SUBJECT / Clinical Quality and Patient Safety
PRESENTED BY / David McNeil – Lay Member for Engagement
Dr James Gair – GP Clinical Lead
SUBMITTED TO / Governing Body, 16thApril 2013
PURPOSE OF PAPER / The Governing Body is asked to:
  • Approveproposals for monitoring the quality and safety of jointly commissioned provider services;
  • Agree in principle the funding of an independent chair for the Cluster Clinical Quality and Patient Safety committee

EXECUTIVE SUMMARY
1 Introduction
This paper provides the Governing Body with an update of proposed future Cluster arrangements for monitoring the quality and safety of jointly commissioned provider services and seeks approval for its progress. In addition, it provides notable actions identified by NHS North Norfolk CCG’s (NHS NNCCG) Quality and Safety Committee following its meeting on March 26th.
2 Future Cluster Quality and Safety arrangements
It is proposed that the Cluster Clinical Quality and Patient Safety committee is maintained by the CCGs in order to have a central group to review jointly-commissioned providers. The committee will report to the CCGs and will also receive reports from CCGs where areas of concern are noted in order to share information with partners and agree where joint action should be taken.
There is a small element of funding commitment which will be required in support of the committee’s independent chair.
3 Notable areas and actions reported by NHS NNCCG’s Quality and Safety Committee
The committee last met on 26th March and the report following provides some detail relating to areas highlighted below, which the committee has identified as requiring additional consideration or action.
  1. Improvements required to current reporting processes by the NHS Anglia Clinical Support Unit: it has been agreed that amore proactive and responsive report is required in order to make quality and safety data more meaningful and useful. A meeting is being arranged to commence negotiations with the CSU to develop and make these changes within the next few weeks.
  1. Further information into the serious incident reporting of unexpected deaths by NSFT
A report designed to contextualise the increased number of reports made relating to unexpected deathshas not provided the detail and analysis that had been requested. Whilst it should be noted that the definitions of an unexpected death include the suicide of a person or a natural death that was not expected, it is nonethelessproposed that we work directly with Norfolk and Suffolk Foundation Trust (NSFT) to break down the analysis of this data in order to assure ourselves that services provided are safe and effective. NHS NNCCG’s GP lead in this regard is progressing this work.
  1. Harmful Falls reported by Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH): Further information is being sought from NNUH in order to establish if there are specific themes around areas that are short of staff, particularly during overnight hours when there are many fewer staff and visitors to ward areas, and what additional support might be available to shore up areas at particular risk.
  1. A representative from HealthWatch attended the meeting to provide an update of progress being made within this organisation and links to CCGs for future working.
  1. An update on the progress made with recommendations from the Winterbourne reportwas provided. A number of NHS NNCCG patients have been identified, some of which have already received assessments and consideration of their current placement and care plan. Dateshave been made to complete the remaining assessments by the end of June.
  1. A risk summit has taken place to review areas of risk relating to the Ambulance serviceand we await details of the actions and timeframes agreed.

1 Future processes for assuring the monitoring of Quality and Safety within Norfolk and Waveney

Following the closedown of PCTs, it has been proposed that the Norfolk and Waveney (N&W) PCT Cluster Quality and Safety Committee, which met quarterly and which previously brought together all Norfolk and Waveney CCGs within its boundaries to share and review quality and safety issues, will continue under the remit of the CCGs. An independent chair has been identified and in future it is planned that the committee will sit every 2 months. Membership, terms of reference and areas for the annual work-plan will be agreed at the next meeting, but conceivably will include key members with regional responsibility for managing various aspects of Quality and Safety. Representation from the NHS National Commissioning Board’s East Anglia Local Area Team (LAT) and Public Health will offer a perspective which is broader than Norfolk and Waveney and will therefore support best practice benchmarking across the region and provide a level of external challenge and contestability.

As outlined earlier, the new committee will both report to, and receive reports from, the N&W CCGs providing assurance that commissioned services are being scrutinised and reviewed for their safe performance and measured for their quality outcomes in patient experience. The committee will also offer scope to identify early warnings for the potential for failings within local services, which will allow timely actions to be agreed and taken forward by N&W CCGs.

NHS North Norfolk CCG’s Quality and Safety Committee (NNQ&SC) currently meets every 2 months. It reviewsa range of quality and safety data and information regarding the provision of health services commissioned by Norfolk and Waveney CCGs, with a particular focus on locality issues as well as taking a wider county-view. The committee provides internal processes for NHS North Norfolk CCG to identify, share and respond to specific quality and patient safety risks, issues and concerns arising within its locality.

In future the NNQ&SC will receive reports from the N&W CCG cluster Q&S committee which will ensure that there is monitoring in place and provision for escalation to the Governing Body and Council of Members. NNQ&SC will also feedin to the cluster committee to raise awareness of concerns, issues and risks that it has identified in order to ensure that this information is shared with our CCG partners and that there is consistency and planning in the action to be taken.

Figure 1: Proposed processes for the monitoring of Quality and Safety across Norfolk and Waveney

The Governing body is asked to approve this as an appropriate and safe process for the future monitoring and review of our Commissioned Health services both within North Norfolk and in collaboration with our cluster CCG colleagues, and that it approves a contribution to the funding for the Independent chair

2. North Norfolk CCG Quality and Safety Committee

This committee met on 26th March to review current quality & safety datasets and information regarding providers’ quality performance. The following actions were agreed and the Governing body will be updated on all counts on progress made in the following areas.

2.1 Quarterly Quality and Safety Report

The Committee received a quarterly Quality and Safety Report, which is provided by the Quality team within the Commissioning Support Unit and which outlines a range of information relating to our commissioned health providers. However, the committee has agreed that:

  • the styling of the report does not provide a clear or detailed account of areas of importance;
  • nor does it provide any outline of actions that have been undertaken in response to issues raised; or provide
  • comparable data relating to other providers which would allow for better valuation of outcomes and benchmarking.

It was proposed that a quality performance dashboard would assist to provide an improved ‘at a glance’ status of how providers are performing across a range of quality metrics which would include:

  • Serious incidents;
  • Quality issues;
  • Patient harms;
  • Mortality rates;
  • Management of healthcare associated infections; and
  • Patient and staff experience data such as friends and family test, staff surveys etc.

In addition, a clear exception report is required to identify where providers are falling short of expected standards, and to identify:

  • what action has been taken in order to improve outcomes;
  • what additional monitoring is required; and
  • timescales for improvements to take place.

These issues have been discussed with the CSU previously but progress has not yet been made. Quality Leads from all CCGs are meeting with the CSU senior manager and quality team in order to agree improved reporting processes and it is expectedthat these improvements will be in place within the next few weeks.

2.3 Report on unexpected deaths reported by Norfolk and Suffolk Foundation Trust

NSFT is a large provider with a number of service strands which provide support to vulnerable groups of patients. They report all unexpected deaths of patients who are currently or have recently received services from their teams, which then requires the identification of root causes and actions which might need to be taken in order to improve the delivery of services. It has been noted that there has been an increase in the reporting levels of these incidents over the last year (2011/12 – 32, 2012/13 56) and the CSU were asked to provide an analysis of any themes or trends which could be identified in order to provide a better understanding of key issues. In addition Public Health was asked to undertake a comparative study to provide some national benchmarking information; this has not yet been completed.

The report provided was incomplete (focussing on only 28 incidents out of the 56) and did not provide sufficient analysis of root causes, the localities where deaths occurred, service streams affected and actions identified for the committee to feel assured that the figures and types of incidents being reported are of a typical level for comparable services. It was therefore agreed that we would try to work directly with NSFT to unpick this information further. We will look to our GP commissioning lead for guidance regarding taking this work forward.

2.4 Harmful Falls for patients at the NNUH

This is an area for which acute trusts routinely have notable reporting, with a higher level of patients falling in their care than elsewhere and following which a number of patients will sustain an injury. It is noted that NNUH have reported a reduced level of these falls within the last quarter. However, on review of root cause analysis reports of four such falls which have occurred within the last six weeks, it was noted that three had occurred during the nightshift, when staffing is at a lower level on wards, and that on these occasions the units involved were functioning within only four nursing staff for 36 patients due to sickness.

While the reduction of falls at NNUH in recent months is recognised, the committee agreed to request a ‘look-back’ for the previous 6 months of falls data in order to identify if staffing and overnight periods are consistent themes to patient falls occurring. It appears that assistive technology is not in use on wards currently and may provide some additional monitoring support for busy staff. We will request that this subject is added to the agenda for discussion at monthly Clinical Quality Review meeting for the NNUH.

2.5 Healthwatch Norfolk

The Interim Development Manager for Healthwatch in Norfolk attended the Committee to describe progress being made around future working processes and recruitment within the organisation and to discuss future links with the CCG.

There has been a range of stakeholder workshops with the following outcomes:

  • Focus on a few things and do them well
  • Make the best use of current forums
  • Avoid being location specific
  • Volunteers need to be assessed/accredited, trained and supported
  • Evidence should be gained independently and without bias.

The key areas of work will include:

  • Support Patient involvement and engagement in health services
  • Provide signposting for the public to obtain the right support and advice in relation to health services
  • Influencing changes to services by local involvement and national representation.

As development takes place we will be updated and opportunities for future working arrangements between the CCG and Healthwatch will be identified.

2.6 Update on Progress made with actions from Winterbourne View Report

Work has been progressing to identify our most vulnerable individuals with Learning Disabilities and Mental Health diagnosis who are currently receiving care and support under the remit of the CCG.

North Norfolk has identified the group of patients for whom we are responsible and have confirmation that reviewing assessments have been undertaken or are in progress to determine if care and placement currently provided are best suited to meet the needs of the individual and that least restrictive options are being considered. The assessments will be undertaken with families, advocates and under Best Interest Decision-Making to assure processes include openness and contestability to consider all options.

We have identified 26 patients who are currently funded by NHS NNCCG under Continuing Healthcare and are receiving care within residential services or through a package of care within their own home. In addition, there are 7 patients who are detained under the Mental Health Act and are in low to medium secure units funded under the Specialist Commissioning Group. All of our North Norfolk patients are currently cared for within Norfolk.

Progress is regularly being reported to the Mental Health Commissioning Board, which will provide the overview for considering future commissioning intentions to meet the needs of patients with specialist needs locally.

2.7 East of England Ambulance Trust

NHS NNCCG had been provided with information that the former Strategic Health Authority had raised concerns in relation to the performance of the EEAT at a risk summit on 26th March. This is a process by which current risks affecting the organisation will be scrutinised and clear actions to support their timely reduction agreed.

NHS NNCCG has previously reported a number of concerns that have affected patients within the locality. These have been included within the report provided by the PCT to the risk summit outlining areas for concern.

The actions from the summit will be picked up by the National Commissioning Board (NCB) who took over operations from the SHA on 2nd April. We await further details of the outcomes and actions agreed.

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