CWM TAF UNIVERSITY HEALTH BOARD FORWARD PLAN FOR CONTINUOUS IMPROVEMENT WORK 2014/15

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Isabel Sparks
5 years ago
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1 PRIORITY LEVEL 1. External must do Externally monitored audits that are driven by commissioning and quality improvement are treated as the priority and appropriate resources are provided to support these. Failure to participate or deliver on these externally driven audits may carry a penalty for the Health Board 2. Internal must do Based on the classic criteria of high risk or high profile identified by health board management. They may include national initiatives with health board-wide relevance but no penalties exist for non participation. Many of these projects will emanate from health board governance issues or high profile local initiatives. 1. External must do National Clinical Audit and Outcome Review Plan Cancer National Bowel Cancer Audit National Lung Cancer Audit National Head and Neck Cancer Audit National Oesophago-gastric Cancer Audit National Prostate Cancer Audit The All Wales Breast Cancer Audit Heart National Heart Failure Audit National Cardiac Rhythm Management Audit National Audit of Percutaneous Coronary Intervention Procedures (PCI) Audit Myocardial Ischaemia National Audit Project (MINAP) Cardiac Rehabilitation Audit National Audit of Psychological Therapies (and Welsh Government Review of Access to and Implementation of Psychological Therapy Treatment in Wales) National Dementia Audit National Audit of Learning Disabilities National Audit of Schizophrenia Respiratory Ears, Nose and Throat 1

2 Older People Sentinel Stroke National Audit Programme (SSNAP) Falls and Fragility Fractures Audit Programme (FFFAP) (includes National Hip Fracture Database) Women s and Children s Health National Neonatal Audit Programme (NNAP) National Childhood Epilepsy Audit UK Obstetric Surveillance Pathology Serious Hazards of Blood Transfusion (SHOT) Comparative Blood Transfusion Audit Nursing Fundamentals of Care Audit Other National Joint Registry Renal Registry National Diabetes Inpatient Audit National Paediatric Diabetes Audit (NPDA) National Diabetes Audit Primary Care Pain Database Trauma Audit & Research Network (TARN) Comparative Audit of Critical Care Unit Adult Patient Outcomes (ICNARC) Welsh Intensive Care Unit Audit Inflammatory Bowel Disease National Chronic Obstructive Pulmonary Disease Audit National Vascular Registry Audit (includes Carotid Endarectomy) Rheumatoid and Early Inflammatory Arthritis Chronic Kidney Disease in Primary Care Clinical Outcome Review Programme (including NCEPOD) Bariatric Subarachnoid Haemorrhage Alcoholic Related Liver Disease Cardiac Arrest Procedures National Emergency Laparotomy Audit National Vascular Registry Audit National Prostate Cancer Audit Lower Limb Amputation Sepsis UK Obstetric Surveillance Tracheostomy Suicide, Homicide and Sudden Unexpected Death by People with a Mental Illness (CISH) Child Health Programme Maternal, Newborn and Infant Programme (MBRRACE) National Review of Asthma Deaths Children s Head Injury Project General General / Trauma & Orthopaedics /Midwifery Nursing Trauma and Orthopaedics Nephrology Primary Care Emergency Primary Care /Emergency / Maternity Maxillofacial// / /Primary Care 2

3 Audits of the Cancer Standards: Dermatology Gynaecology Head and Neck Respiratory Palliative Care Maxillofacial National Institute of Health and Clinical Excellence (NICE) Audits: Number Technology Appraisal TA278 Omalizumab for treating severe persistent allergies TA292 Bipolar disorder (adolescents) - Aripiprazole CAMHS TA70 Imatinib for Chronic Myeloid Leukaemia TA65 Guidance on the use of Rituximab for aggressive non-hodgkin s lymphoma TA266 Rituximab for the treatment of follicular non- Hodgkins lymphoma TA174 Rituximab for the first-line treatment of Chronic Lymphocytic Leukaemia TA267 Chronic Heart Failure TA287 Pulmonary embolism and recurrent venous thromboembolism - Rivaroxaban TA261 Venous thromboembolism treatment and long term secondary prevention Rivaroxaban TA298 Chorodial neovascularisation (pathological Ophthalmology myopia) Ranibizumab TA274 Ranibizumab for treating diabetic macular Ophthalmology oedema (rapid review of TA237) TA283 Ranibizumab for treating visual impairment Ophthalmology caused by macular oedema secondary to retinal vein occlusion TA155 Ranibizumab and pegaptanib for the Ophthalmology treatment of age related macular degeneration TA229 Dexamethasone intravitreal implant for the Ophthalmology treatment of macular oedema secondary to retinal vein occlusion TA301 Diabetic macular oedema flucinolone Ophthalmology acetonide intravitreal implant TA105 Laproscopic surgery for colorectal cancer TA128 Stapled haemorrhoidopexy for the treatment of haemorrhoids 3

4 TA121 Prucalopride for the treatment of chronic constipation in women CG56 Head Injuries CG50 Management of the Acutely ill patient CG76 s Adherence: Involving patients in decisions about prescribed medicines and supporting adherence CG83 Rehabilitation after critical illness All Specialities CG03 Preoperative Testing All Specialities CG09 Eating Disorders CAMHS CG 121 Lung Cancer and Lung Cancer Standards CG162 Stroke Rehabiliation CG167/172 Myocardial Infarction CG169 Acute Kidney Injury CG32 Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Feeding CG67 Lipid Modification: Cardiovascular risk /Biochemistry assessment and the modification of blood lipids for primary and secondary prevention of cardiovascular disease CG103 Delirium / CG156 Assessment and Treatment for people with /Gynaecology fertility problems CG63 Diabetes in Pregnancy /Gynaecology CG70 Induction of Labour /Gynaecology CG55 Electronic Fetal Monitoring /Gynaecology CG44 Endometrial Ablation /Gynaecology CG171 Urinary Incontinence in Women /Gynaecology CG68 Photodynamic therapy for age related Ophthalmology macular degeneration CG85 Glaucoma and Ocular Hypertension Ophthalmology CG145 Spasticity in children and young people with non-progressive brain disorders CG150 Management of Headaches CG142 Autism: recognition, referral, diagnosis and /CAMHS management CG168 Varicose Veins CG74 Surgical Site Infection Prevention and Surgical Specialities Treatment of SSI CG88 Low Back Pain Trauma and Orthopaedics 4

5 All Wales s Strategy Group Audits () Lisdexamfetamine dimesylate (Elvanse) 2813 For attention deficit hyperactivity disorder Lixisenatide (Lyxumia) 3113 For the treatment of type II diabetes 5-aminolaevulinic acid (Ameluz) 2713 For the treatment of actinic keratosis on the face and scalp Ferumoxytol (Rienso) For the IV treatment of iron deficiency anaesmia in non haemodialysis dependant adult chronic kidney disease Botulinum toxin type A (Botox) For the management of urinary incontinence in adults with neurogenic detrusir overactivity Elvitegravir / cobicistat/emtricitabine/ tenofovir disoproxil fumarate (Stribild) For the treatment of HIV 1 Argatroban (Exembol) For anticoagulation in patients with heparin-induced thrombocytopenia Adalimumab (Humira) For the treatment of severe axial spondyloarthritis C1-Esterase inhibitor (Berinert) For the treatment of acute hereditary angioedema C1 Inhibitor (Cinryze) For the pre-procedure prevention of angioedema attackes in adults and adolescents Ceftaroline Fosamil (Zinforo) For the treatment of complicated soft tissue infections where MRSA is suspected Ulipristal Acetate For pre-operative treatment of moderate to severe symptoms of uterine fibroids Sodium Phenylbutyrate As adjunctive therapy for urea-cycle disorders CAMHS General General General / General / Urology Microbiology, Gynaecology and Sexual Health 5

6 2. Internal Must do CWM TAF QUALITY DELIVERY PLAN: QUALITY IMPROVEMENT PRIORITIES FOR 2014/15 Focus on improving patient flow and frailty care Improving the pathway for fractured neck of femur patients Reducing the risk of hospital and community falls Improving care and experience of patients with cognitive impairment Improving communication Trauma and Orthopaedics and Primary Care All relevant specialties EXTERNAL ACCREDITATION SCHEME(S) AUDIT e.g. Welsh Risk Management Standards Ionising Radiation (Medical Exposure) Regulations (IRMER) All Wales Surgical Site Surveillance for Total Hip Replacement & Total Knee Replacement Global Rating Scale (GRS) - Endoscopy British Thoracic Society Audit - Respiratory CARIS Congenital Anomaly Register Trauma and Orthopaedics Midwifery Welsh Risk Management Standards (compliance audits) Unscheduled Returns within 48 hours Inappropriate Attendance and redirection Feverish Children Pain in Children & Adults Renal Colic An Audit of asthma in Adults and Children Paracetamol Overdose Fractured Neck of Femur Head Injuries Shoulder Dislocation Major trauma Sepsis Management and Sepsis Six D-Dimer Requests Safeguarding Children Review of Mortality in Emergency Department Radiology Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency 6

7 Hand Injury Spontaneous Pneumothorax in Adults Recording of Vital Signs in the Major and resuscitation Areas of ED Retention of Urine Caesarean Sections DVT Risk Assessment Safety Briefing Checks Reducing mortality and harm from venous thromboembolism in pregnancy and the postnatal period Recognition and response to the acutely deteriorating woman Early Warning Charts Amniocentesis Normal Labour Pathway WHO Surgical Checklist Emergency Emergency Emergency Emergency /Theatres CONTINUOUS IMPROVEMENT IN CARE Reduction in healthcare associated pressure ulcers and compliance with indicator improvement Reduction in hospital-acquired thrombosis and safe anticoagulation management Reduction in healthcare-associated infections Demonstrate continuous improvement with compliance of stroke care bundles Staffing assuring appropriate nursing establishments to deliver safe, effective care General CONTINUOUS LEARNING TO INFORM IMPROVEMENT Aligning staff development and Quality Improvement training, education, appraisal and revalidation Engaging and learning from user, patient, carer feedback and engagement Learning from staff feedback to inform quality improvement Learning from concerns to inform quality improvement Learning from clinical audit outcomes to inform quality improvement Learning from Fundamentals of Care audits to inform quality improvement Mortality Reviews learning from avoidable deaths to inform quality improvement 7

8 IMPROVEMENT PROGRAMMES (former 1000 Lives Plus initiatives). s Management: Anti-psychotics Acute Coronary Syndrome Rapid Response to Acutely Ill Patients (RRAILS) Incorporating; Sepsis Reducing catheter associated urinary tract infection Reducing harm from peripheral venous cannula Early Recovery After (ERAS) Colorectal Orthopaedics Transforming Theatres First Episode Psychosis All relevant specialties /Trauma and Orthopaedics Theatres HEALTH BOARD-WIDE AUDIT Cancer Services Annual Survey Late diagnosis of Cancer in Primary Care Documentation in Case notes Consent to treatment GP Communication Chronic Obstructive Airways Disease (COPD) in collaboration with GlaxoSmithKlein (GSK) Speech and Language Assessment in Stroke Patients Hand Hygiene Compliance Organ Donation Pneumonia Audit Acute Oxygen Therapy Omitted and delayed critical time medications Last days of life care priorities and Primary Care All surgical specialties and Primary Care and Primary Care and All specialities 8

9 Audits of Enhanced Services (ES)in Primary Care Enhanced Service (ES): Extended Opening ES: Nursing Homes ES: COPD ES: Minor ES: Woundcare and Minor Injuries ES: Alcohol misuse ES: Substance Misuse ES: INR ES: Intra Uterine Contraceptive Device ES: Near Patient Testing ES: Learning Difficulties ES: Diabetes ES: Depo provera ES: Nexplanon ES: Service Development Other: GP Out of Hours Doctors Audit 9

TABLE 1. Eligible to participate. Yes* Yes*

TABLE 1. Eligible to participate. Yes* Yes* 1 6th National Project of the Royal College of Anaesthetists 2 Acute coronary syndrome or Acute myocardial infarction (MINAP) 3 Adult Asthma (BTS) 4 Adult Bronchiectasis (BTS) Not applicable (audit did