annual quality statement 2013 - 2014€¦ · monitoring how well we’re doing through the eyes of...

ANNUALQUALITY STATEMENT2013 - 2014

SEPTEMBER 2014

If you would like further information about this statement or if you would like to comment on it please contact:

Robert Williams, Board Secretary and Director of Corporate Services,Cwm Taf University Health Board,

Ynysmeurig House, Navigation Park,Abercynon,CF45 4SN

[email protected]

all NHS Wales organisations are required to publish an Annual Quality Statement. We are reporting to the public in an open and trans-parent way on progress with the quality and standards of the services we provide and our Annual Quality Statement is published alongside our Annual Report.

The views of our patients, carers and the public are at the heart of improving the way we deliver our services. Monitoring how well we’re doing through the eyes of people who use our services is the most effective way of knowing what we do well and what we can do better. Our Quality Strategy (2014-17) and Quality Delivery Plan (2014/15) confirm our commitment to delivering safe and ef-fective care and achieving excellent patient, carer and staff experience.

Cwm Taf University Health Board provides primary, community, hospital and mental health services to almost 300,000 people living in Merthyr Tydfil, Rhondda Cynon Taf and surrounding areas. The University Health Board is also responsible for the pro-vision of child and adolescent mental health services for South Wales.

We employ more than 8,000 staff, run two district general hospitals - Prince Charles and the Royal Glamorgan– and have a bud-get of around £600m a year. We are commit-ted to providing high quality, compassionate, equitable and safe care to all.

In accordance with the Welsh Government’s five-year vision Together for Health and the requirement for absolute transparency on the performance of Quality Delivery Plans,

CONTENT

01 WELCOME AND INTRODUCTION 0402 OUR ACHIEVEMENTS 05

OUR CHALLENGES 06OUR PRIORITIES 06

03 MEETING STANDARDS 0804 OUR STAFF 10

EQUALITY & DIVERSITY 11DEVELOPING THE WORKFORCE 11

05 OUR SERVICES 12PATIENT FLOW 14CHILDREN AND YOUNG PEOPLE 15

06 REDUCING INFECTIONS 1607 CLINICAL AUDIT &

IMPROVINGCARE18

PRIORITY AREAS FOR IMPROVEMENT IN 2014-2015

20

08 IMPROVING QUALITY OF CARE TOGETHER

21

09 STAYING HEALTHY 2210 PATIENT AND PUBLIC

ENGAGEMENT23

11 PRIMARY CARE SERVICES 2412 PUTTING THINGS RIGHT 2513 EXAMPLES OF HOW WE ARE

LEARNING TO IMPROVE SAFETY26

14 LEARNING FROM MORTALITY REVIEWS

27

15 RESEARCH & DEVELOPMENT IN CWM TAF

28

16 LOOKING TO THE FUTURE 2917 LINKS TO OTHER KEY

DOCUMENTS30

Page 3Annual Quality Statment 2013-14

http://www.cwmtafuhb.wales.nhs.uk/annual-reports

WELCOME AND INTRODUCTION

A MESSAGE FROM THE CHAIRMAN AND CHIEF EXECUTIVE

The Quality agenda matters to us all. The Trusted to Care report, published in May this year, was a sad period not just for the health board involved, but for everyone in NHS Wales. Those failings in basic care must never happen again. Compassion is not an add-on, it is integral to what the NHS stands for. We give our personal assurance that any failings within Cwm Taf that are brought to the University Health Board’s attention will be fully investigated and addressed.

Our philosophy is Cwm Taf Cares, and quali-ty improvement for the benefit of our patients and their carers is at the heart of everything that we do.

We hope you’ll see in this statement clear evidence of excellent practice across Cwm Taf during the last 12 months, but also a rec-ognition of where things have gone wrong and the actions we have taken to put things right.

We value your feedback and your views are vital to help us continually improve our services.

We’ll be glad to hear from you.

Welcome to our second Annual Quality Statement which we hope will give you an overview of the work we are doing to ensure that the healthcare we provide is safe, compassionate and of the best possible quality.

Producing this statement provides us as a University Health Board, not only the opportunity to reflect on im-provements we have made over the last year, but also to ask ourselves some import-ant questions. Are we meet-ing people’s needs? What more needs to be done? How can good practice in one area be rolled out to others?

Allison WilliamsChief Executive

Dr Chris Jones CBEChairman

OUR ACHIEVEMENTS

Cwm Taf University Health Board is committed to im-proving the quality and safety of healthcare and is proud to have made some significant improvements over the course of 2013-14.

This year we have:

• Carried out more than 1.2million operations, hos-pital appointments and scans

• Developed an ambitious 3-Year Integrated Plan which will deliver innova-tive service-change and improve performance

• Won an NHS Wales Award for our work on improving patient flow, resulting in fewer unnecessary hos-pital stays and improved outcomes for patients

• Achieved, with the support of our aca-demic partners, Cardiff University and University of South Wales, University Health Board status, and started the build in partnership with Cardiff Univer-sity on a new 70-place medical school at Keir Hardie University Health Park in Merthyr Tydfil to train the doctors of tomorrow in community–based medicine

• Established a Joint Emergency Therapy Team (JETT) made up of occupational therapists and physiotherapists working with local authority colleagues to prevent avoidable admissions to acute hospital beds and ensuring safe and rapid dis-charge planning

• A further reduction in the total number of Clostridium Difficile infections, which remain the lowest in Wales due to sus-tained good practice by staff

• Been named the best performing health board in Wales for transferring patients who arrive by ambulance at A&E to the next stage of their care within 15 minutes

• Improved admission times for stroke patients, with 94% arriving on the stroke ward within 24 hours by January 2014 compared to 62% in October 2013

• Produced a world-first in interactive apps to support patients with bowel cancer



section 1 section 2

OUR CHALLENGES

Like all other health boards in Wales, in Cwm Taf we con-tinue to face significant de-mographic and financial chal-lenges.

These include:

• an increase in prevalence of dementia, chronic con-ditions such as cardiovas-cular, respiratory diseases and cancers

• of all Health Boards, Cwm Taf University Health Board has the highest proportion (34%) of its population living in the most deprived areas of Wales

• residents of Cwm Taf ex-perience the lowest life expectancy in Wales

• higher proportions of peo-ple reporting key illnesses and unhealthy lifestyles in Cwm Taf than across Wales

• teenage conception rates are reducing yet remain among the highest in Wales

We recognise that it is more important than ever that we understand the way in which our population is changing and that we renew the focus on improving population health overall as well as ensuring that the patients we treat receive the very best care.

OUR PRIORITIESOur philosophy is Cwm Taf Cares. We are committed to ensuring that patients and carers are at the heart of our work, and that we listen to those who use our services to improve our services and address any con-cerns.

Our Quality Strategy and Quality Delivery Plan embrace this philosophy to ensure that services are safe and effective, and deliv-ered compassionately.

Our three-year Integrated Plan reflects our drive to further improve quality, safety and efficiency and we intend to build on cur-rent good practice, focusing on the quality improvement priorities across NHS Wales including working closely with the 1000 Lives Improvement Service.

This includes:

• Further and sustained improvements in patient flow

• Developing the Inverse Care Law Pro-gramme

• Embedding the staff training model Im-proving Quality Together

• Providing accurate, useful and relevant information to our patients and their fami-lies

Quality Delivery Plan

Our Quality Delivery Plan identifies a num-ber of key measures that are regularly reviewed by our Quality Steering Group to determine and support priorities and actions for quality improvement. Our priorities are:

• To improve patient flow • Improve the care pathway for fractured

neck of femur patients• Reduce the risk of in-hospital and com-

munity falls• Improve the experience of patients with

cognitive impairment/dementia• Improving communication for patients

and create a culture of care

Our quality and safety priorities for 2014-2015 are outlined in greater detail through-out this quality statement. We measure and publish the quality of our service delivery in our Integrated Quality & Performance Dashboard with key indicators published for:

• Patient experience/feedback• Pressure ulcer damage• Nutritional risk assessment• Infection rates• Hand hygiene compliance• Mortality Rates• Immunisation Rates



section 2

MEETING STANDARDS

Standards for Health Services

‘Doing Well, Doing Better – Standards for Health Services in Wales’, published by the Welsh Government in 2010, underpins the visions, values, governance and accountabili-ty framework for NHS Wales.

Cwm Taf University Health Board has embedded these 26 Standards into all areas of our work.

The Fundamentals of Care Standards and AuditThe Fundamentals of Care (FOC) Standards were developed by the Welsh Government and implemented nationally to improve the quality of fundamental aspects of health and social care, for patients and service users in Wales.

Our audit of compliance during 2013 pro-vides a good level of assurance, and has also highlighted areas for us to prioritise our quality improvement work in three areas:

• Sleep and rest (Standard 6)

• Ensuring comfort and alleviating pain (Standard 7)

• Ensuring personal hygiene and foot care (Standard 8)

437 patients surveyed expressed high levels of satisfaction (87%) with the standards of care they have received from staff within CTUHB.

Leadership WalkRoundsThese visits connect Executive Directors, In-dependent Members of the Board with front-line staff and patients. Weekly WalkRounds are conducted in all areas of patient care, including GP surgeries. They provide an op-portunity for leaders to talk with frontline staff about safety issues; show their commitment

to the quality of patient care and safety, and listen to staff concerns. This year we revised the Patient Safety WalkRound Guide (link needed) so that the process is clear and informs quality improvement.

Trusted to Care (The Andrew’s Report)We take every opportunity to learn when things go wrong – both from within and outside the University Health Board. On May 13, 2014 the Health Minister published Trusted to Care, a report which followed a review of the quality of care for older people at the Princess of Wales and Neath Port Talbot Hospitals – part of Abertawe Bro Mor-gannwg University Health Board. The report highlighted serious failings in basic care for older people at the two hospitals, specifically.

The focus now is on putting things right. In response, we developed a detailed frame-work to provide assurance and expedited actions for improvement within our existing plans. We had also already reviewed our progress against actions in response to Dig-nified Care? - the report of the older peoples commissioner from 2010 - and used this to inform our plans.

We recognise that being in hospital is a particularly challenging time for the frail and elderly. We have produced a new handbook for staff called Caring for the confused in hospital - to help staff better understand how and why confusion can sometimes im-pact on a patient’s behaviour and to provide guidance to reduce the impact this can have.



section 3

OUR STAFF

The University Health Board’s workforce is our most signifi-cant and valuable asset and it is through the commit-ment, professionalism and dedication of our staff that we are able to deliver high quality services to our popu-lation.

The way in which we recruit, support and develop our staff is vital if we are to meet the increasing service and finan-cial challenges we face. The average number of contract-ed staff in post is 8,166, con-sisting of an average 7,000 whole time equivalents

A healthy working environ-ment presents significant benefits to both employees and employers. It can result in a productive and creative workforce with reduced sick-ness absence and ultimately better quality of care for pa-tients.

Promoting employee health and wellbeing, a good work-life balance and activities to promote a healthy lifestyle is a priority for us as a health board.

Staff are encouraged to highlight problems and share ideas for improvement across Cwm Taf in a number of ways. These in-clude:

• Via the ‘Grapevine’, an online system to ask questions and gain information anonymously

• Posting comments on the Chief Execu-tive’s weekly blog and a new Quality in Care blog, written by the Clinical Execu-tive Directors

• Sharing good practice and ideas on the intranet news section and via staff forums

We also need to make sure we have the right people with the right skills to deliver excellent healthcare. This needs to take ac-count of the new developments and changes to services, as well as issues such as the Chief Nursing Officer’s nursing workforce recommendations which will involve rebal-ancing the nursing workforce across our wards and hospitals and reducing bank and nursing agency use.

Some examples of how the University Health Board is ensuring safe staffing levels are maintained and recruitments difficulties are tackled are:• The introduction of a Maternity Support

Worker (MSW) role to allow qualified midwives the time to dedicate to caring for pregnant mothers. The introduction

of MSWs will also allow the release of qualified midwives to undergo additional training in order to undertake the ex-amination of new born babies which is currently done by junior doctors, also helping to reduce the pressure on ju-nior doctor rotas. It is proposed that 5 MSW are recruited and trained initially and then the workforce increased on a phased basis as the qualified midwifery workforce is rebalanced

• An Invest to Save bid to support the development of a Mental Health Acute Liaison Service to enable improved as-sessment of mental health patients who also have physical health problems has been successful. This service will pro-vide initial assessment of patients and extend cover to A&E during office hours seven days per week on both acute hospital sites

Equality & Diversity

Key achievements include:

• Continued progress in integrating equal-ity in training, leadership programmes and a range of initiatives and new devel-opments throughout the organisation

• The development of a policy on Domes-tic Abuse, Violence Against Women and Sexual Violence. Training has been developed and delivered to key staff and this will be extended throughout CTUHB

• The procedure for accessing an inter-preter has been reviewed and aware-ness raised throughout the organisation

• Welsh language awards for our commu-nity hospital at Ysbyty Cwm Rhondda

Developing the Workforce A highly trained, developed and motivated workforce is key to ensuring patients are provided with the best possible care. In 2013-14:

• The University Health Board achieved its targets for both Revalidation and Ap-praisal rates, with 100% compliance for all medical appraisals by April 2014

• Cardiff University School of Medicine established a new programme – the C21 - which allows medical students to spend two years embedded into communi-ty-based learning at Cwm Taf University Health Board

• Plans to build a new £2.8m undergrad-uate medical education facility at Keir Hardie University Health Park were approved and the new build is due for completion in January 2015

• We have worked with our partners to deliver a combined teaching programme for Foundation doctors, Core Medical Trainees and General Practitioner train-ees. In addition to this, weekly sub-spe-cialty teaching programmes are provided at both Prince Charles Hospital and the Royal Glamorgan Hospital

• Our Nurse Education Department con-tinued to support our nursing workforce leading on the education, training and continued professional development of all pre-registration student nurses, regis-tered nurses, midwives, specialist com-munity public health nurses, healthcare support workers and other staff groups



section 4

OUR SERVICES

As well as the big initiatives, it’s the little things that our staff do each and every day that make a real difference to patients.

Here’s a snapshot of some of our services and the amazing work our staff have done

over this last year:

Commissioner’s recommendations and more recently we reviewed progress against the plan. We have made substantial progress and it remains one of our highest priorities in order to provide our older population with the best care to meet their needs.

We have introduced tangible actions to fos-ter a culture of dignity and respect such as: • Use of ‘forget-me-not’ to identify patients

who have dementia/Alzheimer’s, con-fusion, cognitive impairment or memory loss. Using such a system raises aware-ness amongst all healthcare profes-sionals that extra level of support may be required with that individual and that the patient has a completed ‘This is me’ leaflet

• Family members encouraged to attend the ward at mealtime to support the patient with feeding or prompting and ensure a mutually enjoyable experience at mealtimes

• From January 2014 all nurse bank health care assistants to undergo Personal Development Review, competency as-sessments and individual development programmes

• Most ward managers have completed Bronze award IQT (Improving Quality Together) and so far nine have complet-

ed silver level training. All managers and deputies involved in our improvement approach to Transforming Safe and Ef-fective Care Together model have com-pleted both

• Rooms available within the wards of each of the new hospital buildings allow for confidential discussions with patients and relatives. Ward refurbishment has in-creased the number of single rooms and bays are either for two or four patients

• The University Health Board’s Spiritual Care department has created a book, Memories Are Made of This to help staff and relatives care for the spiritual well-being of patients in our hospitals. Primarily developed for use with patients who have dementia, it provides a means of building relationships through trigger-ing memories which still hold meaning today

• A Community Intravenous infusion ser-vice has been implemented and allowed individuals to be cared for at home rather than be admitted to hospital

Providing modern healthcare in our state of the art community hospitals:

Ysbyty Cwm Rhondda

Ysbyty Cwm Rhondda has 108 beds for medical and surgical Reha-bilitation, continuing care and respite care. There are 4 palliative care beds transferred from Ysbyty George Thomas. This is the main focus for community hospital services for the Rhondda Fawr and Rhondda Fach.

Ysbyty Cwm Cynon

Ysbyty Cwm Cynon is a brand new £70 mil-lion purpose-built community hospital provid-ing integrated community and intermediate care services to the populations of Merthyr Tydfil and Cynon Valley. It has 100 beds for medical and surgical rehabilitation and com-plex discharge planning. It also has eight palliative care beds and one 16-bed ward for continuing assessment for older persons’ mental health.

Implementing the recommendations of the Older People’s Commissioner’s re-port Dignified Care?

The University Health Board has developed a comprehensive plan to comply with the

THE STAFF WERE ALL SO WONDERFUL TO MY FATHER…ENCOURAGING, COMPASSIONATE, CHEERFUL AND KIND. WE CANNOT PRAISE THE HOSPITAL ENOUGH IN THESE

TIMES OF CRITICISM AND RECRIMINATION WE WOULD AP-PRECIATE OUR FEELINGS BEING SHARED WITH ALL CON-

CERNED…STAFF, MANAGERS AND INDEED THE CWM TAF UNIVERSITY HEALTH BOARD

“

“

EXCELLENT THAT DIFFERENT SERVICES ARE ALL IN ONE

PLACE ON SAME DAY“

“

SINCE I CAME INTO THE HOSPITAL ALL THE STAFF WERE SO GOOD TO ME. IF IT WAS OUT OF 10, I WOULD GIVE THEM 12. NOTHING WAS ANY TROUBLE TO THEM

“

“



section 5

OUR SERVICES

We also provide tailored com-munity services for our frail and elderly population.

The @Home service compris-es the Community Integrated Assessment Service (CIAS), Community Ward, Re-able-ment Service and Intrave-nous Service, and was orig-inally established to prevent unnecessary admissions of frail elderly patients to hos-pital. It continues to develop and expand its remit.

Emergency Care Centre (ECC) and Accident and Emergency (A&E) by facilitating safe and rapid discharge planning from these departments. It currently operates across both Prince Charles Hospital and the Royal Glamorgan Hospital sites. To date the team has provided input for 803 patients - two thirds were discharged with input solely from JETT and did not require admission to acute wards. The team works closely with commu-nity health and local authority colleagues to achieve successful outcomes for patients.

As a result of our patient flow work we’ve also made improvements to our waiting times:

• 90.21% of patients are seen within four hours in A&E and 99.53% of patients seen within eight hours

• We are the best performing Health Board in Wales for transferring patients who arrive by ambulances to the right place for the next stage of their care within 15 minutes

• Improved admission times for all stroke patients with 94% of stroke patients transferred to the stroke ward within 24 hours by January 2014

• stablished the Community Chronic Pain Service Merthyr & Cynon – this involves nurses and hospital doctors and GPs working together making it much quicker for patients to be seen

Improving the flow of patients through the hospital system to minimise waits and improve outcomes

We have made great progress this year in improving patient flow to help ensure that our patients are in the best setting to receive care. The “Focus on Flow” project was intro-duced with the aim of identifying blockages and delays in the hospital system. The initia-tive was a great success, which very much depended on a whole system approach from pre-hospital assessment through to the point of discharge. Numerous initiatives were implemented including work with the Welsh Ambulance Service Trust, in our acute and community hospitals, in partnership with the @Home Service and our partners.

At the start of the project there were 137 patients with lengths of stay of 40-days plus in our community hospitals, but by January 2014, only 18 remained in a community hos-pital setting, making the beds available for those who needed them. The success of this initiative has been recognised throughout Wales and won an award at the NHS Wales annual awards in 2014.

A multidisciplinary team comprised of Oc-cupational Therapists, Physiotherapists and generic support staff established the Joint Emergency Therapy Team (JETT) to prevent avoidable admissions to acute beds from the

Children and Young People

Over the past year we have:

• Developed an Outreach Neonatal Nurs-ing Service to provide support for fami-lies in the community and monitor ba-bies discharged from the neonatal unit, especially those with complications such as home oxygen therapy

• Improved the facilities in the High De-pendency Unit with high flow oxygen facilities to reduce the need for invasive ventilation of babies and reduce need for transfer to a Paediatric Intensive Care Unit at another hospital

• Relocated the dental list to the Children’s Ward. Patients had previously been admitted to an adult ward; but are now treated in a child friendly environment

• Further developed Children’s Commu-nity Nursing Team to improve the care of children with chronic conditions in the community and reduce hospital admis-sion rates for these patients

• Listened to children – Bubble Boards encourage children to write what they would like if they were in charge of the ward - suggestions have included free Wi-Fi, a sweet shop, different food, and larger beds – these comments are influencing improvements and changes, where possible

THE LITTLE THINGS MATTER…WHEN A PATIENT WHO HAD SUFFERED THE LOSS OF AN EAR

NEEDED TO WEAR GLASSES, STAFF MADE AND FITTED A PROSTHETIC ONE

““



section 5

REDUCING INFECTIONS

Cwm Taf University Health Board is committed to a zero tolerance approach to-wards Health Care Associated Infections (HCAIs).

The use of robust systemat-ic processes of surveillance and audit to monitor, prevent and control HCAIs maintains its momentum in reducing numbers of HCAIs.

Norovirus CasesSuspected Confirmed

2012-13 2013-14 2012-13 2013-14Apr 4 1 2 2May 8 0 3 0Jun 2 2 0 1Jul 2 1 0 0Aug 0 1 0 0Sep 3 1 1 0Oct 4 1 0 0Nov 2 1 2 0Dec 6 4 6 0Jan 5 1 0 0Feb 2 0 0 0Mar 3 0 0 0Total 41 13 14 3

Numbers of infections:

CTUHB Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total Clostridium Difficile for in-patients aged 66+

2012-13 5 8 5 5 2 2 5 4 5 3 1 7 522013-14 3 6 3 4 1 6 4 5 3 3 5 8 51

MRSA Bacteraemias 2012-13 2 2 2 1 1 4 0 3 0 4 0 0 192013-14 0 1 0 1 1 0 2 0 3 0 4 2 14

MSSA Bacteraemias 2012-13 4 5 6 3 7 6 2 9 5 5 6 5 632013-14 6 7 8 9 4 13 5 7 9 9 5 9 91

Key achievements over the past year include:

• A further reduction in the total number of Clostridium Difficile infections, which remain the lowest in Wales due to sus-tained good practice by staff, investment in a vaporising machine which deep cleanses rooms, and the hard work of housekeeping staff. The University Health Board was unable to achieve the national 20% reduction target set by the Welsh Government for inpatients 66 years and over this year because of the significant reductions in previous years and sustained very low numbers

• National targets for the reduction of Methicillin Resistant Staphylococcus Aureus (MRSA) blood stream infections have been achieved

• Numbers of Methicillin Sensitive Staph-ylococcus Aureus (MSSA) bacteraemia

Challenges for 2014 - 15 Three of the main priorities for achieving further reductions in HCAIs are:

• Reviewing antimicrobial prescribing and stewardship – aimed at reducing antimi-crobial resistance, as well as contributing to minimising the risks of patients devel-oping Clostridium Difficile infection

• Detailed work to analyse the causes of MSSA bacteraemia so that areas of con-cern can be identified and improvements made

• To gain commitment and engagement from clinical staff in order to improve compliance with care bundle documenta-tion. Close monitoring of medical devices and prompt removal when no longer required will reduce device related bacte-raemias

have increased, however on investiga-tion the majority of these are not health-care associated. The increase seen in Cwm Taf reflects the picture across Wales

• A significant reduction in the number of bed days lost and disruptions to ward ar-eas due to suspected or confirmed viral gastroenteritis

• An increase in the use of hydrogen peroxide vapour (HPV) as a method of environmental decontamination has been achieved

• Ongoing audits of hand hygiene and environmental cleanliness suggests that the compliance with improved clinical practice has been sustained

• The principle of ‘Bare Below the Elbows’ has been promoted and encouraged as good practice across the University Health Board



section 6

CLINICAL AUDIT & IMPROVING CARE

To ensure we deliver the highest standards we imple-mented a number of initia-tives which promote continu-ous quality improvement.

These include clinical audit (national and local), a vari-ety of improve¬ment pro-grammes in response to national or local issues, and implementa¬tion of National Institute of Health and Care Excellence (NICE) guidance.

Whilst more of the Univer-sity Health Board’s clinical audit activity is driven by na-tional guidance, it is import-ant to balance local clinical audit work, as many of the best proposals are identified where staff or patients rec-ognise an area of practice in need of improvement.

National Clinical Audit & Clinical Out-come reviews

In 2013/14, 429 high quality projects have been undertaken, 81% had standards set as part of the audit and the number of audits with changes implemented or identified as ready to occur was 74%. This figure is well above the national average and reflects the commitment of our clinical staff to deliver evidence-based care.

The following are some examples to demon-strate improvements made through our wide range of activities:

• The National Emergency Laparotomy Audit (NELA) began in January 2014 under the leadership of a team of Con-sultant Anaesthetists and Surgeons. The audit emphasised the need for routine risk assessment in emergency surgical cases, and has highlighted the need for clear, standardised admission docu-mentation. As a result a surgical clerking proforma is currently in development

• National Hip Fracture Database – This issue was highlighted in 2013 as a pri-ority quality improvement project for the Health Board and steps have been taken to streamline care, including dedicated hip fracture admission beds on both trauma wards and a dedicated weekend theatre space at Prince Charles Hospital

• National Joint Registry - In 2012/13 issues were highlighted on the increased Surgical Site Infection (SSI) rate at Royal Glamorgan Hospital but further audit of the figures determined that there was

an over-reporting of SSI and the data was inaccurate. Teaching sessions from Public Health Wales were provided through the clinical audit meetings and have resulted in a drop in SSI, below the national average at both Prince Charles Hospital and Royal Glamorgan Hospital

Implementing National Institute of Health and Care Excellence (NICE) Guidance

• NICE Technology Appraisal No 49, Inser-tion of central venous catheters using ul-trasound locating devices. The results of a compliance audit against this guidance carried out at Royal Glamorgan Hospi-tal, indicated various training needs. To address this need interactive training sessions have been held for multi-disci-plinary teams by a group of Consultant Radiologists, with improved outcomes

• NICE Clinical Guideline No 124– The Management of Hip Fractures. After identifying poor compliance with the guidelines especially concerning bone protection medication and falls preven-tion steps were taken to improve oste-oporosis prescribing and audits are in progress across both hospital sites

A further audit of NICE Hip Fracture Man-agement has looked specifically at the time to surgery for patients admitted out of hours. In order to reduce delay of surgery, theatre scheduling has been amended to allow for weekend trauma surgery. Most recent figures have shown an improved time to surgery, with more now reaching the 24 hour target set by Welsh Government.

Local Pneumonia Clinical

As a result of an audit in the Summer of 2013, the following improvements are now being implemented:

• appropriate antibiotics treatment given within 4 hrs of presentation to hospital

• Testing of blood cultures for all patients• Ensuring Oxygen is correctly prescribed

on medication charts• Better documentation of events, such as

fluid balance & delivering fluid promptly• Medical on call team to be made aware

promptly of medical patients in A&E, par-ticularly for patients with serious illness

Re-audit of Emergency Oxygen

Following the audit recommendations were made to introduce the role of an ‘Oxygen Champion’ to promote good practice in the provision and monitoring of oxygen and to improve training and education for staff in the use oxygen.

Patient Survey on Operating Theatre Service

In 2013, 96% of patients scored the experi-ence as either ‘good’ or ‘very good’. Howev-er, the survey revealed a largely negative ex-perience of the Surgical Elective Admissions lounge. As a result facilities were moved to a more user-friendly environment, allowing easier access to the operating theatre.



section 7

PRIORITY AREAS FOR IMPROVEMENT IN 2014-2015

Falls in hospital The University Health Board aims to reduce the number of all reported inpatient falls by 15% by the end of 2017 and reduce the incidence of harm caused by a fall and fra-gility. This will support our Vision to prevent ill health, protect good health and promote better health.

Reduction in hospital acquired thrombosis – improving safetyVenous Thromboembolic disease (VTE) comprises deep venous thromboses, or clots, which may progress to pulmonary embolism and death. Patients in hospital who are nursed in bed are at increased risk of VTE. Improvement work in Cwm Taf has focussed on two main aspects - develop-ment of HAT (hospital acquired thrombo-sis) reporting, and designing and piloting a system to improve prevention of VTE with risk assessment designed into the drug chart with compliance continuing to improve (from 20% to over 85%).

SepsisSepsis is a common and potentially life-threatening illness. It kills 2,000 people in Wales each year.

Timely diagnosis, escalation and simple, effective treatments have been shown to reduce harm and mortality, reduce or avoid admission to critical care, reduce lengths of stay and also save resources.

Excellent progress has been achieved in this area of work, and now every Adult Acute Clinical area has a Sepsis Six Bag or Box containing most of what is required for SEP-SIS SIX treatment including documentation and laminated sheets of aides-memoire for the SEPSIS-screening tool and Antibiotic guidelines.

Stroke CareThe key features of our proposed new model for stroke care are:

• Centralisation of acute and early rehabilitation stroke services into one dedicated stroke unit on an acute hospital site

• Centralisation of longer term stroke rehabilitation services on one community hospital site

• Creation of a community-based stroke Early Supported Discharge service

Over the last year we have achieved:

• Improved Performance• Due to the success of our pa-

tient flow work, in early December 2013 we were able to ring-fence a stroke assessment bed on our acute stroke wards at the Royal Glamorgan and Prince Charles Hospitals

• In 2013 we developed and piloted a Stroke “Patient Passport” to pro-vide accessible information and a joint goal planning tool for stroke survivors and carers which won a Mediwales Innovation Award in 2013

• Developed a Stroke Delivery Plan

IMPROVING QUALITY OF CARE TOGETHER

Improving Quality Together (IQT) is a national initiative.

A model for improvement and national quality improvement learning pro-gramme for all NHS Wales staff and contractors.

Through the IQT programme, staff are being equipped with the skills and confidence to transform our services.

The model for improvement has been applied through the 1000 Lives programmes and Transforming Care.

Significant numbers of staff have already been trained (more than 700 at bronze level and over 100 at silver level). By spring 2015, we aim to have trained 25% of all Health Board staff in IQT skills.

Transforming Care Transforming Care, which was initially intro-duced as part of the 1000 Lives campaign, guides and supports healthcare staff to im-prove patient’s experience of care and ensure the safety and quality of services. Last year we reported that 42 wards were well established within Transforming Care; to date 65% of areas now participate, including seven mental health wards.



section 7 section 8

STAYING HEALTHY

Tackling Smoking

The NHS Wales Delivery Framework for 2013/14 es-calated smoking to a Tier 1 target identifying that 5% of smokers, should make a quit attempt via smoking ces-sation services. In Cwm Taf, 3.75% had made a quit at-tempt during the first nine months of the year.

The number of Community Pharmacies providing smok-ing cessation support was in-creased to 39, geographically spread across Cwm Taf.A smoking cessation re-search project (MAMSS – Mod-els for Access to Maternal Smoking Cessation Support) was developed with mater-nity services, the Chronic Ob-structive Airways (COPD) proj-ect was launched this year, working with GP practices to support patients .

The Cwm Taf Smoke Free Homes initiative continues to expand, and training has been delivered to Communities First clusters and Registered Social Landlords

Tackling Obesity

A weight management support and resource toolkit has been developed for use by communities. To date, 21 community weight management groups have been established and a good practice scheme is being devel-oped to support the groups.

Tackling poverty and social disadvan-tage

The Community Health Development Net-work has been established to bring togeth-er representatives of Communities First Cluster Groups, Cwm Taf University Health Board, Cwm Taf Public Health and other service-providing organisations who have an interest in reducing health inequalities across Cwm Taf.

Immunisation

Uptake of flu immunisations has contin-ued to improve this year, but still falls short of the 75% target, as is the case across Wales. However childhood immunisations continue to increase with:

• 95% uptake for all immunisations up to age 2 years

• 89.9% uptake for all at age 4 years – the highest in Wales

PATIENT AND PUBLIC ENGAGEMENT

Look, listen, learn. These are the principles we abide by.

Throughout 2013-14, the Uni-versity Health Board has used a range of opportunities to engage with patients and their families:

• Regular public meetings as well as meetings of the Stakeholder Reference Group have been held which include representa-tives from a wide range of community bodies

• Patient Participation Groups are in place in a number of GP practices across the localities

• The new “Patient Experi-ence Specialist Network” works with the Health Board on key patient expe-rience and quality improve-ment projects

• Focus groups have been held with ser-vice users who have recently undergone the transition process from Paediatric to Adult services to gauge their experience of service

• The Patient Experience Plan was launched this year. It embraces our philosophy of Cwm Taf Cares and reflects feedback re-ceived from our patients and their carers

Throughout 2013-14 further developments have been made in gathering patient stories which are used in meetings and in training to improve the quality of care and services.

Case Study

This year one of our clinical nurse specialists was recognised for her outstanding work in improving the lives of patients with Parkinson’s Disease. She worked in partnership with the independent sector to plan and deliver a rolling programme of structured education to health care professionals in care home settings which aimed to address the specific care needs of those with Parkinson’s. To date 60 care home staff have been trained, with positive changes made to working practice, including effective medicines management.



section 9 section 10

PRIMARY CARE SERVICES

Independent Contractor Services; Health Board sup-port and provision.

Primary Care is delivered by a wide range of highly skilled independent contractors in-cluding GPs, dentists, phar-macists and opticians.

These are mainly provided by independent contractor services, but include primary care services provided directly by the Health Board, as well as those in place to support.

Training initiatives are just one of the areas where im-provements have been made:

• Diabetes Patient Education in Primary Care practice nurses are being trained on a cluster basi

• Development of Healthcare Support Workers training and governance pro-gramme to support practices to deliver flu vaccination as part of the 2014/15 immunisation programme

• GP opening times and availability of appointments has continued to improve within Cwm Taf through the hard work and commitment of the Access Improve-ment Group and the individual practice teams themselves

• GP Out of Hours is currently being re-modelled with the view to integration with A&E and the development of a fully integrated emergency service co-located in the two acute sites

The Patient Experience Survey undertaken in March 2014 reflects a high level of satis-faction with this service – the graph shows patient’s scoring of their overall experience:

Primary Care Support Unit and Community Resource TeamCwm Taf University Health Board is unique in that it has a well established Primary Community Support Unit (PCSU). This team comprises of 20 salaried GPs, and 19 nurs-es, advanced nurse practitioners and health care support workers, and administrative support. This service has enabled the Uni-versity Health Board to deploy clinical staff to support struggling and vacant practices, at sometimes very short notice to maintain the delivery and availability of general medical services.

Level of satisfaction



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0

5

10

15

20

25

30

35

Very bad Average Very good

section 12

Annual Quality Statment 2013-14


EXAMPLES OF HOW WE ARE LEARNING TO IMPROVE SAFETY

• Concerns raised by a pa-tient with visual impair-ment resulted in all-paper towel dispensers in the disabled toilets across the hospital sites to be re-pro-grammed to automatical-ly dispense a paper towel without the patient hav-ing to activate this via the magic eye

• A ‘Paediatric Early Warning Score’ patient observation system has been intro-duced to help staff recog-nise a deterioration in the condition of a child

• Midwives who may be concerned about the con-dition of the baby during the antenatal period, are now able to request an ultrasound scan to confirm or exclude problems when a foetal heart cannot be heard abdominally from 28 weeks of pregnancy

• The clinical practice of a Consultant Or-thopedic Surgeon has changed following a legal claim which resulted from a delay in diagnosing issues relating to a knee injury which required surgery. CT scans are now undertaken on all patients who need the same procedure, and an audit has been undertaken to confirm safe practice and identify any further improve-ments needed

• As a result of a trend in incidents relating to hospital acquired thrombosis, a train-ing course was introduced for all medical staff in relation to detection, investigation and treatment of Deep Vein Thrombosis

Learning from the Concerns team is shared across the University Health Board and, where appropriate, with other organisations. Learning is shared via a number of methods including patient stories, training using anon-ymous examples, and the ‘CLICS’ Newslet-ter (Concerns Leading to Improvements in Care and Services).

It is also important to note that Cwm Taf has robust scrutiny arrangements in place that review all complaints, claims and clinical incident trends which ensure that we are learning and, where appropriate, implement-ing corrective action.

LEARNING FROM MORTALITY REVIEWS

All deaths from 1st April 2013 occurring in Prince Charles and Royal Glamorgan Hos-pitals (known as in-patient deaths) have been or are eligible for the Mortality Re-view Process.

The total number of deaths reviewed so far is 1142 (ap-proximately 85% of all deaths between April 2013 and end March 2014).

The Mortality Review Team includes General Practitioners, specialist doctors (including trainee and non consultant grades) and senior nurses led by an Assistant Medical Director with experience in investigation of deaths on behalf of the Coroner. In addition, further support is available from pharma-cists.

As a result of the Mortality Review Process, opportunities for quality improvement have been identified and action is being taken. As an example, a review of the management of warfarin therapy has been led by a senior and experienced physician and recommen-dations for improving the service have been made.

Other issues identified is the need for a 24-hour Endoscopy service to treat patients who are bleeding internally and an integrat-ed nutrition team to manage patients with highly complex feeding requirements.The Mortality Review team has been ex-panded to cover non-acute hospital sites from April 2014. Review teams at all sites will be adopting the Universal Mortality Re-view questionnaire. The training package for this process is in place in anticipation of the new Medical Examiner system expected at some time in 2015.

section 13

Annual Quality Statment 2013-14


RESEARCH & DEVELOPMENT IN CWM TAF

The importance of encourag-ing and demonstrating a high quality collaborative research culture was an es-sential part of the Health Board’s successful applica-tion to gain University Health Board status in November 2013.

UHB status provides opportu-nities for NHS and academic researchers wishing to collab-orate through improved com-munication, networks and partnerships.

This will help ensure the quantity, quality and subject matter of research will be reflected in benefits to NHS service delivery, quality improvement, safety, innovation and patient care. To help strengthen the relationship, the University of South Wales has announced the establishment of two Founding PhD Fel-lowships in partnership with the University Health Board.

Ultimately all our research is aimed at pro-viding Cwm Taf patients with the opportunity of new therapies and treatments and, our Research and Development department has been working hard to promote high qual-ity research activity across the University Health Board. We have increased NHS R&D allocation from NISCHR Welsh Government by 16% to £591,000 for 2014-2015. The An-nual Research & Development Conference was very successful and a separate Annual Report on all our R&D activity is available from our R&D department.

LOOKING TO THE FUTURE

We are steadfast in main-taining a focus on quality of delivery, improved patient experiences, and ensuring equitable access to services.

Our Three-year Integrated Plan 2014 – 2017 and Quality Strategy reinforce the strong commitment we have made to quality and safety which underpins all our work

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We will continue to drive our programme of clinically-led transformation to deliver strengthened primary care services, improv-ing integration of services, implementation of the South Central Acute Care Alliance to improve specialist services in the region and an overarching focus on the reduction of health inequalities. Working together has never been as important and it is now es-sential if we are to make our vision a reality.

Our quality improvement agenda will contin-ue to be one of our or highest priorities.

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LINKS TO OTHER KEY DOCUMENTS


Concerns Annual Report 2013-14 Fundamentals of Care Audit 2013Three Year Integrated Plan Quality Strategy for Cwm Taf University Health BoardQuality Delivery Plan for Cwm Taf University Health BoardPatient Experience Plan Executive Walkround guide Internal Audit Standards for Health ServicesInternal Audit NPSA AlertsStroke Delivery Plan for Cwm Taf University Health BoardNational Stroke Delivery PlanForward Plan for Clinical Audit and Continuous Improvement for 2014/15Research & Development Annual Report for Cwm Taf University Health Board“Trusted to Care” Andrew’s report An independent Review of the Princess of Wales Hospital and Neath Port Talbot Hospital at Abertawe Bro Morgannwg University Health Board (Professor June Andrews Mark Butler)Caring for the confused in Hospital‘Memories Are Made of This’ A book of reflection produced by the Chaplaincy Department

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http://www.cwmtafuhb.wales.nhs.uk/opendoc/247926




http://cthb-intranet/useful/Annual%20Reports/Cwm%20Taf%20Health%20Board%20Annual%20Quality%20Statement%202012-13.pdf




http://www.wales.nhs.uk/sitesplus/documents/865/12%20Appendix%201%20Stroke%20Delivery%20Plan%202013-16%20Cwm%20Taf%20v6%20FINAL.pdf

http://wales.gov.uk/topics/health/publications/health/reports/plan/?lang=en



http://wales.gov.uk/topics/health/publications/health/reports/care/?lang=en





Cwm Taf University Health Board, Ynysmeurig House, Navigation Park, Abercynon, Rhondda Cynon Taff CF45 4SN

Tel: 01443 744800www.cwmtafhb.wales.nhs.uk

@cwmtaf

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