Issue 27 Spring 2012
Leeds and York Partnership NHS Foundation Trust
TOMs:
Supporting Care in Learning Disabilities
Pages 3 - 5
Life of an Incident Form
Pages 7 - 9
Medication and Patient Counselling
Page 15
Welcome all to QuESt the 27th edition It has taken some time but at last I have been unleashed on the editorial and I will make the most of this because it will also be the last. Leaving the NHS at the end of May after 37 years, as Chief Financial Officer at this Trust for the last 7 years, I have often been quoted as saying ‘cash is king’. So why might you ask am I writing in this publication? Quite simply it is because providing a quality service to all the people who have and will use our services is and rightly should always be our top priority. It is why we all joined the NHS in the first place. So back to my usual quote; well if ‘cash is king’ then ‘quality is queen’. There can be no longterm financial success without good quality services. They are not and never have been mutually exclusive. Just reading the latest Health Service Journal one might be concerned that quality per se is falling victim to the current changes in the NHS but not, interestingly because of a lack of funding. Not yet at least anyway as far as I can see. The trouble is, apart from the performance measures on which we tend to be regulated externally, it is often difficult to get to grips with the real concept of quality. It means so many different things to different people. That is why I am very pleased to see the article on Therapy Outcome Measures feature so prominently in this issue. We need to see quality from a number of perspectives, most importantly through the perceptions of those who use our services and those who care for them. It was an eye opener, for me at any rate, to read that 1 in 100 adults have an autism spectrum disorder. Whilst we can attempt to assess and understand the quality of the service we give to those who use our services, should we not also measure our success in the proportion of such people who
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access our services as a proportion of all those in need, as well as the ones who actually use it? We are reminded of the value of good incident reporting. No doubt the impact of the next Mid Staffordshire report will be felt across the NHS when it is published in October. If ever there was a reminder about the need to be open and learn from issues that arise then this will be it. We are, however, a high reporting Trust which to me represents a healthy attitude and enables us to move forward. Prescribing is the Trust’s main non-discretionary non-pay spend. The value of good drug therapy is highlighted in this edition and with it the increasingly important role played by our pharmacy colleagues. Reading the section on health records, I am pleased to see a high level of involvement in this initiative which will in its turn help improve outcomes for service users. There will also be much to see in the Trust’s refreshed information strategy this Summer. I have been struck by the gathering momentum surrounding the ‘What’s Your Goal’ campaign. This is an important initiative for a Trust with recovery principles at its core. Finally, it is reassuring that the Trust has been assessed as ‘green’ for governance by Monitor in the last quarter of 2011/12. This is a welcome return to what had been the norm for so long and long may it continue. I would like to leave you with a one thought. It has been a privilege to work in the NHS and in particular this Trust for so many years. So many dedicated people all striving to do the best for everyone in our care. I am proud to have been associated with a part of the Trust’s journey and wish you all every success in the future Guy Musson, Chief Financial Officer, Deputy Chief Executive
TOMs: Supporting Care in Learning Disabilities Following on from Don Brechin’s Article on; “Outcome Measures in LYPFT” in the Winter edition (issue 26) of QUEST magazine, this article focuses on the Therapy Outcome Measures or TOMs, one of the outcome measures featured.
• As clinical leads we have strived to develop a strong AHP community within LD services. We needed an outcome measure that would support the strengthening of this community, providing a shared language for understanding and communicating the measurement of health need and change.
It describes the Learning Disabilitiy Services experience of embedding this outcome measure within its services, the clinical reasoning behind outcome measure selection a description, summarising the outcome measure selected and the process undertaken for embedding the measure within the service.
• Carers are key partners to the successful implementation of our interventions. We needed a measure that took into account carer perspectives and well being.
How can we demonstrate that the clinical interventions that we, Learning Disabilities, Allied Health Professionals (AHPs) are providing, are improving the health and lives of Adults with Learning Disabilities living in Leeds? This was a key question that as AHP Lead and Clinical Leads for Physiotherapy, Dietetics, Occupational Therapy and Speech & Language Therapy we were asking about ourselves and the services that we are responsible for. Constantly striving for the delivery of high quality services is not something new to AHPs working in LD services, but being able to evidence this high quality in a demonstrable way does pose some specific challenges within Learning Disabilities. One of the ways that we thought to address these issues was through the introduction of an outcome measure, but which one? A number of factors would influence our clinical reasoning and decision making in selecting an appropriate outcome measure. These included;
• 47% of the referrals into our service are for a physical and or sensory need. We therefore needed an outcome measure that could be used to measure both physical and mental health need.
• Many of the service users accessing our services have long term conditions. Our interventions often focus on preventing, maintaining or slowing the rate of deterioration and the management of symptoms as well as recovery. As a result we needed an outcome measure that did not focus on “cure” or the absence of disease and disorder. • Due to issues relating to cognitive impairment and communication, we needed an outcome measure that did not rely on the completion of questionnaires or self reporting. • As well as being able to demonstrate and communicate health outcomes to service users and Carers, we recognised the importance of being able to describe AHP service outcomes to Service and Trust Managers, Governors and Commissioners. We needed a measure that would engage and communicate AHP service outcomes in a language that others, not always from a clinical background, could understand.
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• We did not want to tie clinicians to their desks, we needed a measure that was quick and simple to administer and record. Using these criteria we reviewed known outcome measures and identified the Therapy Outcome Measures tool or TOM’s.
What is TOMs? The Therapy Outcome Measures tool was designed by Professor Pamela Enderby, Alexandra John and Brian Petheram in the early 1980s. It has been designed to be used by a range of health care professionals, not just Allied Health Professionals. It is a person centred and holistic measure of health that enables the clinician, through the use of an ordinal scale, to measure the abilities and needs of a service user across four domains, these being; •
IMPAIRMENT: Concerned with the integrity of body systems and includes; psychological, physiological structures and functioning.
•
ACTIVITY: Concerned with the limitations on
activities for an individual given their abilities / disabilities. • PARTICIPATION: Concerned with the disadvantage experienced by the individual regarding social participation, interaction and autonomy.
• WELL BEING: service user and carer (separate measures): Concerned with emotions, burden of upset, concern and anxiety and level of satisfaction with the condition. (N.B: These domains originate from the dimensions of World Health Organisation International Classification of Impairments, Disabilities and Handicaps (1980) and corresponds with the (2001) International Classification of Functional Disability and Health.)
Through these domains TOMs measures how a service user’s health need affects their ability to engage in activities such as; self carers, eating and drinking and domestic activities. It then measures how both their health needs and needs relating to activities affects their ability to participate in areas such as; family life, their local community and education / employment, before finally measuring how the impact of all these areas affects the service users and their carers’ well being.
How? Embedding TOM’s within the LD AHP services: • Staff Ownership: As clinical leads, we identified early on that the key to the successful
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implementation of TOMs within the service would be the ownership of the measure by staff. Careful thought was given to the importance of getting the process of implementation right. This included spending time with staff and demonstrating the importance and context behind the need for clinicians to be able to measure the outcomes of the interventions they provide. • Governance & Assurance: Ensuring that the work completed around TOM’s was firmly embedded within governance frameworks was fundamental in providing evidence & assurance that our services were safe & effective and were using measures that were approved. As well as LD Service governance frameworks, TOMs has been ratified for use within the Trust Outcome Measures Group and has been presented to the Executive Team and members of the Trust Board of Governors through service performance reviews. We have also regularly communicated with Professor Enderby (one of the authors of TOMs) to discuss with her ideas, innovations and difficulties to ensure that we are embedding TOMs correctly.
• Staff Training & Support Systems: All AHP staff were trained in the use of TOMs on the same day by Professor Enderby. This was to ensure that staff were at the same point in their learning so that they could support one another in implementing the measure within clinical practice. Work had already been completed on creating a UDF to record and collect TOMs data on PARIS. This meant that within the same week as being trained on how to complete & use TOMs, the clinician could then use and record TOMs straight away. Not only was this an important factor in ensuring the quality of data inputted but also in motivating staff to use the tool. A process map was designed to support staff to know at what part of the service user journey to complete TOMs. An electronic resource pack was created to house items such as the process map and to provide support and clarity for clinicians when using TOMs. • Service Users & Carer Involvement: We have developed accessible information to support clinicians to explain to service users and their carers what outcome measures are, and how TOMs measure health outcomes. Through the involvement of service users, their carers and clinicians, we have developed an accessible TOMs
Service User Outcome Report which documents the service user’s TOMs outcome scores. A robust consultation process was carried out to obtain feedback from service users, their carers and clinicians on these resources. (Further, more detailed information about this work will be available in the next QUEST magazine). • Review and Evaluation: TOMs was made a CQUIN (Commissioning for Quality & Innovation) indicator for the Trust early in 2011. This was an incredibly exciting, if not intimidating, development. Having TOMs as a Trust CQUIN has supported us to embed TOMs within our services in a number of ways. It supported us to be “SMART” in setting goals for development. As the CQUIN needs to be reported on a quarterly basis, it also supported us to regularly review and evaluate the development and progress of TOMs and consider our next goals and future actions. Other benefits have also included raising the profile of LD AHPs both internally and externally. Regular review and evaluation was also a vital aspect of securing ongoing staff ownership for TOMs. Feedback opportunities are provided bimonthly within the LD AHP Forum. Within these sessions staff discuss the issues that they are experiencing using TOMs, peer support can be gained during these times and problem solving sessions carried out. Information gained at these times, from staff contributions and feedback, has been invaluable for the successful development of TOMs. TOMs features as a standing agenda item within profession specific practice development meetings. At these meetings a case will be presented and each group member will individually rate a TOMs. Each staff member’s scores are shared and then checked for interrater-reliability. As well as providing a valuable opportunity to support staff in using TOMs, this process also supports the consistency and quality of TOMs assessments and thereby increases the reliability of data available for TOMs. • Partnership Working with Corporate Services: A significant factor to the successful embedding of TOMs within LD AHP services was the collaborative working and support from Corporate Services. Information Services supported the design and ongoing development of TOMs documentation on to PARIS. This in turn enabled
the Health Informatics team to gather process and make available, TOMs data. The Performance Team not only supported TOMs becoming a CQUIN, but also supported the formal reporting of quarterly feedback to NHS Airedale, Bradford and Leeds. In the early stages of implementing TOMs within AHP services, time was spent with project management to explore and map the benefits of TOMs to a variety of stakeholders. This process requires the identification for how benefits will be realised, evidenced and monitored. As a result ideas and innovations, such as the Service User Outcome Report and the TOMs information leaflet, were identified.
Summary: Through the accessible information leaflet and the Service User Outcome Report, TOMs has enabled us to develop partnership working and greater transparency between service users, their carers and clinicians. TOMs has provided us with a framework to communicate and demonstrate the outcomes for the interventions that we provide with Service and Trust managers and people outside of the Trust, such as Commissioners, in an accessible and tangible way. TOMs has provided LD AHP clinicians with an outcome measure that is quick and simple to administer whilst still providing them with clear evidence and indicators for measuring and communicating the outcomes of their interventions with other non AHPs. No tool is perfect, but having the Therapy Outcome Measures tool embedded within our service has enabled us to clearly demonstrate the unique contribution of LD AHPs in improving the health and lives of people accessing our services.
I would like to take this opportunity to thank Claire Tiernan (clinical lead for OT), Marian Emly (clinical lead for Physiotherapy), Sue Warren (clinical lead for Dietetics) and Helen Jeffries (clinical lead for Speech & Language Therapy) as well as all the AHP staff working with the Learning Disabilities services for their ongoing energy and motivation to support the successful embedding of TOMs within our services. Lyndsey Charles Allied Health Professional Lead for Learning Disabilities Tel: 0113 3055947 E-mail: lyndsey-jayne.charles@nhs.net
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LADS:
Leeds Autism Diagnostic Service It’s estimated that 1 in 100 adults in the UK have an autism spectrum disorder (ASD), but over half have never been diagnosed. Traditionally, apart from some service users with LD, LYPFT service users have had to travel to the Sheffield Autism Clinic to be assessed, but now there is a new option in Leeds.
The service Based in Aire Court, LADS was set up in September 2011 to provide diagnostic assessments of ASD in adults. We are a multi-disciplinary team with members from both the Learning Disabilities and General Adult Mental Health Directorates, so we can assess people across the whole range of IQ and level of functioning. We accept referrals from any part of the Trust and primary care.
Assessment The assessment process has three steps: 1. Structured clinical interview using the autism diagnostic interview (ADI-R) or the adult Asperger assessment (AAA). It’s important the service user comes with a parent or carer so we can get a childhood developmental history. 2. Meeting with the multidisciplinary team, when diagnosis and recommendations are made. 3. Follow up appointment after a few weeks to answer any questions and signpost to additional services if needed. So far we have received 75 referrals. 27 service users have been through the whole assessment process, 23 of whom have been diagnosed with ASD.
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Feedback We use a Trust approved feedback questionnaire to get feedback from every service user. Feedback so far has been universally positive, with 100% of patients rating the service as ‘good’. A selection of representative comments is reproduced below:
• ‘The staff were very competent’ • ‘It has greatly improved our lives and I don’t know how I managed without this service’ • ‘For the first time ever someone recognised a problem and actually followed it up with some action’ •
(How could we make the service better) ‘If we had ongoing help and support following the diagnosis, maybe an online support group’
How to refer Any clinician within the trust can refer to us. The service user must be over 18. Referrals can be made on PARIS. Otherwise, send a referral letter to: Leeds Autism Diagnostic Service C/o Michaela Craggs medical secretary Aire Court Lingwell Grove LS10 4BS Conor Davidson specialty registrar (ST5) Tel: 01274 363839 E-mail: conor.davidson@nhs.net
The Life of an Incident Form
Why do we complete them? The Department of Health report “An Organisation with a Memory” (2000) highlighted the need for health care providers to develop systems that allow organisations to learn from failure and respond effectively to preventable patient safety incidents to stop them happening again. The LYPFT incident form, known as the IR1, enables initial incident data to be collected. This may lead to more in-depth information gathering using the 12 hour Fact Find, or a Root Cause Analysis Report highlighting possible latent and causational factors. In addition to gathering information for a single incident, a systematic review of IR1 forms submitted from a particular location or of a particular type of incident can be used to indicate clinical and non clinical practice. The Trust can then respond to any issues or problems identified, and develop
solutions that effectively improve safety and thereby improve the care provided. This article looks at the “life“ of an IR1 form, outlining the various stages through which it passes, how information is reviewed, and how lessons are learned and changes to practice implemented. So what happens to your completed IR1 form? Stage 1: Completion of the IR1 form Following an incident, the front page of the IR1 form is completed. This provides an historic account of the incident, identifies actions taken to immediately resolve the event and the immediate plans developed to reduce the risk of it occurring again. It is the first point of learning and changes in practice, as the person completing the form considers practice and the factors that led to the incident. This is known as “learning at point of reporting”. Stage 2: Review of the Clinical Team Manager The line manager, from the location where the incident occurred, reviews the completed front page to assess the incident and immediate actions taken, and considers: • If issues need to be carried forward to improve practice
Stage 1:
Stage 2:
Stage 3:
Completion of the IR1 incident form
Review by Team Manager
Submission to Risk Management Team
for the individual(s) involved, Stage 4: Review of trends
Stage 5: Action planning and lessons leaned
Stage 6 Embedding and sustaining change
Individual reflection when completing the initial stage of the incident form
Team Manager reviews incident, actions and trends
Review of Incident Form by Trust Leads
Directorate reports
Change to working processes and systems
Commence processes to embed change (short, medium and long term)
Formation of any lessons learned at individual level
Team Leader reviews for any local trends
Review by Leads for any trends and lessons learnt
Routine report submission into possible "incident hot spots"
Changes to Policy and Procedures
Continuous monitoring of service delivery
Formulation and actioning of immediate controls to reduce reoccurence
Formation of any lessons to be learnt: Local level
Formation of any lessons to be learnt: Local level
Bespoke reports for Directorates, Clinical Governance groups or individuals
Service Improvement aimed at the individual, local environment or Trust Wide
Link to previous mechanisms to aid learning
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• if there is a wider impact to the unit or department, • if there are any trends noted at a local level, • if the incident needs to be investigated further. As in stage one, learning occurs through the analysis of the IR1 form and local changes to systems and practice can be instigated. Stage 3: Submission to the Risk Management Team Following review by the line manager, the IR1 form is submitted to the Risk Management Department. Here each form is reviewed by a designated lead related to the type of incident which has occurred, such as Security, Resuscitation, Fire, Moving and Handling, Patient Safety, Health and Safety and Clinical Risk. These leads decide if additional clarification is required, and recommend supplementary follow-up actions where necessary. The paper IR1 form is then input onto the Trust’s electronic risk management database system, known as DATIX and the paper form is archived. Stage 4: Review of trends Using the electronic database, themes and trends can be identified and reviewed. These may relate to: Directorate review • Individual service users named within the IR1 • A particular location, such as a clinical area or Directorate • Incident type, such as falls, medication errors, self harm • Time of day or place where the incident occurred • Use of any keywords as part of a search criterion Based on forms submitted, each Directorate receives an individualised report on a monthly basis identifying trends and other relevant data. These reports are reviewed at Directorate Risk meetings, trends are noted, discussed and actions to reduce recurrence are formulated. Routine reports into incident types Individualised reports are submitted to lead groups to review a specific type of incident, such as falls, medication errors and security incidents.
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Spot checks of incident trends As part of the monitoring process, a bespoke report may be produced and analysed. For instance, if there appears to be an increase in a type of incident, or in the frequency of incidents involving a particular service user. There is close liaison with the clinical areas to ensure a complete picture is obtained. Stage 5: Action planning Through the review of trends highlighted within the reports, lessons are being learned at an individual and local level at all stages. Production of bespoke incident reports supports reviewing groups in formulating action plans to address incident ‘hot spots’ within a particular team, Directorate or Trustwide. Lessons learned can be linked to an individual’s practice, or to processes and systems in place and may be disseminated through a variety of ways: • • • • • • • •
Directorate Risk Forums Any of the Means Goals and their supporting groups Distributed via the Trustwide Safety Alert System QuESst Bulletin for a particular theme Distribution of lessons learned from all Committees through Risk Management External Alerts distributed electronically from the Risk Management Department and hard copies are sent to areas without electronic access Learning points and Alerts placed on the Staffnet site Information of incident data published on the Risk Management Staffnet page.
Changes to policy and practice In addition to informing learning, themes highlighted from IR1 forms are translated into practical procedures, and resulting actions are implemented at the appropriate level. These practical changes are prioritised, to provide a clear agenda for action. The LYPFT clinical governance structure is a vital tool in ensuring that information on change is both disseminated and acted on. Where there is an action resulting in consultation in policy,
local working practice and local generated measures, then a lead is identified to review policy and ensure findings from incidents, working practices and National guidance are all taken into consideration. This ensures that the most up to date information available for staff to follow.
• • •
Introduction of a new policy/procedure/ practice. Insertion of a lesson learned into other ongoing LYPFT initiatives (Transformation and Service Reconfigeraton). Amendments and agreed working practices at the interface point with partnership organisations.
Stage 6: Embed and sustain changes The resulting actions to implement and apply improvements on the ground are an essential part of the learning process. Lessons can be ‘learned’ on one level, in that there is a strong awareness of what needs to change and why, but if there are barriers in place to the application of that learning in practice, then the active learning process will fail. Within the embedding and the sustaining of change, LYPFT outlines the process in which the implemented changes will be embedded and monitored. This is either through routine reports, formal or informal, or through external reporting. Monitoring and evaluation of service delivery Continuous monitoring of changes and improvements in practice are an essential part of ongoing learning and improvement. All the evidence suggests that the latter stages in this learning process are critical in ensuring that organisational behaviour is actually changed as a result of the lessons drawn from adverse incidents, and that true ‘learning’ requires more than just the identification of valid lessons. Review of current mechanism to aid learning As illustrated, following the instigation of an IR1 form, LYPFT has a number of processes in place to inform the individuals, teams and Trustwide of lessons to be learned. These are based around: • Information giving (raising awareness, changes in practice) • Changes in systems in which people operate • Integration into mandatory training • Highlighting within individuals clinical and/or managerial supervision
Conclusion The IR1 incident reporting form is the foundation stone of incident reporting. This process is a fundamental tool of Risk Management, the aim of which is to collect information about adverse incidents, including near misses, ill health and hazards, which will help to facilitate wider organisational learning. If the reporting of incidents is not properly managed or documented, a false picture of practice across the Trust may be created and a limitation set on the lessons learned, ultimately this may lead to potential harm to service users and staff. The open reporting of incidents though the IR1 incident reporting system (including near misses and ‘errors’) is positively encouraged by the Trust, as an opportunity to learn and to improve safety, systems and services.
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Top Tips for Completing IR1 Forms 1. Write forms clearly, using black pen and capital letters. 2. Complete all sections. 3. Always write the full name of people involved in incidents – NO INITIALS. Remember IR1 forms are confidential. 4. Please include the PATIENT number to prevent any confusion between service users with the same/similar names. 5. Always give the roles of people involved, e.g. are they members of staff, service users, or visitors? 6. Please ensure that a service area where the incident has occurred has been clearly identified. 7. Use extra sheets for descriptions if necessary, do not use another IR1 form. 8. Spelling is important especially with medical terms and medication. 9. Clearly identify whether members of staff are Trust employees, bank or agency staff. 10. Complete a form for all those directly affected by the incident, especially if they have been injured. 11. Do not use abbreviations unless they are ones easily recognised by others. 12. Ensure forms are sent to the clinical service manager/relevant manager for
the reverse of the IR1 form to be completed before it is sent to the Risk Management Department.
13. If an incident is RIDDOR reportable, the RIDDOR form should be attached to the IR1 form. If this is not available, the RIDDOR reference number should be given. 14. Staple ALL additional pages (witness statements, restraint forms, etc) to the IR1 form. 15. Send all forms to the Risk Management Department in sealed envelopes. Gareth Flanders Patient Safety Manager Email: Gareth.flanders@nhs.net Telephone: 0113 2952382
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Helena Skorski Risk Management Information Officer Email: Helena.skorski@nhs.net Telephone: 0113 2952450
What’s Your Goal? Campaigning to Improve Health and Lives Our 2012 What’s Your Goal? campaign is all about reducing mental health stigma by getting people talking. We have over 14,000 members of our NHS Trust and we have a duty to both encourage new people to join and engage with people who already have done so. We’re continually searching for ways to make our member recruitment meaningful by influencing attitudes and behaviours of people we come in contact with. We hope that by getting people talking, we will improve the experience and outcomes of people using our services, by making our community a better place to live in. It’s really that simple. An annual campaign enables us to find fresh ways to get people thinking, talking and coming together. What’s your Goal? is inspired by the Olympic and Paralympic Games. We know everyone’s going to be talking about them and we want to help people make the connections between setting aspirations/goals and sporting achievement with positive mental health and wellbeing. So what ideas underpin our campaign? There’s quite a bit of evidence that setting goals is good for our wellbeing. Writing down a goal means we’re much more likely to achieve it. Achieving a goal is good for our self-esteem. Looking after our physical health is good for our mental health. Exercise has positive benefits for people experiencing mental distress. Lastly, coming together to work towards a common goal is good for all of us. We hope to raise awareness by sharing information, stories and directing people to local resources. We are organising and participating in lots of events throughout the year where we’ll encourage people to set a personal goal. We’ll be asking people to represent their goal on a piece of bunting. We’ll then connect all the individual bunting-goals into one enormous (hopefully!) Guinness World Record breaking piece of bunting. We love the idea that each individual goal will be an integral part of an overall goal – bringing lots of different people at different events together for a common purpose.
And we hope to recruit some members along the way, so we can continue to engage local people with our campaigns and increase their influence in the future direction of our NHS Trust. Our Trust strategy has recovery principles at its core – hope and optimism for the future and enabling people to set their own goals and take control of their lives. That’s why we also want to support people who use our services to set their own goal and participate in our Guinness World Record attempt. The campaign is organised by our communication and engagement team. We’re so keen that we’re all setting goals for ourselves to raise money for physical exercise equipment for people who use our services. We’ll be doing this through a sponsored run, zumbathon, football tournament, sponsored walks and cycle. Who knows what else we’ll cook up during the year. If you want to get involved then we’d love to hear from you. All money raised will go to healthy living equipment for people using our services to help them become more physically active. Earlier in the year, Keith Woodhouse, (one of our nonexecutive directors) set himself a massive goal to undertake a sponsored climb up the highest mountain in the Americas. You can find his blog on the campaign section of our website: www.leedsandyorkpft.nhs.uk. We’re recruiting volunteers to visit groups, and other spaces where people who use our services congregate, to talk about the campaign and help them set goals. If you’d like us to organise a session with your service then please do get in touch. If you’d like to find out more about the campaign, get involved either individually or as a service, we’d love to hear from you. Please contact Fran at fran.limbert@nhs.net
Here’s a link to more campaign information and a regular blog on our website http:// www.leedspft.nhs.uk/campaigns Victoria Betton associate director - Partnerships Tel: 0113 3055926 E-mail: victoria.betton@nhs.net
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Health Records Audit: Project 054 Cycle 2 The Health Records Audit (Project 054) based on the Health Records Policy (IG002) is currently in progress across services within the former Leeds NHS Partnerships Foundation Trust. The aim of this audit was to establish adherence with national professional standards and Trust guidelines/policies relating to the practice of clinicians working within the Trust. The results will be used to improve practice at a local level by individual teams and at directorate level. By improving the quality of health records the impact is safer and consistent
care, maximising the likelihood of preferred outcomes being achieved for the service user. Clinicians across all four Directorates were involved in the data collection, with every team in all services returning a locally agreed sample. The Clinical Audit Support Team would like to say a special thank you to everyone for their hard work in connection with the Trustwide Record Keeping Audit. This was the second cycle of audit activity for this project, which has been identified as a priority project on the five year rolling Trust Annual Audit Plan. The total number of returns this year was greater than the first previous cycle; this was due to the involvement of more services within the Directorates. The returns were as follows:
2011 Returns
2010 Returns
Adult Mental Health Directorate
741
732
Older People’s Services Directorate
423
453
Learning Disability Services Directorate
241
224
Specialist Services Directorate
292
272
1697
1681
Total
The Trust total returns of 1697 forms across all teams and services are an increase of the total number of returns in 2010.
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In February 2012, each Directorate received a Directorate report of their findings, along with a copy of the Trustwide Report. These reports included the findings from the previous cycle alongside the findings from the current cycle to illustrate previous and current adherence.
From the re-audit, the following areas were identified as priority action plan topics based on the frequency of occurrence in action plans. These areas saw an improvement to clinical practice:
What was identified:
What was planned (example actions from 2010)
First Priority Action
Service User identified on each sheet
• Discuss the findings and raise more attention to this issue: • [To] check in supervision • Staff to attach a patient ID sticker to each page of the assessment, these are freely available from patient notes [and] where no stickers available staff to write ID on each page.
An improvement of adherence to 66% Trustwide in paper entries (previously 46% adherence)
Second Priority Action
Service User consent to disclose information
• [Service] to develop new front sheet for records which highlights consent to disclose: • To consult with other services and look at form being used by the Trust • Remind staff of the consent to share information section in the admission documentation. If unable to consent on admission, to be revisited within one week of admission as part of the care plan.
An improvement of adherence in both paper (56%) and PARIS (43%) entries (previously 42% in paper and 31% in PARIS entries)
Third Priority Action
Identifiable signatures
• Discuss the findings and raise more attention to this issue: • [To] check in supervision • Inform team of this criterion and remind them to write their name and designation under signatures.
An improvement of adherence to 66% Trustwide in paper entries (previously 43% adherence)
Priority Action
Local summary reports were developed for each team involved in the data collection; a total number of 84 local reports were generated. The findings were then sent to the clinical team manager of each service to circulate the findings amongst colleagues and develop an MDT action plan based on any issues raised. Once received by CAST, these will then be sent to a nominated lead within each Directorate to review, agree and to support local actions to enable an improvement in record keeping across all of the clinical areas of the Trust. If you would like to request a copy of the report from your service, please contact Calei Smith (contact details on right).
The Result
Thanks to your input we have nearly completed a second successful cycle of audit activity, and plans are underway for the re-audit in September 2012, which will also include all services across York and North Yorkshire. The third cycle will be revised again, and will require extensive consultation and support from clinicians across the entire Leeds & York Partnership NHS Foundation Trust. Calei Smith, Clinical Audit Facilitator Email: calei.smith@nhs.net Tel: 0113 30 58263
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Clozapine:
Medication & Patient Counselling:
The Facts
What is Clozapine? Clozapine is an atypical antipsychotic, licensed for use in treatment resistant-schizophrenia and in schizophrenic patients who have severe, untreatable neurological adverse reactions to other antipsychotic agents, including atypical antipsychotics. What needs to be done before prescribing clozapine? Patients, their consultant, and the supplying pharmacy must be registered with the relevant monitoring service BEFORE starting clozapine treatment. There are three brands of Clozapine (Clozaril, Denzapine and Zaponex) and each has its own monitoring service. LYPFT mainly use the Clozaril brand of tablets. Any patients requiring a liquid formulation require the Denzapine brand. A recent FBC (full blood count) is required to register a patient with the relevant monitoring service. What monitoring needs to be done? FBCs are checked weekly, fortnightly or monthly to monitor for agranulocytosis. Without these results, Clozapine cannot be supplied beyond a set time period. Whilst initiating and increasing the dose of Clozapine, physical monitoring including pulse, temperature and BP should be checked regularly to monitor for potential cardiac side effects of Clozapine. Clozapine plasma levels can be taken to monitor compliance and assist prescribers in deciding if the patient is receiving an appropriate dose. Blood samples for plasma levels should be taken 12 hours after the last evening dose and before any morning dose is administered (it may be necessary to delay the morning dose to ensure the blood sample is taken at the correct time). Why is smoking status significant for patients taking Clozapine? Smoking increases the rate of metabolism of Clozapine. If a patient taking Clozapine changes their smoking habit it is important the prescriber is made aware of this immediately
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How Pharmacy can help as the Clozapine dose may need to be amended (stopping smoking can cause toxic levels of Clozapine, and starting smoking can reduce the clozapine level) What are the important side effects to be aware of when taking Clozapine? Weight gain is a common side effect of Clozapine. It is important that a patient’s weight is monitored regularly whilst they are treated with Clozapine and that they are advised about healthy lifestyle choices Hypersalivation is a common side effect of Clozapine. This may cause distress to the patient, but is routinely managed by antimuscarinic medication such as hyoscine hydrobromide tablets (which should be sucked or chewed). Please encourage patients to discuss such side effects with their prescriber. Constipation can be a potentially fatal side effect of Clozapine. It is important that any reports of constipation are brought to the attention of the prescriber and appropriate treatment is promptly initiated. How is Clozapine supplied to patients in community? Clozapine is classified as a ‘Red Drug’ on the Leeds Health Pathways, and is therefore NOT available from GP’s and community pharmacies in Leeds. When discharging a patient, arrangements should be made before the day of discharge to confirm where Clozapine blood tests and medication will be supplied after discharge. Please contact your nearest LYPFT pharmacy if you need any further guidance or advice about the use of Clozapine. Newsam Pharmacy Becklin Pharmacy The Mount Pharmacy St Mary’s Pharmacy York Pharmacy under construction Sam Taylor Specialist Clinical Pharmacist E-mail: samantha.taylor1@nhs.net Tel: 0113 3056782
0113 30 56320 0113 30 56782 0113 30 55531 0113 30 55513
Medication is often the optimum treatment for many disorders; however it has been estimated, that overall compliance with medicines is around 50%. Patient counselling is a primary duty for pharmacy staff (both hospital and community based). Counselling is a two-way interactive communication process, where participants are invited to seek further information. Over the years many terms have been adopted in an attempt to significantly improve patient’s compliance to medication, some of which are described below. Compliance The term ‘compliance’ has been defined as ‘the extent to which the patient follows the doctor’s instructions’. This approach does not recognise the patient as an active subject in managing his/ her own condition. Concordance The most recent model of interaction between health professionals and patients is referred to as concordance. It is based on the notion that the pharmacist and patient interact as equals, hence allowing for a therapeutic alliance between them. A concordant approach supports the patient to construct his/ her own knowledge of attitudes towards the use of their medication. What can pharmacists offer? Pharmacy staff within LYPFT form a crucial role in patient counselling and their aim in this process is to ensure the patient: • Understands why medication is helpful to maintain or promote well-being • Accepts the support from pharmacy in establishing a working relationship and foundation for continual interaction and consultation • Is able to make appropriate medication-related decisions concerning his/her medication regimen • Is able to improve or enhance strategies to manage medication side-effects and drug interactions. The process of patient counselling is essential in all aspects of patient care, but in mental health this service can be crucial. The LYPFT pharmacy department always endeavour to ensure that:
• Every patient leaves hospital knowing what their medication is for and how to take it • Any counselling received by a patient leads to a positive behaviour by which the patient is motivated to adhere to their medication • Every patient becomes more informed and an active participant in their disease treatment/management and self-care • Every patient if suitable is provided with both verbal and written information to achieve better outcomes of patient counselling. The pharmacy department in conjunction with other healthcare professionals wish to assist patients in achieving a desirable concordant end-point. Therefore please feel free to refer any patient on to us for advice about their medication. Patients can also obtain information on their medication at the following web address www.choiceandmedication.org.uk The LYPFT pharmacy departments can be contacted Monday – Friday (9am – 5pm) on the telephone numbers listed. Becklin Centre 0113 - 3056780 The Mount 0113 - 3055530 Newsam Centre 0113 - 3056319 St. Marys Hospital 0113 - 3055153 York Pharmacy under construction References 1. Counselling, Concordance and communication – Innovative Education for Pharmacists – (2005). International pharmacy Federation 2. Blenkinsopp A, Parton R, Anderson C (2000) – Health Promotion for pharmacists, Oxford University Press 2nd Ed 3. Marinker M (1997). From Compliance to Concordance. Achieving Shared Goals in Medicine Taking. Royal Pharmaceutical Society and Merk Sharpe & Dohme 4. Raynor DK, Savage I, Knapp P, Henley J, - We are the experts: People with Asthma Talk about their Medication Information Needs 2004;53:167-174 Caroline Dada - Lead Pharmacist (Medicine Risk Management), Tel: 0113 30 56474 Email: caroline.dada@nhs.net
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Dates
for the Diary 2012 A calendar of events is now available at the bottom of the Staffnet homepage. It is easy to add details of events you are organising – just click calendar of events, click new item, add the detail to the proforma, save and close. Details of how to book a place are on Staffnet too. A reservation form and study leave form must be completed, authorised and submitted before a place can be reserved. Some examples are given below:
Jun 12 Thursday
14
Monday Thursday Tuesday
18 21 26
Nursing 2012: Care and Compassion Fourth Annual Mental Health and Learning Disabilities Conference Essentials: Human Rights-Implications for Clinical Practice Clinical Audit Essentials: Dementia and End of Life Care
Jul 12 Wednesday Friday Wednesday
4 6 18
Aspergers Awareness Training Essentials: Sleep Disorders and Mental Health Critical Appraisal Training
3 20
Safeguarding Adults Awareness Training Hand Hygiene (Clinical)
10
CBT for Depression: A Skills Based Workshop
Aug 12 Friday Monday Sep 12 Monday
The above is a snapshot of the learning opportunities and training & development courses available. More information can be found in the calendar of events on Staffnet, Andrew Sims Centre website or by contacting the Development Team. Details of how to book a place are on Staffnet. A reservation form and study leave form must be completed, authorised and submitted before a place can be reserved.
Your Feedback QuESt is your newsletter for sharing and learning about good practice focused on clinical quality. Please send your ideas, suggestions or articles to Gina White, Head of Quality, Medical Directorate, Trust Headquarters, Thorpe Park or ( 0113 30 55980 or 7 gina.white@nhs.net
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Next Edition The deadline for articles for the next edition is Wednesday 27 June 2012.