Leeds Teaching Hospitals NHS Trust



4598670-37161000Overview of the Quality and Safety Framework during COVID-19 PandemicSummaryThe purpose of this report is to provide a summary of the interim quality and safety framework introduced to support CSU’s during the COVID-19 pandemic. BackgroundIn order to support the CSU’s and gain continued assurance regarding the quality and safety of our clinical services during the COVID-19 pandemic, an interim quality and safety framework has been introduced.Key elements have been streamlined in order to provide assurance regarding the safety and quality of our services throughout the pandemic. A monthly report will be prepared by the Patient Safety & Quality Managers to support the discussion and actions required; the template report is included in Appendix 1. Further Quality Review meetings will be arrange for January where any issues can be further explored and reviewed with the Executive and Senior Management team. Interim Framework An outline of the requirements in relation to Quality and Safety standards are outlined in Table 1. Table 1:Incident Management – reporting and investigationA weekly report will be provided to all CSU’s from the Patient Safety and Quality Managers, the CSU will review these reports and agree action as required. Incident investigations to be undertaken utilising table top reviews and short reports to identify root cause, contributory factors, key learning points and actions to reduce risk of recurrence.CQUINSAll CQUINS data collection and submission has been suspended for Q1, Q2 and Q3 (20/21). Quality requirements and data submissions set out in the local Contract have been reviewed with the CCG and deferred where plaints and PALSPALS team to provide direct support to CSUs to resolve local enquiries directly where this can be done, liaising with CSU for key information to address plaints process to continue – Patient Experience team to contact patient on behalf of CSU when complaint received to confirm if there will be a delay due to the coronavirus pandemic response.QA process to be streamlined, to be undertaken by Patient Experience team, supported by corporate teams.Mandatory nursing audit/medical auditAll mandatory nursing and medical audits have been suspended for Q3.NCEPODAll NCEPOD studies requiring clinical input have been completed for 2020/21. National Audit Participation in National Audits continues, and clinical teams should continue to participate and submit data where required.NICE Guidance All NICE guidance received will be reviewed by the quality team. Any urgent or significant updates will be disseminated to relevant clinical teams. The completion of all other baseline assessments relating to NICE guidance will be suspended.Perfect Ward Meetings Matron to review Perfect Ward dashboards on a weekly basis and escalate any areas of concern to the Head of Nursing for further discussion and action. Corporate Nursing will continue to provide oversight of the key quality and safety indicators and escalate any areas of concerns to the CSU.CSU Quality Assurance Groups CSU Quality Assurance Group will meet monthly via Microsoft Teams, these meetings will be concise and report by exception; a CSU assurance report will be prepared by the Patient Safety & Quality Manager, which will inform the discussion and outline associated actions (see appendix). Attendance does not have to be quorate as outlined in the ToRs, however there should be at least one representative from the tri-team, nursing, medical and a business manager/ service manager present at the meeting. M&M and Mortality Screening Tool and SJR Routine mortality reviews to be suspended (M&M).Mortality screening tool to be completed for all inpatient deaths on PPM+; specialties to conduct this when completing the Medical Certificate of Cause of Death (MCCD).SJR will be required if ‘Yes’ is documented in response to the following questions; Are you concerned that any problems in healthcare occurred? Have you any concerns that this death was avoidable?Is this case subject to an investigation?Did the Family / carers have any significant concerns regarding the quality of care provided?If there are concerns following completion of a SJR then this must be escalated.Falls and pressure ulcer RCA meetings Local RCA meetings to continue virtually. No change in Stop the Line process. Falls and pressure ulcer panel meetings will be held virtually. HCAI Audits Daily Hand Hygiene audits will continue to be submitted on the Nursing hub.Covid -19 IPC assurance audits will continue weekly and evidence kept locally.QI collaborativesQuality Improvement (QI) Collaborative meetings will continue at a reduced frequency, as agreed by the lead(s). Wards or departments that are part of a collaborative may continue to implement any new interventions if deemed appropriate.Data relating to the collaboratives will continue to be collated and shared with CSUs. Duty of Candour The processes relating to Duty of Candour (DoC) Regulations will continue. Support from the Patient Safety & Quality Managers will be available to prepare DoC letters including incidents related to hospital-acquired COVID-19, working in conjunction with CSUs. Duty of Candour letters will be prepared for the CSU by the Serious Incident Investigation and Learning Manager for all level 3 serious incident investigations.Mixed Sex BreechesNational reporting has been suspended, however internal reporting to continue by submitting a datix. If a Mixed Sex Breach has occurred, a verbal apology needs to be given to the patient. Corporate Nursing will review reported breaches when the datix is submitted, liaise with the CSU and facilitate completion of an abbreviated RCA document. Separate arrangements are in place for ACC and this arrangement is to continue.Ward Healthcheck metrics and Compassion AuditWard Healthcheck metrics will continue in an abbreviated form and will be performed weekly.Outpatients departments and Leeds Dental Institute will continue with monthly Healthcheck metrics. The monthly submission of the Compassion Audit is to continueReactive ward/department assurance visits The Clinical Support Team in Corporate Nursing will liaise directly with CSU’s to arrange reactive assurance visits where these are required.VTEVTE RCA’s will be completed by the VTE Clinical Nurse Specialist using the patient’s electronic records. Support will be sought from the medical team if this is required. This process will be reviewed and may be revised depending on the capacity of the VTE Clinical Nurse Specialist.If there are any emerging risks or issues requiring urgent discussion or Trust Board sign off (externally reportable information), CSUs have been requested to escalate these to the Quality Governance Team/Corporate Nursing Team for further discussion. 4727797-281222Appendix 1CSU NameQuality Assurance Report (dd/mm/yy-dd/mm/yy)Well-Led Staff Health & WellbeingDue to the increased pressure on staff during the COVID-19 pandemic it is essential that staff know how to access support if needed. Details of the services available to staff can be found on the LTHT intranet via the following link: Risk Register Brief highlights of the risk register with a focus on COVID-19 related risks, new risks to be added to the risk register and risks which are due for review. CQC enquiriesCommunications from CQC – enquiries, complaints, engagement meeting - learning pointsAction Required: SafeIncident ReportingThe CSU Tri Team will receive a weekly report of all incidents that have been reported on Datix from the previous week via their Patient Safety and Quality Manager. The most common themes in incident reporting have been X. Duty of CandourThere have been X incidents reported categorised as moderate harm, or above, where Duty of Candour applies.Potential Serious Incidents and Never EventsThe following incidents were escalated as potential SIs in this period (datix ref/brief description).Safeguarding referrals – brief description/locationKey learning pointsHealthcare Associated InfectionX HCAI reported - locationsHospital-acquired COVID-19 related outbreaks – key learning pointsFallsX falls reported (datix ref/location) – key learning points from RCAsPressure UlcersX pressure ulcers reported (datix/location) – key learning points from RCAsKey learning pointsAction Required: EffectiveGuidelines Details of clinical guidelines and best practice guidance (NICE) requiring urgent review.Learning from DeathsKey learning points/SJRsAction Required: ResponsiveOpen Complaints on dd/mm/yySummary of open complaints from last complaints report circulated.Open PALS on dd/mm/yySummary of open PALS from last PALS report circulated.Action Required: CaringFFT for X Summary of FFT responses from last FFT report circulated.Mixed-sex accommodation breachesLocation/key learning pointsAction Required: Appendix B - Assurance/Escalation Form to be completed by the CSU Triumvirate team Assurance/Escalation Form – For use during COVID-19Meeting:Date of meeting:Attendees:Key Decisions / Actions Areas of risk / New risks identified Actions underway ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download