incidents and never events

Specialty Metric Standard 2016/17 Q1&2

Incident Wrong pt 0% 0

Incident Wrong side 0% 0

Incident Wrong IOL 0% 0

Incident Unplanned readmission < 30 days No target 0

3. Patient experience

3.1 Survey/satisfaction questionnaires

Patient feedback survey was introduced in June 2016 and the data is gathered via an ipad survey. This is located at the reception desk for patients to complete during the check-out procedure, once the appointment is completed. All staff have been informed about the activation of the survey and will be actively encouraging patient’s to use.

The survey was completed by 227 patients and achieved an overall score of 97%.

MEHCAD achieved the target or above on all measures apart from Question 11, Explained Financials during the months of June, August and September. This has been shared with the team, with the responsibility given to the Administrative Supervisor to ensure all staff are providing this information to patients.

Question 14: Would you recommend this Hospital to a family member/friend? Yes 95% Excellent results each month this year, all above 90%. In addition, over target for MEH Benchmarking/Average of 79% and we have met the minimum response rate of 15%. We received some additional suggestions from the survey regarding improving the children’s waiting area by increasing the toys and games available during the dilation waiting time. Colouring books have now been added to the waiting area. A number of patients have requested additional services, including an onsite pharmacy, increased services for cornea and Glaucoma. Patients also suggested better signage outside and inside the hospital. This information has been shared with the marketing teams.

3.2. Complaints

Over the first quarter there were 2 complaints for the same issue, lack of air conditioning. Both complaints were raised on the 8th May 2016. The patient was contacted on the same day to acknowledge the complaint and ensure that the maintenance were working to fix the problem. The lack of air conditioning complaint was resolved on 15th May 2016. No further action required. Despite only two complaints recorded on the paper based complaints form, there was a verbal

patient complaint about waiting time.

During quarter 2, there was 1 complaint regarding waiting time. 3.3 Formal/HAAD Complaints No formal/HAAD complaints received this quarter


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3.4 Learning and Improvement

Incidents were not reported correctly during the first quarter. Once this was identified, a teaching

session was arranged for all staff. The training allowed staff to share their concerns and reasons

for not reporting, complete and review an IR form, and understand the importance and reasons

why it is necessary to report incidents. There was improved reporting during Q2 in terms of format,

however a low number of incidents were reported. One of the reasons for this was that the initial

incidents raised were related to the opening of the new facility. Most of these concerns have been

resolved during the first few months of opening with the contractors. A further training session was

also provided to the team to ensure correct reporting for equipment and maintenance, rather than

always using IR forms. This will be monitored closely by the Quality Manager and Senior Nurse

with regular facility visits.

MEHD is in the process of moving to an online IR system. This model will be tested in Dubai

during the latter half of this year. If successful, the software could be implemented at MEHCAD.

A Senior Nurse was appointed from Moorfields London at the beginning of this year. This has

provided support to the Head Nurse, nursing team and clinical team on infection control measures.

The Senior Nurse is in the process of reviewing all Infection Control audits and processes to

ensure they are in line with Moorfields London and meet our standards and targets with our local

partners, UEMS and AJCH. Part of the Senior Nurse role is to setup a clear infection control

nursing team, structure and process. 2 nurses have been assigned to the Infection Control team

and have been formally trained in IC practices (September 2016). The focus is now to implement

an IC structure for the staff to manage and follow to ensure regular IC review, clear action plans to

improve and ensure consistent IC practice and communication to MEHCAD staff for learning and

improvement.

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