Impact of national clinical audit at an acute trust Anne Jones, Head of Clinical Audit and Effectiveness Jonny Flett, Lead for Falls QI Project Kingston Hospital NHS Foundation Trust

Content Introduction to Kingston Hospital Process for acting on national clinical audit reports Example – National audit of inpatient falls Drivers for quality improvement Challenges Summary

Kingston Hospital NHS Foundation Trust Acute hospital supporting 350,000 people in South West London 520 beds 2,750 staff – 177 Consultants One main site but also outpatients in community Three divisions – Emergency Services, Clinical Support Services and Specialist Services – and 17 Service Lines

Additional Quality Account NCAs NCAPOP programme 2016/17 Additional Quality Account NCAs Arthritis: rheumatoid and early inflammatory Adult asthma (BTS) Cancer: Bowel Asthma care in ED (Paediatrics and adult) (CEM) Cancer: Lung Blood Transfusion: Blood management in surgery Cancer: Oesophago-gastric Blood Transfusion:Red cell transfusion in palliative care Cancer: Prostate ICNARC Case Mix programme COPD National Cardiac Arrest Audit Dementia Paediatric pneumonia Diabetes: Adult IP/OP/Foot/Maternity Severe sepsis and septic shock in ED Diabetes: Paediatric TARN Emergency laparotomy Falls and fragility fractures (Hip Fracture Database) National Confidential Enquiry programme Heart: Cardiac arrhythmia Child Health programme Heart: Coronary angioplasty Learning disability mortality review Heart: Heart failure Maternal, Newborn and Infant programme Heart: MINAP Medical and Surgical programme Inflammatory bowel disease Mental Health – Suicide and homicide – report only National Joint Registry Neonatal intensive and special care (NNAP) Ophthalmology Stroke

Acting on reports Report published Clinical Audit and Improvement Facilitator summarises report, assessing trust position against local/national average Summary and report sent to Clinical Lead Clinical Lead reviews and discusses at Service Line governance meeting Results risk assessed and action plan produced. Where action plan is large/complex, QI project initiated Action plan progress overseen by Service Line/QI steering group Monitored via Trust’s Committee structure

National audit of inpatient falls 2015 Comparison to national average Organisational – better Falls/1000 bed days – better 7 key indicators - worse Published Nov 2015 Results summary, rating and risk assessment

Main results – 7 key indicators and falls rates STANDARDS 2015 National Results Kingston Hospital Rating Delirium RAG Rating   80 - 100% Green 50 - 79% Amber 0 - 49% Red 42.9% BP 4.2% Medication 17% Vision 56.7% Mobility Aid 44.4% Continence CP 15.4% Call Bell 73.1% Falls resulting in moderate/severe harm or death per 1,000 OBDs 0.19 0.12  Falls per 1,000 OBDs 6.63 5.60

What do we need to work on? Recommendation Assess patients >65 and those 50-64 at high risk of falling (rather than using risk prediction tool Review multifactorial falls risk assessment Dementia and delirium assessments Lying and standing blood pressure Medication review Visual impairment Walking aids Continence care plan Call bells

Impact of national audit Before Long standing Falls Steering Group Bi-annual local clinical audits Self assessment of NICE guideline CG161 (published June 2013) – partially compliant with action plan Good practice, including patient exercise classes After Action plan established for Falls NCA which required substantial work QI project initiated with re-launched Falls Steering Group

Aims of Falls QI project Reduce preventable falls and avoidable harm Improve Trust’s performance in next National Falls Audit Improve patient safety and experience Agree improvement plan for each ward Hold ward to account for delivery Staggered approach, 2-3 wards at a time

Stage 1 – Review Current Documentation Agreed a new Falls Prevention Checklist for all patients admitted >65 and high risk fallers Agreed a new SI form Agreed a post-falls checklist for non-SI falls Agreed a new continence care plan Piloted new documentation across 3 wards with good feedback from the ward sisters and matrons In the process of transferring it across to the electronic patient record

Stage 2 – Using the Data as Indicators Issues with categorising falls data – unclear / duplicate categories Needed to simplify the reporting process for staff in order to develop clearer feedback for wards Re-categorised falls into 10 discrete categories to allow generation of more meaningful falls reports

Stage 2 – Using the Data as Indicators Developing electronic reports to provide regular feedback to wards on their performance against national audit criteria Criterion Trust national audit result 2015 Cardiology Ward Latest local audit Orthopaedic Ward Dementia/delirium assessment 42.9% 85% 64% Blood pressure L+S 4.2% 31% 0% Medication review 17% 77% 91% Vision 57% 100% 55% Mobility aid 44% 92% 82% Continence care plan 15% 27% Call bell 73%

Stage 3 – Falls Prevention Encourage wards to use their data to develop more specific actions plans e.g. bay-based nursing, yellow socks and blankets Develop crib sheets / posters

Drivers for local improvement from NCA at Kingston ‘Improvement’ rather than ‘assurance’ Timely and easy to read reporting to clinicians Risk assessment, comparison and escalation where appropriate up to Trust Board Active involvement of Medical Director QI methods for ensuring actions are taken to improve results QI patient/public volunteers NCA data used as a catalyst for initial change

Challenges General Volume of NCAs and other competing work Data issues Report structure variation Time between NCA cycles Resources Falls Electronic documentation needs adjusting to support the collection of national audit criteria Lying and standing blood pressure MORSE score linked to falls care plan Continence care plan – not recorded separately Slow, lengthy and sometimes costly process to amend

Summary NCA programme allows the Trust to benchmark against national results and local/similar hospitals Very useful when national audits are explicitly linked to NICE guidance Senior Leader support helps drive improvement as does ethos of clinical audit as ‘improvement’ activity Volume of NCA work impacts on Trust’s ability to support local audit and QI priorities Welcome work to: Standardise and speed up reporting with NCA providers Produce metrics for trust comparison (Joint HQIP-CQC)

Thank you Questions?