Patient Safety and Quality Improvement
Swansea Bay University Health Board is placing quality and safety at the centre of its service. This publication illustrates how mortality and life expectancy are measured and scrutinised.
One of the key elements of our Quality Improvement programme is analysing and understanding all available information we have about people who die in our hospitals.
Almost half of the deaths of people in our communities take place in hospital, mainly because many people who are at the end of their lives come into hospital during their final days.
Just over 2,000 people died in hospital in Swansea, Neath and Port Talbot in 2018, accounting for 49% of all deaths. In addition, 223 people died in our hospices. In total, 52.5% of deaths took place in SBU hospitals or hospices.
However, we are aware that in some cases, people died in hospital when it may have been better for them and their families if they had been able to die at home, in familiar surroundings.
For this reason, we are supporting Care Pathways to be used at the end of life which enable more people to have the choice to die at home, if it is their wish.
Due to Covid-19, collection of the Friends and Family forms has been suspended from 23rd March until the 31st July 2020. The Patient Experience Team took the following actions to gain patient experience during the pandemic instead:
Developed an electronic survey available on line which is also being sent out weekly via SMS messages to discharged patients across the Health Board. The survey focuses on communication, virtual visiting/appointments and the availability of clothing and toiletries.
The Covid-19 survey results are being shared with the Health Boards Intelligent Network to help inform the recovery work and the IT team. The results are also shared with Person Centred Care Cancer Steering Group, Eye Care Collaborative Group and the Health Boards Charity Manager to take any action as required in relation to the Wish List.
Discharge Covid-19 Survey: Sent 1,738 SMS messages out, 453 returned the survey = 26% return rate for May 2020.
The feedback for the surveys in May is being analysed, although appears to be in the main positive in terms of the changes made. Issues were identified in relation to Wi-Fi access and some concerns in relation to people who do not know how to use, for example, FaceTime and Skype, which IT are considering.
Feedback was also collected for a Neuro pilot using ‘Attend Anywhere’ clinics, (some questions were completed over the telephone, just before Attend Anywhere started on 27th April). For assessment four appointments are required. Previously all four appointments were held in a hospital setting. If the pilot is successful the team are looking at running three virtual and one ‘eyes on’, appointment which will significantly improve waiting times and disruption to families coming in to the hospital for appointments.
One of the comments:
"The assessor could see my daughter's behaviour in her own environment, it was relaxing being in your own home, easier to work around working patterns"
F&F App - During the Covid-19 pandemic, the Health Board stopped all visiting and iPads were used for patients to FaceTime/Zoom loved ones. The Patient Experience Team worked with the Mobilisation team to develop the F&F app and place it on all Apple devices across the organisation. To date 2,315 iPads now have the app installed. The aim is to increase online F&F feedback.
QR codes: F&F QR Code has been placed on bilingual posters across hospital sites.
The link to the feedback survey has been posted on social media, and the team is using this time to evaluate whether the majority of surveys can be completed online going forward and whether they can cope with the increase once normal service resumes.
The units are requested to promote the completion of the survey via iPads available in the ward areas.
For the month of May there were 267 returns of the survey which results in 92% of people stating they would highly recommend the Health Board to friends and family, which was a 2% increase on April 2020.
Each of the Service Delivery Units (SDUs) receives a monthly detailed report identifying the themes and they develop an action plan for improvement at SDU level.
During Covid-19, we will continue to monitor all online feedback and report any issues directly to the Units.
Patient Experience Team Work
Cancer feedback Prehab2rehab: Work continues with the joint collaborative T&F Group with Cardiff and Vale Patient Experience leads, and Macmillan. The aim being to develop a feedback survey which will be sent out (via SMS text) to cancer patients who have had their treatment delayed. The SMS message survey will also be sent out with Keep Well information for patients.
Discussions on an All Wales Platform are underway in terms of collecting the data. The WG Delivery Unit are keen to support health boards on this project.
Thank you bulletin: We are using the feedback we have received from the Covid-19 surveys to develop staff bulletins and press releases. The aim being to share and boost staff morale and let them read some of the amazing comments patients have written about them. This was well received by staff and the communications team.
Staff survey: Patient Experience Team has been asked to build the Health Board's staff survey. There was initially a plan for this to be done by WG across all health boards. At this current time this work is being discussed and we will update you next month on developments.
Wales Fertility Clinic: We have been asked to develop a bespoke survey to capture the views of patients currently undertaking fertility. Discussion are ongoing and the team is developing a set of possible questions. We will keep you updated on this development.
Covid-19 Staff and Patient Story Wall: The development of Staff and Patient Covid-19 stories continues to go from strength to strength. At this time we currently have 23 stories in various stages of development. One story is due to be played in the Board meeting on 25th June. Primary care have also requested two of the stories for their Q&S meetings. NPT Q&S have also requested a story. The aim is to post all these stories on the Health Board's intranet site to share (with the consent of the individuals).
Swansea Bay UHB Falls Policy
Swansea Bay UHB falls policy is now live, ensuring we offer our patients the very best care. All the evidence shows if the steps in this new policy are followed, it will not only help prevent falls in the first place, but, if a fall does occur, we can ensure the quickest and best outcome for the patient.
When a patient falls there can be both physical and psychological implications for both the patient and their family. There is the risk the patient will need surgery, long term care, and suffer loss of mobility. Even if they recover, their confidence could be damaged because they are frightened of falling again. Sadly, in the worst cases some patients can die following a fall.
We are aware that falls can be catastrophic. However this new falls policy provides the knowledge and guidance to aim to prevent falling in the first place. It also provides in-depth falls insights to enhance the chances of a good recovery.
Swansea Bay Patient Portal (powered by Patients Know Best)
The provision of a patient portal is a key component of the National and Health Board Digital strategy and is an enabler for the delivery of a Healthier Wales, empowering patients with their own online patient controlled record, to support their health and well-being. Swansea Bay Patient Portal has been live since July 2018 and is now lives across all acute sites.
Swansea Bay is the first health board in Wales to offer patients access to their electronic online information, which currently allows patients to access their pathology results and clinic documents for Swansea Bay University Health Board only.
SBUHB is now live in 19 services with 1426 patients signed up across the Swansea Bay, including Princess of Wales hospital.
As well as having 24/7 access to their records, patients can now choose who they want to share the information with, and work much more closely and easily with clinicians to manage their future care as a team. Care plans can be created digitally with input from patients and clinicians, and videos and other media content to help patients better understand their condition and manage their care are also available.
By making it simpler for patients to choose who can see their information, patients can easily share it with other agencies or healthcare professionals, smoothing the way for much easier cross-boundary or multi-agency care. They can also share the information with relatives and carers.
As an example of where benefits have been introduced through the introduction of Swansea Bay Patient Portal (PKB), the dermatology team in Singleton hospital are using the portal to work closely with the systemic patients who need regular blood monitoring. Each of these patients would normally come to hospital every 12 weeks for an outpatient appointment. With the introduction of the portal patients can be reviewed virtually without the need to attend a clinic appointment and will allow the team to free up 3 appointment slots per patient per year. These slots can be allocated to patients that need a face to face appointment.
During the period of COVID-19 a number of teams have signed up patients in order to work with them in a virtual way. An example of this is with the Complex Childrens Service in Singleton, led by Dr Jo Griffiths Consultant in Child Health, working with parents of children with complex needs to provide them with a vast range of library links and information relating to COVID-19 and what to do in certain situations.
Swansea Bay Health Board also offer all members of staff access to their own portal account. To date 424 members of staff have registered for an account. A total therefore of 1850 patients/staff have registered to use the Swansea Bay Patient Portal to date.
In order to provide assurance that the best possible care has been provided to our patients at the end of their lives and to identify any areas for potential improvement, we are required by Welsh Government to undertake Mortality Reviews on all in-hospital deaths.
We currently use a three-stage approach and our own electronic Mortality Review Application, or e-MRA, to support the information that is generated. The doctor certifying the death responds to a number of All-Wales Universal Mortality Review (UMR) questions. These first stage questions (UMRs) are presently the only mandated aspect of the Mortality Reviews process and we are consistently the best in Wales in terms of compliance.
For us, the responses to some of the UMR questions could trigger a local second stage and more in-depth review of the case, by a consultant who was not involved with the patients care. After a number of years, the All-Wales Steering Group is now very close to releasing the final version of an All-Wales Stage Two which we will adopt, roll-out and monitor as required. This will allow us to benchmark ourselves against other Trusts and Health Boards in Wales, supported by the development of a Once for Wales electronic system which we have been involved in designing and piloting.
In the meantime, we continue to use our own three stage approach. We felt it was important to have a third stage to pull together all of the information gathered in order to generate any themes for learning and action. This stage is currently undertaken at a high level, by the Unit Medical Directors.
Review of Hospital Mortality Indicators
An independent review of hospital mortality indicators was undertaken by Professor Stephen Palmer, professor of epidemiology at Cardiff University, which examined whether risk-adjusted mortality, which is used in hospitals across Wales, is reliable and how it is being interpreted. The review found that mortality data can be misleading and does not provide an accurate measure of the quality of care.
Prof Palmer concluded that the current risk adjusted mortality index (RAMI) is not a meaningful measure of hospital quality. He believed the process of reviewing the medical records of all patients who died in hospital in a standardised way – a system pioneered in Wales – provided a better, more robust way of assessing safety and quality of care at a hospital. (Please see 'Mortality Reviews' section above)
A written statement published in July 2016 by The Welsh Government acknowledged the work undertaken by Prof Palmer and concluded that, following the implementation of a range of actions previously recommended in the Palmer review (2014), the publication of RAMI indicators was no longer required.
Whilst these indicators will no longer be published, the Health Board will continue to monitor and scrutinise all available mortality information on a regular basis to identify and investigate any unusual patterns or clusters which may be a cause for concern.