24 November 2020 Patient Safety webinar 3 - 4.30 pm - Hospice UK
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24 November 2020 Patient Safety webinar 3 – 4.30 pm Welcome. Thank you for joining us today. We are just setting up. Please do mute yourselves while joining or during presentations. (We may mute you on entry – this is not an audio fault and you can of course unmute yourself any time). Do introduce yourself in the Chat Box and please make use of it throughout for Q&A. Any issues please message ‘Tech Support’ in the Chat Box and we will try to assist. We are not recording today but will issue slides and resources after the event. www.hospiceuk.org
Agenda Item Welcome Dashboard update Presentation: Jo Nicholls, Trinity Hospice Current Year: Q1 & Q2 Falls Deep Dive Audit update Future Webinars Summary and Close www.hospiceuk.org
Dashboard update www.hospiceuk.org
www.hospiceuk.org
Regional Dashboards
18
16
14
12
Count of hospice
0. 1. 2. 3. Grand
Children Small Medium Large Total
10
Wales 1 1 1 3
East Midlands 1 2 3 8
Northern Ireland 1 3 4
North East 2 1 1 4
6
South Central 2 5 1 8
London 1 4 4 9
West Midlands 2 5 2 9 4
South West 5 7 12
Scotland 4 4 5 13 2
South East Coast 1 9 3 13
East of England 1 5 5 3 14
1 7 5 2 15 0
Yorkshire and…
North West
East Midlands
North West
London
South West
Northern Ireland
North East
Scotland
Wales
East of England
South Central
South East Coast
West Midlands
Yorkshire and 1 3 9 3 16
Humberside
Grand Total 3 34 59 27 123
0. Children's 1. Small 2. Medium 3. Large
www.hospiceuk.org
Interpreting the Pressure Ulcer Data Jo Nicholls - Trinity Hospice, Blackpool www.hospiceuk.org
Jo Nicholls Quality & Governance
Compliance Co-ordinator
Trinity Hospice & Palliative Care
Services
What do the Benchmarking
figures mean to us?
Putting meaning to our own stats
leads to assumptions and
interpretation
Challenges with reporting
Pressure Ulcers?
• Remembering it’s the number of Ulcers not
patients being reported
• Ensuring not to Double Count - Tracking changes
in the same Ulcer
• Only Reporting an Ulcer at the end of a period of
care not in the month it is reported
• Accurately reporting where an ulcer is related to
medical equipment‘The Law of Averages’ means no-one
is average
If you looked at these figures what assumptions
would you make?
We are a Hospice with an 18 bedded Unit
Number of Level 1 Pressure Ulcers we Average reported for other Medium
reported to the end of quarter 2 Sized Hospices to the end of quarter 2
On Admission = 23 Average On Admission = 2.1
New = 14 Average New = 4.6
We seem to I want it looking into why
have a lot of we have so many compared
Pressure with other Hospices
Ulcers!Should we try to find meaning? • In order to this we would need to ensure all reporting is the same across Hospices? Can we really do this? • Is the most important part of Benchmarking to stimulate debate and continuous learning and contribute to a National Dataset. • The figures should not be used to apply value judgments.
Questions/Discussion?
Current Year: Q1 & Q2 www.hospiceuk.org
Data Submissions
Count of hospice Column Labels
Row Labels 2020/21 Grand Total
01 113 113
Quarter 1
02 113 113 April – June 2020
03 113 113
04 102 102
05 96 96
06 96 96 Quarter 2
07 7 7 July – September 2020
08 1 1
Grand Total 641 641
• Thank you for the full submission of data in Quarter 1
• Still awaiting data from 17 hospices for Quarter 2
• Please still submit Q2 as it will go towards the end of year report
• Any issues with submission please contact us at: clinical@hospiceuk.org
www.hospiceuk.orgPressure Ulcer Data
Quarter 1 & Quarter 2
Quarter 1 & Quarter 2 Adults Adults Adults
2018/19 % 2019/20 % 2020/21 %
Pressure Ulcers - New - Category 1 376 21 357 21
Pressure Ulcers - New - Category 2 851 48 800 47
Pressure Ulcers - New - Category 3 102 6 127 7
Pressure Ulcers - New - Category 4 15 1 16 1
Pressure Ulcers - New - DTI 297 17 293 17
Pressure Ulcers - New - Unstageable 116 7 114 7
Total 1757 100% 100%
Pressure Ulcers - New - Total 1326 32 1757 34 1707 35
Pressure Ulcers - PUOA - Total 2869 68 3356 66 3138 65
Total 4195 100% 5113 100% 4845 100%
Number of patients with Number of
pressure ulcer(s) pressure ulcers
www.hospiceuk.orgSubmission Dates
2020 / 2021 Submission Final Reports
Months
Quarter Deadline Circulated by
Q1 Apr, May, Jun 1 Sept 2020 15 Sept 2020
Q2 Jul, Aug, Sep 16 Oct 2020 29 Oct 2020
Q3 Oct, Nov, Dec 15 Jan 2021 29 Jan 2021
Q4 Jan, Feb, Mar 15 Apr 2021 30 Apr 2021
2021 / 2022 Submission Final Reports
Months
Quarter Deadline Circulated by
Q1 Apr, May, Jun 15 July 2021 31 July 2021
Q2 Jul, Aug, Sep 15 Oct 2021 31 Oct 2021
Q3 Oct, Nov, Dec 15 Jan 2022 31 Jan 2022
Q4 Jan, Feb, Mar 15 Apr 2022 30 Apr 2022
Submission link request:
https://www.hospiceuk.org/what-we-offer/clinical-and-care-support/quality-assurance/patient-safety
www.hospiceuk.orgQuestions/Discussion?
Falls Deep Dive Audit www.hospiceuk.org
Falls: Deep Dive Audit
• 12 Hospices agreed to participate in the Patient's NHS Number
Fall Category
audit, trialling these standards Date dd/mm/yy
Day (autofill)
• Retrospective data collection approach Time hh:mm
Area / Location of fall
• Deep Dive into the last 10 falls at each Type of fall
hospice Further comments (free text)
• 7 Hospices have returned their completed BP recorded on admission?
audits: submission deadline has been Visual impairment (if present please state nature in comments) at time of fall?
extended to Friday 11 December Delirium or cognitve impairment at time of fall
No of medications administered in 24 hours prior to fall
• Outcomes / learning from the audit will be Mobility aids required?
Continence assessment conducted?
ready for sharing at the next webinar Continence assessed as:
Did continence contribute to the fall?
• We look forward to the subsequent Was there a history of any falls prior to admission?
discussions How many falls has this patient had during this admission that are not recorded on this
sheet?
• Special thanks to Martin Powell from Phase of Illness
Royal Trinity Hospice Further comments (free text)
• Any volunteers to undertake the audit Average dependency score that day
No of RN on duty
please add your details to the Chatbox
No HCA on duty
Were RN staffing levels adequate at the time of the fall?
Were HCA staffing levels adequate at the time of the fall?
Further Comments (free text)
www.hospiceuk.orgFuture Webinars www.hospiceuk.org
Webinar Dates and Topics
Dates for 2020/2021 Start Time Focus
25 February 2021 15.00 Quarter 3: Patient Falls
27 May 2021 15.00 End of Year Reports: Metrics Definitions
Dates for 2021/2022 Start Time Focus
26 August 2021 15.00 Quarter 1: Medication Incidents
25 November 2021 15.00 Quarter 2: Pressure Ulcers
24 February 2022 15.00 Quarter 3: Patient Falls
26 May 2022* TBC End of Year Reports: Metrics Definitions
*Potential for face-to-face event at Hospice House, London
www.hospiceuk.orgWebinar Content Sharing experiences and creating feedback loops Request for: • Topics for presentations • Case studies • Shared experiences • How you use the data • Improving patient safety www.hospiceuk.org
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