St Giles Hospice Quality Account 2017 St_Giles_Hospice_Quality_Account_2017 | Page 18

CQUIN goals agreed with our commissioners
A CQUIN stands for Commissioning for Quality and Innovation. Birmingham Cross City Clinical Commissioning
Group agreed a CQUIN concerning Advance Care Planning, ACP. ACP is an approach to enable people to
consider, record and share their wishes about their care at end of life. As part of the CQUIN we undertook an
exploratory study using survey and focus groups to consider the attitudes, enablers and possible barriers to
people and staff engaging with ACP. This helped us create an action plan for the hospice.
We also reviewed the way we record information about ACPs and people’s preferences. In addition we delivered
new education and training to our own and external staff about ACP. This training has helped us understand the
ways in which we need to refine and expand this training to help clinical staff improve their understanding and
how they work with people who would benefit from ACP.
Data Quality
Each year we submit data about
our services for the national
Minimum Data Set and this helps
us benchmark ourselves against
other similar sized hospice services.
2016/17 was the final year of MDS
because of a loss of funding. The
most recent National Minimum
Dataset issued by The National
Council for Palliative Care covers the
period 1st April 2015 to 31st March
2016. We have used the national
median from this data to benchmark
hospice performance.
The Information Governance
Statement of Compliance (IGSoC)
is a commitment by organisations
accessing national systems to
maintaining appropriate access
controls and security standards. It is
a requirement for all organisations
delivering NHS contracts. The
hospice has achieved level 2
compliance.
We currently hold 53352 electronic
records.
In 2016/17 we offered support
to a total of 7,000 people
1,681 patients were supported at
home
731 people stayed in our
inpatient units
2,306 people received
bereavement support
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Inpatient Unit - Whittington
466 patients were admitted
42% were discharged home or to a
care home
The average length of stay was 13
days
The average occupancy level was 83%
Inpatient Unit - Walsall
 65 patients were admitted
2
35% were discharged home or to a
care home
The average length of stay was
12 days
The average occupancy level
was 70%
Advice and Referral Centre
Our Advice Line was contacted
700 times following its launch in
May 2016.
51% were from healthcare
professionals
46% were from members of
the public
4% were from social care
professionals
64% of calls were on behalf of
the patient
Referrals
 e received 1,498 referrals
W
received – an increase of nearly 4%
from the previous year
88% were supported by
Community CNS or another
hospice department
415 new referrals were made
to District Nursing Teams – this
meant nearly 28% of patients being
referred to specialist palliative
care were not known by a District
Nurse.
Our participation in
clinical audits
The hospice has an active
internal audit programme which
we select according to national,
local or internal priorities. As an
independent hospice, St Giles’ has
not participated in the national NHS
clinical audit programme as there
are currently no national clinical
audits or national confidential
enquiries covering NHS services
relating to palliative care. We review
the NHS programme annually to
identify any such audits that may be
relevant.
Planned Audits Outcome
Self-Assessment Audit for
the controlled Drug Ac-
countable Officer (CDAO) Audited against a nationally developed tool from HospiceUK we were able to
evidence 100% compliance for the 2nd year.
Health Records including
Moving and Handling Throughout the year we averaged 92% compliance – each quarter the
results were fed back to the team h ighlighting both good practice and
areas for improvement. Specific areas of inconsistent practice are regularly
revisited by the senior team to support staff.
Infection Prevention
and Control We audit against the Health and Social Care Act to provide evidence that the
management of our service is compliant on the prevention and control of
infections. Using an updated national tool from Hospice UK we evidenced
99% compliance. The re-audit identified an area of policy which needed
updating.
Diligent auditing and monitoring by Infection Control Lead and support staff
ensure prevention is a priority within the hospice.
Highlights
• Compliance rate of 99.78% for hand hygiene practice
• Quarterly auditing of patient areas, clinical rooms, patient bathrooms and
toilets – average compliance score of 95.78%
• Yearly auditing of kitchen areas on ward, hand hygiene, sluice / dirty
utility, care of deceased patients, sharps, protective equipment,
public areas including toilets, offices within clinical areas and visitors’
accommodation – average compliance score of 93.26%
Medicines
Management Yearly audits are undertaken using national tools developed by Hospice UK. For
Controlled Drugs we averaged 96.65% compliance and for General Medicines
the average compliance was 98.5%
To ensure we remain vigilant we audit quarterly using tools developed by our
palliative care pharmacist – overall we averaged 90% compliance during the year.
The forward audit programme
is developed by liaison between
Deputy Chief Executive, Nursing
Director, Heads of Department and
Quality and Audit Manager. The
programme is shared internally with
Trustees and Clinical Governance
Committee and externally with our
commissioning groups.
The hospice recognises the
importance of audit in influencing
and monitoring good practice.
Involvement of frontline staff is
recognised as essential to raise
awareness of ways to improve.
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