Evidence Bite – Pressure ulcers and moisture lesions

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

Pressure ulcers (also known as pressure sores or bedsores) are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time.

“The National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA) defined moisture lesions as a separate category; while acknowledging moisture damage can contribute to the formation of pressure ulcers”

Date of publication: May 2018

Evidence Bites: Technology on ward rounds

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

Why are ward rounds a patient safety concern? Ward rounds are complex clinical activities, critical to providing high quality, safe care for patients in a timely, relevant manner. They provide an opportunity for the multidisciplinary team to come together to review a patient’s condition and develop a co-ordinated plan of care, while facilitating full engagement of the patient and/or carers in making shared decisions about care.

Date of publication: May 2018

Evidence Bites: Safety checklists in Radiology

An evidence summary inspired by safety discussions held at the Wirral University Teaching Hospital NHS Foundation Trust’s Safety Summit

Is there a safety checklist for radiology? In March 2009, The Royal College of Radiologists (RCR) published guidelines for radiologists in implementing the NPSA Safe Surgery requirement1. Subsequently, checklist for radiological interventions was produced, based on the WHO Surgical Safety Checklist.

Date of publication: Oct 2017

State of Care Report 2015/16

Title of driver: The state of health and adult social care in England 2015/16

Impact on library policy/practice:

Libraries are a knowledge hub providing services such as evidence summaries, literature searching and current awareness which can be linked to challenges faced by the specific organisation (CQC inspection reports for individual organisations can be searched for on the CQC website and can be a good way to identify local priority areas).

We can ensure that the best clinical and management knowledge is available to decision-makers in the organisation, in order to tackle the challenges identified in this report. Libraries are ideally placed to identify and disseminate best practice to assist health care organisations in providing quality care with limited resources.

Collaboration across organisational boundaries is identified as a means to improve services, and this may have implications for libraries as users move between organisations or work jointly between organisations that may have different resources or library access arrangements.

Source: Care Quality Commission (CQC)

Link to main page
Link to 2015/2016 State of Care Report

Publication format: PDF (149 pages)

Date of publication: October 2016

Summary of driver:

Many health and care services were providing good quality care, despite a challenging environment,
but there was substantial variation remaining. Some health and care services were improving, but some were also failing to improve or deteriorating in quality.

People’s views of services broadly remain positive, but this masked significant variation in experiences of care

There were indications that the sustainability of adult social care was approaching a tipping point, and hospitals are under increasing pressure. The CQC was concerned about the sustainability of quality

Key features of driver:

• 71% of the adult social care services inspected, 83% of GP practices, and 51% of core services provided by hospitals were rated good
• By the end of 2015/16, NHS providers had overspent their budgets by £2.45 billion. Local authorities were reported to have spent £168 million more than they budgeted for
• More than eight out of 10 NHS acute trusts were in financial deficit at the end of 2015/16
• Strong, visible leadership continues to be a major factor in delivering and sustaining high quality services, and in making improvements
• The difficulties in adult social care were already affecting hospitals. Bed occupancy rates exceeded 91% in January to March 2016, the highest quarterly rate for at least six years. And in 2015/16, there was an increase in the number of people having to wait to be discharged from hospital, in part due to a lack of suitable care options
• All parts of local health and care systems – commissioners, providers, regulators and local people – need to work together to help transform local areas.

The document looks at the state of care in the period 2015-16, as well as looking at the future resilience of health and social care services in the context of an ageing population.

Throughout the document, there are examples from services rated as outstanding as to how these ratings were achieved.

After the initial review, the report gives more details for each of sectors it regulates.

A summary and infographic of the report findings are also available.

Primary audience: All health and social care providers in England, members of the public and other stakeholders.

Date last updated: May 2017
Due for review: May 2018
Group member responsible: JC

State of Care Report 2014/15

Source: Care Quality Commission (CQC)

Link to main document
Link to 2013/2014 State of Care Report

Publication format: PDF (120 pages)

Date of publication: October 2015

Summary of driver: This is the sixth annual CQC report on the state of health and care services in England. It highlights that despite the challenges of increased need and tough financial demands, inspections show that improvement is possible. It outlines the need to look to the best to understand what works and why.

Key features of driver:
Despite pressures, many services are managing to maintain or improve quality.

• 50% had improved.
• Fewer than 7% had deteriorated further.
• All of these re-inspections took place within a year of the original rating.

• However, some people are receiving care that’s unacceptable. Of the providers rated by the end of May 2015, 7% were inadequate.
• Quality is variable with large differences in quality of care between different services and providers.
• Sometimes quality varies according to who you are or what you need. For example people with mental health needs and long-term conditions and some ethnic minority groups are less likely to report good experiences of care.
• Safety is the biggest concern: of the services we’ve rated so far, 13% of hospitals, 10% of adult social care services and 6% of GP practices were inadequate for safety.

The following are critical to quality improvement:

• Engaged leaders building a shared ownership of quality and safety.
• Staff planning that goes beyond simple numbers.
• Working together to address cross-sector priorities

A summary and infographic of the report findings are also available.

Primary audience: All health and social care providers in England, members of the public and other stakeholders.

Impact on library policy/practice: Libraries are a knowledge hub providing services such as evidence summaries, literature searching and current awareness which can be linked to challenges faced by the specific organisation. We can ensure that the best clinical and management knowledge is available to decision-makers in the organisation, in order to tackle the challenges identified in this report. Libraries are ideally placed to identify and disseminate best practice to assist health care organisations in providing quality care with limited resources.

Date last updated: December 2015
Due for review: October 2016
Group member responsible: TP

The Mid Staffordshire NHS Foundation Trust Public Inquiry

Title of driver: The Mid Staffordshire NHS Foundation Trust Public Inquiry

Source: Chaired by Robert Francis QC

Link to main document

Publication format: Web page with links to each volume

Date of publication: February 2013

Summary of driver:
The Mid Staffordshire NHS Foundation Trust Public Inquiry was launched in 2010 and was a full public inquiry into the role of the commissioning, supervisory and regulatory bodies in the monitoring of Mid Staffordshire Foundation NHS Trust. It builds on the Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 to March 2009, and provided a detailed analysis of what contributed to serious failures in care.

It concluded that what happened was the result of a system failure, as well as a failure of the organisation and called for a fundamental change in culture across the NHS.

In February 2014, NHS England published a progress report called ‘The Francis Report: One Year On‘ detailing some of the changes that have taken place as a results of the public enquiry.

• Launching the Friends and Family Test
• Rolling out a the Compassion in Practice strategy
• Review of the quality of care and treatment provided by 14 hospital trusts that are persistent outliers on mortality indicators
• Network of Patient Safety Collaboratives
• Every Trust in England has been directed to publish actual versus expected nurse, midwifery and care staffing levels and to clearly explain how they have decided on their staffing numbers in each ward and clinical area.
• New National Patient Safety Alerting System (NPSAS)
• Quality Surveillance Groups have been put in place
• Begun publication of outcome data from consultants in 12 surgical specialties
• Plans for a new national safety website

Key features of driver:

• The report contains 290 separate recommendations.
• The Government published a response in November 2013, covering each these, though not all of which were accepted in full
• The Government response addresses 5 thematic areas (‘Compassion and care’, ‘Leadership’, ‘Values and standards’, ‘Information’ and ‘Openness and transparency’)

Primary audience: Policy-makers, managers and leaders, education providers, CCGs, NHS Trusts and professional bodies.

Impact on library policy/practice:

Among the recommendations accepted by the Government are several that could have a direct impact on libraries, including:

• Recommendation 187 is that aspiring nurses have one year’s practical experience as a health care assistant before entering an undergraduate nurse education course and this could have implications for the numbers of health care assistants needing to access library services
• Recommendation 194 suggests that in time nurses will be required to undergo revalidation
• Recommendation 197 that nurses have access to leadership training and this could be a driver to support the development of leadership resources in libraries

Date last updated: June 2014

Due for review: June 2015

Group member responsible: JC

Morecambe Bay Investigation

Title of driver: Morecambe Bay Investigation

Source: Department of Health

Link to main document: https://www.gov.uk/government/organisations/morecambe-bay-investigation

Publication format: Web page

Date of publication: 12 September 2013

Summary of driver: Between January 2004 and June 2013 there were a series of deaths of mothers and newborn babies in the maternity and neonatal services unit at Furness General Hospital. The Morecambe Bay Investigation looks independently at the maternity and neonatal services in Morecambe Bay NHS Foundation Trust.

Key features of driver:
– The investigation will focus on the actions, systems and processes of the Morecambe Bay NHS Foundation Trust.
– The investigation will also consider the actions of regulators and commissioners where those actions affected the safety of maternity and neonatal services provided by the Trust.
– A report to the Secretary of State for Health will be published by summer 2014.

***Amendment anounced March 2014 – the publication of the report has been extended tothe autumn of 2014

Primary audience: As with any investigation, the lessons from this investigation will be of interest to all healthcare providers.

Impact on library policy/practice: Library staff are collating and managing the information flows with the investigation team

Date last updated: 11.4.2014

Due for review: Autumn 2014

Group member responsible: TP

The Keogh Mortality Review

Title: Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report

Source: Professor Sir Bruce Keogh KBE 

Link to main document: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf

Link to additional information: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx

Publication format: pdf

Date of publication: 16th July 2013

Summary of driver: On February 6 2013, the Prime Minister announced that he had asked Professor Sir Bruce Keogh, NHS Medical Director for England, to review the quality of care and treatment provided by those NHS trusts and NHS foundation trusts that were persistent outliers on mortality indicators. A total of 14 hospital trusts were investigated as part of this review.

Key features of driver: The review considered the performance of the hospitals across six key areas:

• mortality
• patient experience
• safety
• workforce
• clinical and operational effectiveness
• leadership and governance

Primary audience: Everyone

Impact on library policy/practice: Provide literature as to how healthcare profesionals can reduce harm to patients.

Date last updated: 6th March 2014

Due for review: March 2015

Group member responsible: TO and JR

Berwick review into patient safety

Source: Department of Health

Link to the document: https://www.gov.uk/government/publications/berwick-review-into-patient-safety

Update published 6th August 2014 “One year on – reflections from the Berwick advisory group”

Publication format: Website, with further PDFs available

Date of publication: 6 August 2013

Summary of driver:

Don Berwick (founder and former President of the Institute for Healthcare Improvement) led an Advisory Group carrying out a review of patient safety, following the breakdown of care at Mid Staffordshire hospitals.

The report identifies changes that could help the English NHS become even more effective, safe, and patient-centered.

The recommendations of the report are grouped into nine categories.

I)             The overarching goal

II)            Leadership

III)           Patient and Public Involvement

IV)          Staff

V)           Training and Capacity Building

VI)          Measurement and Transparency

VII)        Structures

VIII)       Enforcement

IX)          Moving Forwards

Key features of driver: 

The report envisions the NHS in England moving forward as a learning organisation.  As a result, the overarching principles of the report are that the NHS should be committed to:

• Placing the quality of patient care, especially patient safety, above all other aims.
•  Engaging, empowering, and hearing patients and carers throughout the entire system and at all times.
• Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.
• Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge

The report includes the following Appendices:

• A note on the methodology
• Letter to Senior Government Officials and Senior Executives in the Health Service
• Letter to the people of England
• Letter to the clinicians, managers, and all staff of the NHS
• A list of Advisory Group Members

Primary audience: Government and NHS England Leaders, NHS Organisation Leaders and Boards and System Regulators

Impact on library policy/practice: To support NHS workers and expand their skills with a commitment to lifelong learning

Date last updated: August 2014

Due for review: December 2015

Group member responsible: LA

Review into the quality of care and treatment provided by 14 hospital trusts in England; overview report (Keogh Review)

Source: Independent review commissioned by the Department of Health and led by Professor Sir Bruce Keogh KBE

Link to main document

Publication format: PDF report

Date of publication: July 2013

Summary of driver:
The report is a review into the quality of care and treatment provided by hospital trusts with a high mortality rate. Fourteen trusts were selected on the basis that they had been outliers for the last two consecutive years on either the Summary Hospital-Level Mortality Index (SHMI) or the Hospital Standardised Mortality ration (HSMR). The final report covers in detail, areas for improvement in each of the 14 trusts as well as identifying common challenges facing the wider NHS. Keogh concludes that significant progress is to be made within two years.

There are 8 ambitions (listed below) – which are common challenges facing the wider NHS after working with these 14 hospitals.

• Progress towards reducing avoidable deaths in hospitals rather than relying on mortality statistics to judge the quality of care
• Boards and leaders of provider/commissioner organisations, patients and the public to have access to good quality data
• Patients/carers/members of the public to be treated as equals in assessment of NHS and confident that their feedback is taken on board and to see how this impacts on future patient care
• Patients and clinicians to become active participants in future Care Quality Commissions assessments
• The development and maintenance of a culture of professional and academic recognition
• Nurse staffing levels and skills mix will match caseload and severity of patients. This information to be reported transparently by trust boards
• The contribution made by junior doctors and student nurses within organisations and the harnessing of the knowledge and innovation they bring
• Recognition of the effect that positive and motivated staff have on patient outcomes

Suggestions include the following:
• All NHS organisations need to think about innovative ways to engage staff
• Patient and public engagement must be a central theme to those who plan/run/regulate hospitals
• Implementation of an early warning system, which has the relevant support/back up in place
• Adoption of systematic processes to ensure staff and patient involvement
• Embracing all feedback, concerns and complaints
• The creation of Quality Surveillance Groups to support the CQC
• Evidence based tools to be used to determine appropriate staffing levels and skill mix

Key features of driver: Each of the 14 trusts was reviewed and the process has three sections. Information gathering and analysis, the rapid response review and finally a risk summit and action plan, which sets out the plan of action that each Trust needed to take to improve and who is accountable. The report includes a summary of findings and actions for the 14 trusts involved.

Primary audience: Department of Health, HEE, NHS Trusts, other provider/commissioner organisations.

Impact on library policy/practice: Libraries could support staff with training. This might include:
• Critical appraisal sessions and Information skills training to help staff find and understand the evidence

Date last updated: November 2013
Due for review: November 2014
Group member responsible: LK