proposed activity & quality data collecting & reporting ... · monthly completion by each...

R MOORE/ M SUTCLIFFE FINAL DRAFT 22 MAY 2012

Proposed

Activity & Quality

Data Collecting & Reporting

2012-2013

Staffordshire, Shropshire & Black Country Newborn Network


Summary

The Staffordshire, Shropshire & Black Country Newborn Network (SSBCNN) has responsibility for the collection of data and reporting service quality from Trusts and through formal network reports, advise on quality improvements and activity to inform future contracting for services.

In order to provide robust and meaningful data to commissioners the SSBCNN has identified a reporting and data schedule in the network as specified in this document. This includes standard Trust activity and staffing reports as well as specific quality measures, clinical outcomes and parent and user experience. This is as part of the network’s commitment to introducing the principles described in the Toolkit for High Quality Neonatal Services (DOH 2009) and to monitoring the Quality standards for specialist neonatal care (NICE 2010).

Introduction

The publication of the Toolkit for High Quality Neonatal Services (DOH Oct 2009) and the Quality standard for specialist neonatal care (NICE 2010) clearly puts high quality services as part of a ‘whole pathway’ collaborative approach between commissioners and providers with managed clinical networks providing the lead on the provision and coordination of care. The ‘Toolkit’ sets out the principles that underpin the delivery of high quality services and provides a basis upon which networks, commissioners and providers are measured. The quality measures accompanying the quality standard for specialist neonatal care aim to improve the structure, process and health outcomes of specialist neonatal care.

The introduction of the unit specific pathways in the SSBCNN from April 2011, along with the already established transport service meets some of the recommendations for change within the ‘Toolkit’. It is important that these initiatives show real improvement for neonatal care and with this in mind it is important that the network ensures better monitoring of services to fully understand the impact that these initiatives will have within the SSBCNN and the real challenges for services.

Other documents published recently are looking at improving not just clinical outcomes and the hard activity and capacity figures but the most important aspect of care delivery, family experience and satisfaction.

The publications of: “Poppy Steering Group. Family-centred Care in Neonatal Units. A Summary of Research Results and Recommendations from the Poppy Project” (2009) and the revised “BLISS Baby Charter Standards” (2009) informed principle 3 Care of the baby and family experience, in the ‘Toolkit’. These documents along with the “Parents’ experiences of neonatal care A REPORT ON THE FINDINGS FROM A NATIONAL SURVEY” (Picker Institute Dec 2011). provide neonatal services with a set of challenges to meet, not only the parents expectations of good outcomes, but also their full and open engagement in the babies pathway of care from admission to discharge as equal partners.

As much as possible the network has taken account of data already collected and reported to minimise any increase in unit workload.


SSBCNN Clinical Effectiveness

In view of the need to collate and monitor data SSBCNN has appointed a Consultant Neonatologist with 2 PAs per week for the network to act as Clinical Effectiveness Lead (CEL). The remit of this role is to lead on Clinical Effectiveness throughout the network focussing on the analysis and use of the neonatal data collected by all units in the network using the Clevermed neonatal data system in order to support the network in meeting:

1. The principles within the Toolkit for High Quality Neonatal Services

2. NICE Quality Standards – “Specialist Neonatal Care”

3. Quality Innovation Productivity Prevention (QUIPP)

4. Agreed Commissioning Quality Initiatives (CQUINS)

5. National Neonatal Audit standards (NNAP)

6. Regional quality monitoring through the QI – the West Midlands QI neonatal clinical indicators

7. Monitoring of safety and mortality review

8. The National Neonatal Dashboard Indicators

In order to fulfil these aspects the post holder requires access to each unit’s anonymised data held in the suite of single unit, network, commissioner and national reports in Neonatal.Net. The CEL will review the monthly returns and if any significant variation to the previous months data are identified the CEL will liaise with the specific unit’s data champion and clinical lead to ascertain any reasons for this.

Reporting Schedules

Activity, Capacity and Operational Challenges

Each Trust is mandated to return the Neonatal Minimum Data Set to the Department of Health and will continue to do so.

Furthermore in 2012 a National Neonatal Dashboard is being introduce (appendix 1) which the monthly completion by each Trust will form a CQUIN for 2012. It is expected that all units will populate the dashboard in order to fulfil this requirement. A copy of each Trusts monthly dashboard should be also forwarded to the Network to collate a network operational report. This is spread sheet based to allow ease of collection and analysis.

In 2012 all units in the SSBCNN have access to the Clevermed Badger Clinical IT system and it is expected that all activity returns will be provided from this system.

Specifically this will include;

Network Activity & Outcomes Matrix

The purpose of the network outcomes and monitoring matrix is to allow adjustments in practice to be made where required. The matrix includes activity data as well as key outcomes data. The Network Manager/Lead Nurse completes the information required for this mostly from the suite of reports in the clevermed badger neonatal data system and in addition asks each unit for information relating to the number of live births and babies cooled each month. (appendix 2)


Mortality Monitoring & Shared Learning

The network will also collect anonymous mortality data on a quarterly basis from each trust, either by receipt of trusts own learning points from review processes or by the completion of the network mortality data collection sheet (appendix 3).

A sub group of the network QIPP group consisting of the Network Lead Clinician, CEL, Network Manager/Lead Nurse, a doctor (Subramanian Mahadevan) and a nurse (Barbara Hodgkiss) representative will collate the learning points received into a brief quarterly report which will be taken to the following QIPP group for dissemination of the learning to all units in the network.

Neonatal Adverse Events Monitoring & Shared Learning

SSBCNN will also collect anonymous data on serious clinical incidents on a quarterly basis from each trusts review processes or by completion of the network Neonatal Adverse events data collection sheet (appendix 4).

The Network Manager/Lead Nurse will collate the information received into a brief quarterly report which will be taken to the following QIPP group for dissemination of the learning to all units in the network.

Neonatal Mortality & Serious Clinical Incidents Review & Shared Learning Process

Individual Unit Leads submit anonymous information of learning points from all neonatal deaths and serious clinical incidents quarterly to SSBCNN

SSBCNN Sub group from QIPP Collates Quarterly Anonymous Information of learning

points from all neonatal deaths into a report for the QIPP Group Meeting

QIPP group meeting discuss reports and identify areas for shared learning within the network and nationally as appropriate

Anonymous shared learning points documented and circulated to each unit in

the network quarterly

QIPP group chair writes to the specific Trust(s) seeking permission to share anonymous information about the identified serious

incident nationally through the BAPM process

Network Manager/Lead Nurse Collates Quarterly Anonymous Information of learning points from all serious clinical incidents into a

report for the QIPP Group Meeting


Parent and Family Experience

Understanding user engagement, involvement and satisfaction at a local level has always been difficult to collect in a meaningful way. It is important that the network becomes better at understanding how neonatal services can be improved from the parent and carer perspective.

The Picker Institute has undertaken a parent experience study across a number of networks, including SSBCNN based on POPPY, BLISS Charter and the ‘Toolkit’. These results have been analysed and action plans formulated to address areas for improvement. SSBCNN expects trusts to report on progress in addressing these points in 2012.

In addition to this the network will require monthly reporting from units via the Clinical Effectiveness Lead on a specific item already collected as part of NNAP and is a data item within the Badger IT system, this is;

Parent Involvement (standard 100%)

All parents and carers have a consultation with a senior member of medical staff in the first 24 hours

Clinical Quality and Outcomes

All units within SSBCNN will be expected to provide the commissioners and the network with validated clinical audit data and analysis as an annual report.

In addition to this all units participate in the National Neonatal Audit Programme and it is expected that units will continue to support this data collection in 2012. As all units have access to the Clevermed Badger Clinical IT system data will be collected via this. It is expected that all units will ensure their registration on the system to provide a consistent approach to data sharing with NNAP through their governance and data sharing agreements with Clevermed.

In addition to the ongoing audit collections and annual reports the Network has identified key items within these for monthly collection directly from Trusts. These are identified for this year as potential key markers of service quality. The CEL will produce a monthly NNAP network dashboard (See Template for this report in appendix 5) of these by liaising with the Badger champion for each unit concentrating on improvement of data for 5 key NNAP items.

1. Parent involvement (as above)

2. Temperature at birth/admission (standard 100%)

(a) All babies < 28+6 weeks gestation have their temperature taken within 1st hour of delivery (b) All babies admitted to the neonatal unit to have a temperature ≥36C – 37C (90% 36.6 – 37.0C)

3. Baby Friendly

Babies <33+0 weeks gestation are discharged home on breast milk (wholly or partially)

4. Antenatal steroids (standard 85%)

Mothers who deliver between 24+0 and 34+6 weeks gestation receive at least one dose of antenatal steroids


5. ROP screening (standard 100%)

All babies <1501g or <32+0 weeks gestation, and still an inpatient, undergo first ROP screening as per current guidelines.

West Midlands Neonatal Quality Clinical Indicators

The West Midlands quality observatory will also be collating data identified to be used in the West Midlands Quality Indicators panel (appendix 6) as agreed at the Stakeholder event. This is being developed and tested in 2012 and may be subject to further refinement.

Patient Pathways and Transfers

Care pathways and the transport service have already improved the care and experience of babies and families by ensuring care in the right place as close to home as possible. As with any system of care monitoring progress and the impact of change and understanding future development needs for services is essential.

Pathways

In order to provide on-going monitoring, units will be required to provide pathway exception reports via proformas for IUT exceptions (appendix 7) and EUT exceptions (appendix 8).

If required the network may, on occasion, require further information from units as to exceptions. In these instances, further specific information required will be requested at the time.

The Network Manager/Lead Nurse will monitor transfer requests through the transport system, unit activity through Badger and exception reporting every month and report on this at the quarterly network board.

Transport

Monitoring of the transport service will be under separate agreement with the transport service. The network has a transport users group with membership from key stakeholders and acute trusts from both network areas which meets bi-annually to review transport reports and discuss issues relating to the service and provide essential feedback from service users. A quarterly summary transport report is submitted to both network boards. See appendix 9

Standards Assessment Tool

Agreed network standards are monitored through the network standards assessment web based tool. This is a dynamic tool which Trusts complete in an on-going manner, where tests are not fully met action plans are generated. The Network Manager/Lead Nurse takes a Quarterly Snapshot Report to the Network Board meeting (Appendix 10) to monitor progress of the trusts in meeting the standards.

Network data governance

Each Trusts’ own employees can access full Badger data regarding their own patients and those that they have transferred to other units.

Each units’ Badger champion should, in addition to this, be able to access patient reports for their own unit.

The Network Manager/Lead Nurse can access Neonatal data through the suite of single unit and network reports developed by clevermed, Caldicott guardian approval has been gained from each Trust to support this.


The CEL, by working with the Badger champion, has access to anonymised patient data from each unit. In certain circumstances the CEL may ask for further information from the Badger champion which can also be anonymised. The CEL may also require “read only” access to certain data to fulfil Network, Regional and National requirements in which case the Caldicott guardian for each trust will be contacted to facilitate this. Any patient identifiable data will always be anonymised before ongoing use.

The quality observatory (WMQI) has access to anonymised data from the Trusts whose Caldicott Guardians have approved this for use to populate the agreed WM QI neonatal quality clinical indicators only.

Any data collected will only be used for the aforementioned purposes for use within the Network only. Any requests from within or outside the Network for Trust specific data will be redirected to the Trust concerned; the Network will not divulge Trust specific data.


Reporting Schedule Summary

Report Frequency Who Completes Where to Send Where Reported

National Neonatal Dashboard Monthly Trusts Commissioners & Network QIPP Group & Board

Network Activity & Outcomes Matrix Quarterly Network Manager/Lead Nurse

N/A QIPP Group & Board

Mortality Report Quarterly Trusts Network QIPP Group & Board

Serious Neonatal Adverse Events Quarterly Trusts Network QIPP Group & Board

NNAP Monthly Dashboard Monthly Network Clinical Effectiveness Lead

Network Clinical Effectiveness Lead

QIPP Group & Board

WM Neonatal Quality Clinical Indicators (in development)

Monthly WM QI N/A QIPP Group & Board

IUT Care Pathway Exception Reports Monthly Trusts Network Network Board

Ex Utero Care Pathway Exception Reports

As they occur Trusts Network Network Board

Transport Monthly Reports

Monthly WMNTS Network Network Board

Standards Assessment Tool Snapshot Report

Quarterly Network Manager/Lead Nurse

Completed on line Network Board

References

Toolkit for High-Quality Neonatal Services. London: DH; 2009

The Bliss Baby Charter Standards. London: Bliss; 2009

Family-centred care in neonatal units. A summary of research results and recommendations from the POPPY project. London: NCT; 2009

NICE Quality Standards 2010

“Parents’ experiences of neonatal care A REPORT ON THE FINDINGS FROM A NATIONAL SURVEY” Picker Institute 2011


Appendix 1 Neonatal Dashboard

Note: An electronic copy is available to each Unit from: http://specialisedcommissioning.com/quality-dashboards-2/ (Password SCG) Measure

Number

Theme Measure Description & Provenance Name of KPI Numerator Denominator Period Type

NIC01 Domain 1: Preventing people

from dying prematurely

Proportion of transfer teams responding to

time-critical emergencies that depart from the

transport base within 1 hour from the start of

the referring call

Number of transfer teams departing

from the transport base within 1

hour from the start of the referring

call

Number of emergency transfers requests

deemed time-critical

One month

NIC02 Domain 5: Treating and

caring for people in a safe

environment and protecting

them from avoidable harm

Proportion of babies born at less than 32

weeks of gestation and/or with a birth weight

less than 1501 g who receive specialist

neonatal care and undergo retinopathy

screening prior to discharge from hospital

Retinopathy screening Number of babies undergoing

retinopathy screening prior to

discharge from hospital

Number of babies born at less than 32 weeks

of gestation and/or with a birth weight less

than 1501 g, receiving specialist neonatal

care and discharged from hospital (only live

discharges included)

One month





Number of babies who have confirmed NEC Babies with NEC Number of babies who have

confirmed NEC

Total number of babies One month





Rate of CA-BSI per 1000 blood culture taken

³72h of age (using standard NPSA/NNAP

accepted definition for CA-BSI: the pure growth

of a recognised pathogen or a mixed growth or

skin commensal PLUS 3 or more out of 10 pre-

defined clinical signs AND the presence of a

central venous

Catheter associated blood stream infection (CA-BSI) Episodes of CA-BSI in neonates

admitted to neonatal units using

the strict case definition.

Total number of catheter days One month





Number of wte vacancies % vacancy for nursing and support staff Number of wte vacancies Number of wte establishment One month





Proportion of babies born at less than 32

weeks of gestation and/or with a birth weight

less than 1501 g who receive specialist

neonatal care who require laser surgery

Laser surgery requirement Number of babies requiring laser

surgery

Number of babies born at less than 32 weeks

of gestation and/or with a birth weight less

than 1501 g receiving specialist neonatal

care

One month





Proportion of babies with antenatally

diagnosed fetal malformations requiring early

surgery who are delivered at a designated

network surgical centre

Planned delivery at surgical centre Number of babies with antenatally

diagnosed fetal malformations

delivered at a designated network

surgical centre

Number of babies born within the network

with antenatally diagnosed fetal

malformations requiring early surgery

One month





Bed occupancy for each level of care Cot occupancy Total Number of Cots Total Number of cots occupied over 80% in a

24 hours period.

One month





Number of admissions for specialist neonatal

care as a proportion of total booked live births

Overall demand Number of babies admitted to unit

for specialist neonatal care in

reporting period

Number of inborn live births in reporting

period

One month





Length of stay for all babies admitted to

specialist neonatal care by gestation ?

Length of Stay No of patient stays on NICU in

reportng period (note each return to

NICU should be counted)

Total number of bed days used in month One month





Number of babies who meet the criteria for

therapeutic cooling

Therapeutic cooling Number of babies who commence

cooling within 6 hours of birth in

reporting period

Number of babies who met the criteria for

cooling including those identified outwith

the 6 hour threshold

One month






Proportion of completed specialist neonatal

care shifts with the correct nursing staffing

levels as specified in the DH toolkit (2009)

Expertise on shift Number of shifts with the correct

nursing staffing levels as specified

in the DH toolkit (2009)

Number of completed specialist neonatal

care shifts

One month





Proportion of newborn babies who receive

specialist neonatal care who have an

admission temperature of less than 36C

Admission hypothermia Number of newborn babies with an

admission temperature of less than

36¡C in reporting period

Number of newborn babies receiving

specialist neonatal care in the reporting

period

One month





Percentage of exclusive breast milk at

discharge from neonatal units

Number of babies receiving breast milk at discharge The number of babies born and

subsequently admitted to NICU who

are recieiving breast milk at

discharge

Total Number of babies admitted to speciaist

neonatal care

One month





Number of wte vacancies % vacancy for nursing and support staff Number of wte vacancies Number of wte establishment One month





Proportion of babies born at less than 26+6

weeks GA who received intensive care in a

NICU in the Network

27 week activity Number of babies born at less than

26+6 weeks receiving intensive care

in a NICU in the network

Number of babies born at less than 26+6

weeks GA within the network

One month





Bed occupancy for each level of care Cot occupancy Total Number of Cots Total Number of cots occupied over 80% in a

24 hours period.

One month





Number of days neonatal unit has closed

beyond 24 hours

Unit closures Number of days of closure beyond

24 hours

Number of days in month One month





Number of babies refused admission to the

unit due to lack of capacity/staffing

Number of refused neonatal admissions Number of refusals Number of admissions One month





Number of babies transferred for non clinical

reasons

Transfers for non clinical reasons Number of transfers for non clinical

reasons

Total number of babies One month





Proportion of mothers whose babies required

specialist neonatal care and who were booked

to deliver in the network who received all their

perinatal care within the network area

Local perinatal care Number of mothers receiving all

their perinatal care within the

network area

Number of mothers whose babies required

specialist neonatal care and who were

booked to deliver in the network area

One month





Proportion of babies who are transferred back

to their local neonatal unit within 24 hours of

request for repatriation

Local repatriation Number of babies transferred back

to their local neonatal unit within

24 hours of request

Number of babies transferred back to their

local neonatal unit

One month


Appendix 2 Network Activity & Outcomes Matrix


Appendix 3 Mortality Reporting

Note: An electronic copy will be provided to each Unit or the Unit can supply an anonymised summary report from their own review process


Appendix 4 Neonatal Adverse Events Reporting

Note: An electronic copy will be provided to each Unit or the Unit can supply an anonymised summary report from their own review process


Appendix 5 National Neonatal Audit Programme Network Monthly Report

SSBCNN NNAP Monthly Dashboard Template

Audit Area Standard Wolverhampton Stoke Dudley Shrewsbury Walsall Stafford

All babies < 28+6 weeks gestation have their temperature

taken within 1st hour of delivery 100%

All babies admitted to the neonatal unit to have a

temperature of:

Temperature >37.5C 0%

Temperature 36.6 - 37.4C 90%

Temperature 36 - 36.5C 10%

Temperature <36C 0%

Mothers who deliver between 24+0 and 34+6 weeks

gestation receive at least one dose of antenatal steroids 85%

All parents and carers have a consultation with a senior

member of medical staff in the first 24 hours 100%

All babies <1501g or <32+0 weeks gestation, and still an

inpatient, undergo first ROP screening as per current

Babies <33+0 weeks gestation are discharged home on

breast milk (wholly or partially)

No Standard -

Benchmarking

Key:

Green if at or above Standard

Amber if within 80% of target

Red if below 80% of target

Please note that as these are small numbers, a small change can appear to make a large difference.


Appendix 6 West Midlands Quality Indicators

TO BE INSERTED WHEN FINALISED


Appendix 7 In Utero Transfer Care Pathway Exception Reporting


Appendix 8 Ex Utero Care Pathway Exception Reporting


Appendix 9 Transport Monthly Board Reports

Month November-2011

Number of requested transfers

% Total Transfer requests

SWMNN 73 62

SSBCNN 30 25

CenTre 4 3

Others 11 9

Total 118

Number of Transfers undertaken Non Transfer % against

% Total Transfers undertaken NTS reason target

SWMNN 56 62 8 89 NB % against target calculated

SSBCNN 22 24 2 93 using non transfer NTS reason

CenTre 2 2 1 vs requested number of transfers

Other 10 11

Total 90 11

Number of Refusals Staffing

On other/

ITU calls

Weather/

Equipment

Deterioration

of baby No beds Parents

Inapprop

request

Canc by

ref unit

No t in our

network

Canc by

rec unit

SWMNN 8 4 3 1

SSBCNN 3 3

CenTre 1 1

Other 0

Total 12

Number of Cancellations

SWMNN 6 2 1 1 1 1

SSBCNN 4 1 1 2

CenTre 1 1

Other 1 1

Total 12

Number of Deferrals

SWMNN 3 2 1

SSBCNN 1 1

CenTre 0

Other 0

Total 4

0 11 0 1 3 1 7 3 1 1

Type of Transfers Undertaken

ITU/HDU 14

CARDIAC 6

SURGICAL 22

ONGOING CARE 41

BED MANAGEMENT 4

OPD/Radiology 0

COOLING 0

NEUROSURGICAL 3

Total 90

Acute = 34

Non Acute = 56

CLINICAL GOVERNANCE Total incidents Low Moderate High Major

Clinical Incidents - 2

Temperature - Hypothermic baby on arrival at referring unit

Blood required for transfusion discarded upon arrival at Birmingham Children's Hospital, not transported in cool bag/with correct paperwork

Equipment - Temperature probe 2 on incubator 2 not working

Equipment - Monitor not displaying ECG or respiratory wave form

Equipment - Pumps were unable to be connected to mains supply after being transferred to transport incubator 2 (1 out of service, 3 in use)

Equipment - Transport skin temperature gave different temperature to axilla temperature when checked

Communication - BCH surgical ward not expecting baby when WMNTS called to inform them they were on the way

West Midlands Neonatal Transfer Service Network Board Report

Other Incidents - 5

REASON FOR NOT UNDERTAKING TRANSFERS

Non NTSAttributable to NTS


Appendix 10 Standards Assessment Tool Snapshot Report

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