Clinical Governance Report Quality Accounts for 2015 Year

Wordle from patient and family comment cards 2014

Teresa Read & Wendy WalkerQuality

April 2016

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Contents1 Executive Summary........................................................................................4

2 Service Improvement:.....................................................................................52.1 The Hospice Strategic Plan 2012-2015...............................................5

2.2 Service Activity........................................................................................6

3 Learning and Sharing Environment..............................................................73.1 Leading in Quality.......................................................................................7

3.2 Te Kete Marie/Caring for People with Dementia.........................................7

3.3 Pressure injuries.........................................................................................7

3.4 Incident Management/Reportable Events...................................................83.4.1 Medication Incidents:...........................................................................................9

3.4.2 Falls incidents....................................................................................................103.4.3 Recommendations for 2016:.......................................................................11

4 Patient/Whānau and Public Community Involvement.............................11

4.1 Consumer involvement.............................................................................11

4.2 Comment Cards:....................................................................................12

4.3 Cultural Consumer Perspective Summary................................................12

4.4 Consumer Rights...................................................................................13

4.5 Consumer Satisfaction Surveys..........................................................13

Patient Satisfaction Survey...............................................................................13

Family Satisfaction Survey – In Patient Unit......................................................14

5 Clinical Effectiveness and Audit..................................................................15

5.1 External audit results...........................................................................15

6 Risk Management and Patient Safety........................................................15

6.1 Risk Register..........................................................................................15

6.2 Health & Safety Education provided.........................................................15

6.3 Restraint...................................................................................................15

6.4 Infection Control and Prevention...............................................................16

7 Conclusion.......................................................................................................17

8 Appendices........................................................................................................18

8.1 Mary Potter Hospice Clinical Governance Framework.............................18

8.2 What have we achieved during 2015?......................................................19

8.3 What we will do during the next 12 months (2016):..................................22

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1 Executive Summary The Vision of Mary Potter Hospice is:

that people in our community who need palliative care have access to compassionate and quality care, when and where they need it.

The quality systems and frameworks at Mary Potter Hospice seek to evaluate and validate the quality of care we provide to patients and their families and whanau.

“Clinical governance is a system through which [healthcare]… organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish1”. This report provides an overview of the clinical governance activities for 2015. Purpose of this report:

To provide an overview of annual trends in quality and safety across the Hospice

To offer insights that guide efforts to improve care received by people To highlight variations in care and outcomes and to provide commentary on

the findings, so that staff can use the data to guide improvement To report on the progress of key initiatives of the Hospice identified in 2013

report that address quality and safety issue To provide evidence and accountability regarding the quality of the

Hospice’s performance.

Key Outcomes 2015

During 2015, two external audit of Hospice services occurred and findings validate the quality of services:

Hospice New Zealand external peer review

'The peer mentors felt that Mary Potter Hospice should feel deservedly proud of the service they offer to those within their region. There is an accepted and expected culture of quality within the executive team which permeates throughout the organisation – all the while keeping the patient/family/whānau at the centre of any discussions and innovations'.

Central TAS external audit against CCDHB contract

There was evidence from governance through to service delivery of MPHs commitment to continuous quality improvement and the achievementof quality goals; it was evident in the review of key documents that the quality programme is based on the principle of continuous quality improvement, clinical excellence and organisational focus. These principles

1 Scally G & Donaldson L (1998) Clinical governance and the drive for quality improvement in the new NHS in England. BMJ, pp61-65

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are implemented through the core functions of the MPH which were stated as clinical services, support, education services and funding, marketing and communication'.

Copies of both reports are available upon request.All Hospice staff are involved in quality activities across all teams. We would like to acknowledge the teams for their contribution to this report and the audit and policy processes in the organisation.

Feedback regarding this report can be directed to:Teresa.read@marypotter.org.nz

2 Service Improvement: Appendix 1 provides an outline of the Hospice’s Clinical Governance framework together with achievements in Quality during 2015.

2.1 The Hospice Strategic Plan 2012-2015

The Hospice Strategic Plan 2012-2015 (‘Towards 2026’)focuses on creating a sustainable future for the Hospice with a focus on increasing access to care in the community for those with palliative care need. During 2014, work continued to focus on the three strategic projects:

Project Achievements 2015

Enhanced Community Service model

Development of business case for Hospice New Zealand Innovative Funding Proposal to enhance services in primary and aged residential care.

Appointment of Day Hospice Manager April 2015

Development of community services structure to supported expansion of services.

Education and Training review

Development of a new online registration system for Education services

Publication of Education report 2015 synopsizing education activities during the year

Development of Compassionate Communities project linking clinical and education services work in the community.

Participation on the working group to implement the newly approved guidelines for last days of life (Te Ara Whakapiri)

Establishing an annual symposium to focus on a specific aspect of palliative care

Facilities Review Service Facilities exploration of; the Kapiti service, Porirua community hub, and the IPU unit – short and longer term.

Future demand modeling for IPU bed demand completed and design options for IPU reconfiguration commenced

Commercial development analysis and funding options advanced

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2.2 Service ActivityMeasuring and evaluating our data and quality activities enables us to validate that patients are receiving adequate care, that our current service model is improving care, and to compare outcomes2. *Source of data: Palcare patient electronic database.

0300600900

Service Activity (per financial year)

2012-20132013-20142014-2015

The number of referrals to the service has increased by 12% from 2012 (10% increase in 2014 year).

Total number of accepted referrals has increased by 27% from 2012 (from 573 to 725 patients)

The median ALOS (average length of stay)has increased by 3 days only so is pretty static. We want to see this increase as access to services is improved.

The total number of inpatient admissions has been reasonably stable but the average length of stay has decreased, showing overall increased activity in the IPU.

2 Casarett DJ, Teno J and Higginson I, (2006) How should nations measure the quality of end-of-life care for older adults? Recommendations for an international minimum data set. Journal of the American Geriatrics Society, Vol. 54, No. 11, 11.2006, p. 1765 - 1771.

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Home Hospice Hospital Other Residential Aged Care

020406080

100120140160180200

Place of Death (per financial year)

Axis Title

The majority of Hospice patients die in the Hospice There was a 9% reduction in number of deaths, despite an increase in

referrals. A decrease in the number of deaths in residential aged care is noted.

Work for 2016 includes analysis of place of death data to determine resources, and factors that contribute to home deaths or death in preferred place of choice.

3 Learning and Sharing Environment3.1 Leading in Quality

The 2015 CCDHB external audit acknowledged that

There was evidence from governance through to service delivery of MPHs commitment to continuous quality improvement and the achievement of quality goals; it was evident in the review of key documents that the quality programme is based on the principle of continuous quality improvement, clinical excellence and organisational focus. These principles are implemented through the core functions of the MPH which were stated as clinical services, support, education services and funding, marketing and communication.

MPH has a robust QMS in place. Quality management and improvement was led by the quality manager and supported by the CEO, Director of Palliative Care and the PAG and evidenced a strong commitment to quality improvement within the delivery of the service for MPH which is embedded throughput the whole organisation.

3.2 Te Kete Marie/Caring for People with Dementia

The Hospice has identified that it is caring for increasing numbers of people with dementia or an identified delirium in the In-Patient Unit that can be challenging for staff. During 2014, development of a tool for the Hospice setting ‘Te Kete

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Marie’ – ‘The Peaceful Basket’ occurred. It includes a toolkit of activities for use with patients

‘This is me Booklet’ That patients and Carers encouraged to complete, to help provide individualised care and knowledge about the patient

Reality orientation material Written resources for patients and families and staff resources

During 2015, two journal articles related to the project were submitted to international journals for publication.

further work included refinement of actviities in 'Te Kete Marie' an update of core care plan guidelines to guide assessment and best

practice. external and internal education provided.

3.3 Pressure injuries “…the multiple pathologies of those receiving palliative care and the complex aetiology…may mean that some pressure injuries are not preventable.”

Stephen-Haynes, J. (2012). International Journal of Palliative Care, 18(1). 9-16.

During 2015 the key focus for pressure injury prevention and management within the inpatient unit has been to continue to reinforce the adapted SKINS bundle approach to care, in alignment with the expectation and recommendations of the International Guidelines (2014).

Achievements 2015

A retrospective annual audit showed significant achievement in all key performance indicators for pressure injury management with a 100 percent compliance in four key pressure area prevention and management areas

Health Care Assistant core competency skill framework

introduced and 8 IPU HCAS have achieved their Pressure Injury prevention and management core competency

Staff workshop: “Principles of Pressure Injury Prevention using the SKINS care bundle approach”

This year’s International STOP pressure Injury Day was recognised throughout the week incorporating visits to the Kapiti and Porirua community bases to provide education and information packs for the wider team. Implementation of “LOVE your IPU SKINS” moto.

New Bedside signage was launched – in response to IPU nursing suggestions to involve patients and families in pressure injury prevention and management as per International Guideline (2014) recommendations.

A consumer education stand was in place in the IPU on STOP PI Day and large posters were made and displayed throughout the inpatient and community bases.

Presenter – New Zealand Wound Care Society (NZWCS) Conference

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Draw and Winner of the “LOVE your IPU SKINS” competition

Team hands on education and awareness regarding pressure injury care for the bariatric patient.

3.4 Incident Management/Reportable Events

Incident forms were refined during 2015 for identified high risk areas of medications, falls and pressure injuries to increase monitoring and risk analysis of level of patient harm.

Development of a case review process and system for all complaints and serious incidents has led to increased analysis and review of incidents linked to complaints.

Further analysis of all incidents reported in 2015 includes a comparative analysis with 2013 data as set out below:

Fall

Fall -

near m

iss

Medica

tion

Notification

Family

mem

ber injury

Patien

t Injury

Proced

ural Er

ror

Hazard

s

Pressure

Area - p

re ad

mission

Pressure

areas

in IPU

Equipmen

t

Staff In

jury0

50

100

150

200

250

300

Clinical Incidents

Tota

l Inc

iden

ts

NB: See table below for comments related to medication incidents

Clinical incidents 2015 (1 Jan 2015- 31 Dec 2015)

Top 3 Clinical Incidents:

2015 (n=490)

% difference from 2014

Comments

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NEW bi-weekly checks of drug charts increased procedural errors reported. Level of harm decreased

Medications 246 ↓1% In 2014 increased surveillance though level of harm decreased

Falls 69 ↓3% Introduction of increased risk assessment, education and surveillance has significantly reduced Falls incidents.

Pressure injury pre-admission

49 ↑23 % The majority of these incidents were low grade pressure injuries. Practice changes during 2014 and 2015 have led to increased surveillance and subsequent reporting.

The total number of clinical incidents decreased by 2% in 2015 despite increased surveillance of the category Pressure injuries that resulted in increased incident reporting. *Includes total of Critical, Serious, Significant and Procedural error

3.4.1 Medication Incidents:

Medication incident data is reviewed by the Medication Committee with root-cause analysis occurring with all ‘Critical’ and ‘Serious’ errors. The focus for analysis of medication errors has been on those two areas where there is the potential for patient harm (‘Critical’ and ‘Serious’) error. Systems review and/or professional development for the staff involved occurs with these errors.

A significant error is one with potential harm for the patient, particularly if not picked up and compounded by another error. Serious and critical errors are reported quarterly at the Board level. Analysis of errors in these categories led to increased training for nursing staff, review of medication, in particular IV line assessments on admission to IPU and also led to improvements in handover between the hospital and hospice teams.

Reporting of medication incidents continues to be boosted with pharmacist input into reviewing charts. The bulk of procedural errors being reported

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include medications not signed for when administered, and medical lapses in signing, dating, or omitting specimen signatures for the drug chart.

All nurses complete an annual medication questionnaire. Work during 2015 also included a review and update of the medication

audit tool, introduction of a new tool for documenting procedural incidents and development of a controlled drug audit.

3.4.2 Falls incidentsFalls are one of the top two incidents at Mary Potter Hospice with Hospice patients being especially at risk of Falls.

There was an impressive 48% reduction in fall incidents as reported in 2014 and the rate continues to decline. Falls incident data reports show 69 patient falls last year, with a decreased rate of 3% from last year. However, there is a 2% decrease in the number occupied bed-days from 2014, which means the results are on par with 2014.

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec0

5

10

15

20

25

Fall Incidents 2013 -2015

Axis Title

It is worth noting that the majority of falls result in ‘no injury’. During 2015, through the Falls working group and staff engagement the following initiatives have occurred: Falls incident form reviewed and updated enabling increased analysis of risk

and environmental factors surrounding Falls

Annual audit of all Falls Acknowledgement and publication of Mary Potter

Hospice initiatives in the Health, Safety and Quality Commission newsletter

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3.4.3 Recommendations for 2016:

Further analysis of data during 2015 through revised incident forms for medications and falls

Retrospective review of all patient injuries and incidence of skin tears on IPU Development of a data management system through the IT strategy to

increase monitoring and enable increased analysis of data trends

4 Patient/Whānau and Public Community Involvement

4.1 Consumer involvement

“...transition must be seen to be much more than just the referral process between organisations but as the individual’s passage through one set of hopes and expectations to another”

The Consumer and Community Engagement project continues with four workstreams:

1. Patient & family experience interviews (completed)2. Public awareness - conversations and listening event (events planning and

engagement) 3. Research and Resource: Literature and other models in practice4. Community Engagement framework design

A work plan outlines the levels of consumer, carer and community engagement within the organisation.

Two consumer experience studies completed: one for bereaved carers of patients with Dementia and one for 'patients experience of admission to IPU and Community'

4.2 Comment Cards:During 2015, the Hospice comment cards provided additional feedback from consumers in addition to surveys. The comment cards ask two simple questions:

List two things that we did well List two things we could do better

The feedback is presented in a wordle below.

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4.3 Cultural Consumer Perspective Summary

Findings from the external audit report:

MPH delivered services in a culturally appropriate and responsive manner. This was supported by the organisation’s cultural policies and procedures. Patients were provided with information regarding other Māori health services that were available and cultural needs and preference were identified on admission and incorporated into the care planning process. Support for consumers of other cultures could be accessed if requested. MPH had a Māori Advisory/liaison who worked with Māori patients both in the community and in the IPU providing cultural support, education and supervision for staff as well as staff received cultural training.Implemented processes and feedback from patients interviewed, confirmed that consumer’s rights were upheld and that staff were aware of and respected their values and beliefs. Satisfaction surveys and patients interviews confirmed that a high level of satisfaction with the services provided.

4.4 Consumer RightsAn audit of all 2015 complaints showed 100% compliance to policy. External audit included consumer interviews and findings showed that consumers interviewed reported that they were aware of and informed of their rights and satisfied that that they had received services consistent with the Code of Health and Disability Services Consumers’Rights. They were aware of their right to advocacy support and how to make a complaint and felt comfortable doing so if needed.

Information available to patients and their family/whānau included: the Code of Health and Disability Services Consumers’ Rights

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Having a Problem with a Health or Disability Service and Information on Advocacy Services.

Health and Disability Commission’s learning from complaints- your rights. There was also information relating to Advanced Care Plans Care plans

that discussed ‘things to think about and plan for the end of life’ and the wishes of patients. These are signed by the patient as a record of their preferences that would only be used when the patient was unable to make decisions.

We have improved the current written information provided to consumers with the review and development of patient brochures during 2015.

Play-based intervention and resources for child and young person (CYP) visitors and their family/whanau member patients in the Mary Potter Hospice Inpatient Unit has been developed and enhanced during 2015.

4.5 Consumer Satisfaction Surveys

Patient Satisfaction Survey

The patient satisfaction survey is one of the key performance indicators of the Quality Performance Systems (QPS) Palliative Care framework currently being benchmarked across 27 hospices in NZ. The questionnaire was developed by hospice members. Hospice NZ commissioned research that tested the acceptability and usability of the satisfaction surveys with patients and their families and results were incorporated into the current tool. A selection of overall views (Inpatient Unit):

A very wonderful staff. Couldn’t do enough for me. The food is so good and lovely manageable portions. I think I put on

pounds and a blood transfusion was averted. Above expectations – your volunteers are also special people to give their

time to help. I was very dubious to go there but now hope to come back sometime.

Many thanks to all.

A selection of overall views (Community Care:

A very wonderful staff. Couldn’t do enough for me. They are always there for you. The staff, the patience, awareness, caring nature and nothing is too much

trouble. Help with managing my medication. The consistent caring supportive attitude from all staff. Responsiveness – frequent contact to establish how well we were doing.

Staff so caring. It was a big step to come to the hospice but I am glad we did. The service

and help I received has made a huge difference.

Family Satisfaction Survey – In Patient UnitNumber of patients surveyed: All discharged patients from IPU

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Responses: 27

1. Care Received...

2. Support Serv...

3. Spirituality / ...

4. Information ...

5. Your Relativ...

6. The Facility

7. Overall V

iews...

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Family Satisfaction Survey Inpatients - Section Results - Total % Score

Average Percentage S...

% S

core

Section / Category Results

Key findings:

The results of the survey provide an overall satisfaction rate was 99.26%. This correlates with 2014.

All categories scored highly.

Family/ Whānau comments received

What is the best thing about the service? All the staff and volunteers with brilliant. I am in awe of your team

and team work. Thank you. You made a very difficult and emotial station somthing that look back on with if not happiness then peace.

Kindness, calm, attentiveness; covered all aspects of care.

The staff we had contact with were wonderful. My mum had resisted earlier efforts to have her go to hospice but after being there she says she’s looking forward to going back.

The intimate, inclusive response and care by all members of the unit – one felt like a family member who was respected and trusted. Felt like a comforting home stay.

Is there anything about the service that could be improved? Perhaps a soft food diet.

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5 Clinical Effectiveness and Audit5.1 External audit results

6 Risk Management and Patient Safety 6.1 Risk RegisterThe risk register is reviewed and updated by the Executive Team six monthly and Board of Trustees annually. The new format increases the monitoring of risks. During 2015, the register included input with key groups at internal Hospice groups (e.g. Quality, Health and Safety committee, Team Leaders forum and the Medication Management committee). Health and Safety

Hazards related to the Newtown building (Inpatient unit) are reported and entered in the Hazard Register.

6.2 Health & Safety Education providedAnnual uptake of education has been excellent by staff on all training via the intranet. Bi-Annual Trial evacuations held.• Health & Safety Orientation Newtown, Porirua & Kapiti• Disasters overview• Armed Robbery• Restraint• De-escalation• ACC Safety Week

6.3 RestraintAll Clinical staff completed Restraint and De-escalation training in 2015.

6.4 Infection Control and Prevention

The Infection Control Programme (IC) at Mary Potter Hospice continues to focus on the three key areas of prevention, education and surveillance. Prevention

The Infection Control Advisory Group (ICAG) ensures the Hospice’s IC programme and annual plan are reviewed and implemented. Specific outcomes of this group have been:

improved monitoring of the IC programme goals and objectives revision of the Hospice IC policies and procedures increased focus on local, national and international IC issues improved implementation of the surveillance programme. Development of an IC Annual Plan to guide the monthly IC activities over

the year. Membership of the national Hospice infection control network which

provides support and guidance within the hospice context. Flu vaccination uptake in 2015 was 87 staff and 3 volunteers, an increase

on 2014 with 76 staff and 5 volunteers vaccinated.

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Education

Staff education was provided by the ICN at the MDT study days in August, with the focus on breaking the chain of infection and hand hygiene. The ICN also provided IC education at the volunteer orientation and annual update evenings, with the development of an IFC information leaflet to support volunteer understanding and practice.

A hand hygiene focus for a week was held in the month of May to coincide with world hand hygiene day. This was informed by Hand Hygiene NZ, the hospice IFC network, and CCDHB, and provided the impetus to refresh our posters in public and staff work spaces.

Surveillance

The Hospice ensures any investment in surveillance is matched by feedback, analysis and action. The surveillance programme is based on international surveillance definitions.

51 (23)

8(7)

1 (1)

2(0)

11(10) 3(0)

2(1)

3(1)1(0)

Pathogen Growth 2015: 31 pathogens (2014: 23)

Nil growthStaph AKlebsiellaPseu-domonasE ColiESBLFungalL ProteusFlu

Reports and results are reviewed by a committee that includes medical review. One third of the total specimens grew pathogens, the main one being E Coli, followed by Staphylococcus Aureus. It appears that appropriate treatment was given for most of the specimens that grew pathogens, with some specimens that didn’t grow pathogens treated with antibiotics. Most infections appear to be acquired prior to admission to hospice with the specimen being taken on the day of admission to the IPU or soon after admission. There are still improvements to be made regarding the recording in Palcare of the specimens taken, and regarding the collation and analysis for useful information to be gained and recommendations to be made.

Monthly environmental audits were conducted according to the audit schedule, and any issues arising are followed up with the relevant staff, and reported to H&SICC and ICAG.

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7 ConclusionDuring 2015 significant work occurred, as demonstrated in this report, embedding clinical governance within the Hospice teams, systems and structures. The external audit review findings provided opportunities for further evaluation of services and also validated that a robust culture of quality improvement exists within Mary Potter Hospice.

Opportunities for Quality Improvement in 2016:The opportunities proposed in Appendix 9.3 promotes continuous quality improvement and will ensure that ‘quality’ is firmly embedded across the organisation. These opportunities will be supported by staff who are proud that Mary Potter Hospice provides a high quality service.

8 Appendices

8.1 Mary Potter Hospice Clinical Governance Framework

In 2013, the Hospice adapted the Clinical Governance Framework from the Health Service Executive, Ireland. The framework outlines the key elements of quality and clinical governance at Mary Potter Hospice.

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The above framework was adapted with permission from the Health Service Executive (HSE) Ireland: Framework for Integrated Quality, Safety and Risk management (4).

The framework also outlines the systems in place that make Clinical Governance happen:

Service Improvement: Identifying bottlenecks, reducing inefficiencies, monitoring service characteristics, strategic planning, quality assurance

Learning and Sharing environment: Learning from incident reviews, learning from patient experience, research and development

Patient/Whanau and Public Community Involvement: Patient information, Consumer advisory group, patient surveys, complaints feedback, and community partnerships

Clinical Effectiveness and Audit: Clinical guidelines, clinical audits, clinical KPIs, policies and procedures monitoring

Risk Management and Patient Safety: Complaints/ incidents, health and safety systems, risk management process

Staffing and Staff management: Staff planning (acuity), recruitment, orientation/induction, continuous professional development

This report is aligned with the Clinical Governance framework above.

8.2 What have we achieved during 2015?

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What we said we would do

Rating Evidence

Service Improvement

Hospice Strategic ProjectsAlign with current strategic projects and integrate national and regional service models/frameworks including the Managed Clinical Network.Develop team action plans and reporting frameworks

Achieved During 2015, workshops with the Leadership group and Executive Team led to revision of the Hospice Strategic Plan (draft).Further development of services also included an Innovative Funding Prosposl submission to the Ministry of Heath and Hospice NZ aligned with development of clinical services with a specific focus on ehnahncing services in primary care/community and aged residentail care services.Work with the Managed Clinical Network also continued.Annual team action plans and reporting frameworks were reviewed linked to the Hospice Startegic Plan

Develop Clinical Governance policy that links to Board of Trustees. Benchmark top three incidents with other HospicesReview incident management systems

Achieved DRaft policy completeBenchmarking occurs via QPS benchmarking programme(check how we compare)

Incident management system review completed and aligned with WHO and HSQC classification systems.

Quality Assurance Achieved External audit reviews of services in 2015 incuded a CCDHB audit against contract (see xx)Hospice NZ peer review visit 2015. See audit report in Appendix 1

Data managementImprove information and data management across services. Increased analysis of service activity and home deaths.

Achieved Enhancement of Palcare, the electronic patient record, occurred through the roll out of version 3 of the Palcare system leading to improved functionality of the system.Home death data was analysed and presented at PCNNZ conference.

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Recommendations linked to team action plan.

Learning and Sharing Environment

Consumer experience studyCommence consumer interviews, complete thematic analysis by October 2015 and present at conference.

Achieved Thematic analysis of research fidnings completed. Results presented at Palliative Care Australia conference 2015.

Research and DevelopmentPublish falls study. Maintain presence and participation at national and international conferences.

Clinical staff authored 9 research publications in national and international journals, delivered 9 conference presentations and 7 poster presentations at national and international conferences.

Joint appointment of a Research Fellow with the nursing school at Victoria University of Wellington.

Professional Development

Achieved A total of 25 (59%) Registered and Enrolled Hospice Nurses registered with the CCDHB Professional Development Recognition Programme (PDRP). This was a 100% increase from 2013.

Incident Management Achieved Development of systems to support increased monitoring, analysis and management of top three incidents.

Staff Satisfaction Survey Achieved High staff satisfaction demonstrated with a 12% increase from 2012 results to a score of 73%. This puts Mary Potter’s satisfaction score above the all-hospice benchmark

Patient/Whanau and Public Community Involvement

Increasing the participation of consumers to our service

Achieved The Hospice Consumer Group endorsed the new Enhanced Community Services model of care and contributed to the review of several patient brochures.Comment cards introduced to enhance feedback from consumers in addition to the patient and family satisfaction surveys.

Achieved A website committee was developed during 2014 and the website upgraded.

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Improving online information for patients and whanau.

A work plan is in place with work in hand expanding information online for consumers and the general public.

Publication of patient brochures online

Achieved Brochures published online include: Our Services

Acupressure in Palliative Care

Feet, Footwear and Falls

Falls prevention

Massage therapy

Counselling service

My funeral planning

Funeral directors

Biography Service

Living with less energy

Managing Breathlessness

Clinical Effectiveness and Audit:

Developing key performance clinical indicators that monitor quality and safety of care.

Partially achieved

The Hospice is working with Hospice NZ to develop national Hospice quality indicators.

Development of KPIs for falls and pressure injuries

Achieved Introduction of key indicator for ‘near miss’ falls

Introduction of key indicator for ‘pressure injury’ as part of pre-admission assessment to Inpatient Unit

Risk Management and Patient Safety:

Analysing our high risk areas such as medications and falls.

Achieved Working groups have developed systems and processes to ensure increased analysis and monitoring of high risk incidents

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occurs.

Staff education has embedded change and raised awareness.

Environmental health and safety audit of the Inpatient Unit

Falls risk assessment tools

Staffing and Staff management:

Organisational Development Strategy

Achieved Objective to build the capability of Hospice leaders through leadership development, strengthened change management skills, and an enhanced organisational culture. During 2014 the Hospice Leadership Group (N=15) completed a leadership programme that focused on:

Leading teams

Successful Change Processes, Resilience and Motivation

Leadership styles

Work styles

8.3 What we will do during the next 12 months (2016):What we will do How?

Service Improvement

Hospice Strategic Projects Align and implementation of current strategic projects and integration national and regional service models/frameworks

Clinical Governance Develop Clinical Governance policy that links to Board of Trustees. Benchmark top three incidents with other Hospices

Quality assurance Evaluation of new initiatives over last two years is a priority focus. Develop KPI's for services.

Data Management Improve information and data management across services. Increased analysis of service activity and home deaths.

Learning and Sharing environment

Consumer experience study Publication of consumer research

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Research and development Publish falls study. Maintain presence and participation at national and international conferences.

Professional development Clinical staff supported to complete online dementia training.

Incident Management Develop systems to enable increased analysis of cause, effect and risks related to incidents.

Patient/Whanau and Public Community involvement

Increasing the participation of consumers to our service

Develop Community engagement via Education service delivery and team action plans

Community Volunteers Develop community volunteer service

Clinical Effectiveness and audit

Death data Analyse place of death data

Developing key performance indicators that monitor quality and safety of care.

Develop clinical indicators and assessment tools

Risk Management and Patient Safety

Patient Safety Analyse degree of ‘patient harm’ caused by incidents and accidents.

Staffing and Staff Management

Organisational development strategy

Continue to build leadership capability

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