Patient Report Forms: Quality Management Procedure · Patient Report Forms: Quality Management...
Transcript of Patient Report Forms: Quality Management Procedure · Patient Report Forms: Quality Management...
Quality Management Procedure for Patient Report Forms Page: Page 1 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
Patient Report Forms:
Quality Management Procedure
Quality Management Procedure for Patient Report Forms Page: Page 2 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
Recommended by Executive Management Team
Approval date July 2015
Version number 2.2
Review date July 2017
Responsible Director Medical Director
Responsible Manager (Sponsor) Head of Clinical Quality
For use by All Trust employees
This policy is available in alternative formats on request.
Please contact the Senior Clinical Quality Manager
on 01204 498392
Quality Management Procedure for Patient Report Forms Page: Page 3 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
Change record form
Version Date of change Date of release Changed by Reason for change
2.0 October 2012 S Barnard
2.1 July 2013 M Peters Review
2.2 July 2015 M Peters Final
Quality Management Procedure for Patient Report Forms Page: Page 4 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
Quality Management Procedure for Patient Report Forms
1. Introduction ............................................................................................................................ 5
2 Purpose ................................................................................................................................... 5
3 Duties ...................................................................................................................................... 5
4. Scope ....................................................................................................................................... 6
5. PRF Quality Completion Standard ........................................................................................... 7
6. Reporting................................................................................................................................. 7
7 Quality Improvement and Action planning............................................................................. 8
8. Equality impact Assessment ................................................................................................... 8
9 Monitoring and Review of the Procedure .............................................................................. 8
Appendix 1: PRF Completion Standard Care Bundle .................................................................... 10
Appendix 2: Trust CPI Process Overview ...................................................................................... 11
Appendix 3: ................................................................................................................................... 12
Quality Improvement Process ....................................................................................................... 12
Quality Management Procedure for Patient Report Forms Page: Page 5 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
1. Introduction
1.1 Patient Report Form (PRF) completion is a legal requirement for the organisation and
the individuals; and constitutes a public record and legal document. The NHS code of
Practice (2006) states: ‘All individuals who work for an NHS organisation are
responsible for the any records which they create or use on the performance of their
duties. Furthermore, any record that an individual creates is a public record’.
1.2 The PRF may be called upon as evidence in a law court of a coroner’s inquiry and
therefore must be a full and contemporaneous record of the care given to the
patient.
2 Purpose
2.1 The purpose of this procedure is to ensure that the Trust has effective systems in
place to monitor and manage the quality of Patient Report Form (PRF) completion
across the organisation.
2.2 Appendix 2 provides an overview of the procedure in flow chart form.
3 Duties
3.1 The Chief Executive has overall statutory responsibility to ensure systems are in
place for the accurate completion of records; for all patients that are assessed and
treated by NWAS NHS Trust.
3.2 The Chief Executive of the Trust has delegated responsibility to the Trust’s Medical
Director who is responsible for ensuring effective systems are in place.
3.3 The Chief Consultant Paramedic has responsibility for ensuring there are systems in
place to monitor and manage the quality of PRF completion; including monitoring
and performance management of the process.
3.4 The Head of Clinical Quality is responsible for the development and implementation
of a system to monitor and manage the quality of PRF completion.
Quality Management Procedure for Patient Report Forms Page: Page 6 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
3.5 The Clinical Quality Manager and Clinical Quality Officer are responsible for
supporting local implementation and performance management of the procedure;
including the provision of advice and support in relation to quality improvement.
3.6 Advanced Paramedics and Service Delivery Management are responsible for the
local operational implementation of the procedure; ensuring the correct action is
undertaken within agreed timescales.
3.7 The Trust management have a responsibility to provide advice and support as
necessary regarding the procedure.
3.8 It is the responsibility of the Senior Paramedics to ensure that PRFs are collected and
audited as per the procedure; including supporting of local quality improvements.
3.9 It is the responsibility of all Trust personnel to ensure they follow and support this
procedure.
3.10 The Clinical Leadership Board is responsible for monitoring and reviewing the
implementation of the procedure.
3.11 The Trust Board and Executive Management Team are responsible for reviewing
reports received in relation to this procedure.
3.12 The Trust Clinical Governance Management Group is responsible for reviewing
reports received in relation to this procedure; including monitoring compliance with
the procedure.
3.13 The Emergency Service Clinical Quality Business Group is responsible for supporting
and monitoring the local implementation of the procedure and ensuring quality
improvements occur when necessary at a Sector level.
4. Scope
4.1 The procedure refers to all paper based PRFs and electronic PRFs used within the
organisation by Service Delivery staff.
Quality Management Procedure for Patient Report Forms Page: Page 7 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
5. PRF Quality Completion Standard
5.1 The Trust will use the PRF Completion Standard Care Bundle (Appendix 1) to define
the minimum standard for all completed PRFs.
5.2 All completed PRFs will be audited on a monthly basis, using the sample defined in
the PRF Completion Standard Care Bundle (Appendix 1).
5.3 The Trust Clinical Performance Indicator (CPI) process will be used to collect and
report data in relation to the PRF Completion Standard Care Bundle. An overview of
this process can be found in appendix 2.
6. Reporting
6.1 The Trust Care Bundle and CPI reporting process will be used to provide performance
information in relation to the quality of PRF completion.
6.2 Care Bundle and CPI reports will be produced using the Trust web-based reporting
tool with a pre-set reporting format.
6.3 Care Bundle and CPI reports will be produced on a monthly basis at station, sector
and area level.
6.4 A Trust and Area level Care Bundle and CPI exception report will be presented to the
Emergency Service Clinical Quality Business Group on a monthly basis.
6.5 Trust Care Bundle and CPI reports will be produced on a quarterly basis for the Trust
Board and Executive Management Team.
6.6 Trust Care Bundle and CPI reports will also be produced on a bi-monthly basis for the
Trust Quality Committee and Clinical Governance Management Group.
Quality Management Procedure for Patient Report Forms Page: Page 8 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
7 Quality Improvement and Action planning
7.1 The Trust will use an agreed Quality Improvement Process to manage the quality of
PRF completion (appendix 3).
7.2 Sector Managers and Advanced Paramedics will be responsible for agreeing and
overseeing the action planning process at Sector level.
7.3 The action planning process will be reviewed on a quarterly basis informed by CPI
quarterly reports.
7.4 All staff involved in the CPI process will be issued with a CPI resource that contains
guidance on the process and a range of quality improvement tools.
7.5 Advanced Paramedics and Senior Paramedics are responsible for acting on and
supporting the quality improvements at local level.
8. Equality impact Assessment
8.1 It was found that the Quality Management Procedure for the PRFs has a positive
assessment as it supports the equality agenda.
9 Monitoring and Review of the Procedure
9.1 This procedure will be reviewed every two year; however, if national guidance or
legislation changes, then the procedure may be reviewed at an earlier date.
9.2 As part of the procedure review process, the effectiveness of the procedure and its
application will be assessed. Information and results from audit systems, adverse
incidents, user feedback and external audits/reviews will be used to inform this
assessment.
9.3 The procedure will be monitored through the following systems:
Quality Management Procedure for Patient Report Forms Page: Page 9 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
Area for Monitoring Monitoring Process
The Clinical Quality Data Hub will be responsible for producing and managing the reporting
defined below.
Fulfilment of duties/responsibilities Presentation and review of reports at least
four times a year to the Trust Board and EMT
including assurance regarding Sector Level
action plans.
Criteria against which the clinical records
must be audited for all healthcare
professionals
Presentation and review of reports at least
four times a year to the Trust Board and EMT
including assurance regarding Sector Level
action plans; specifically return rates for the
audit.
Frequency of audit of clinical records Presentation and review of exception
reports on return rates to the Emergency
Service Clinical Quality Business Group on at
each meeting.
Minimum content of audit reports Presentation and review of reports at least 4
times as year to the Trust Board and EMT
including assurance regarding Sector Level
action plans
Arrangements for the development and
review of action plans
Audit of Sector Level action plans twice a
year by the Clinical Quality Manager
including presentation of an exception
report to the Trust Board, EMT and Clinical
Governance Management Group.
Quality Management Procedure for Patient Report Forms Page: Page 10 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
Appendix 1: PRF Completion Standard Care Bundle
PRF Completion
Short Description Percentage of patients with a completed Patient Report Form
Reason for this indicator Healthcare Professionals Code of Practice
NHSLA Ambulance Standard
Full indicator description 100% of patients should have a completed PRF with at least a minimum of
data attached
Definitions All patients that receive ambulance attendance
Target 100%
Measurement Method Any patient recorded by Emergency Service Staff
Sample 30 patient report forms per location (station)
Frequency Monthly
Additional Actions A separate PRF completion standard is applicable for Urgent Care Desk staff
Metric Standard %
Exception Data Source
PR1 Incident Number
95 Failure of Alert/MPDS PRF
PR2 Date 95
PRF
PR3 Response times – including time arrived at patient (excluding Triage, handover and Clear Hospital time)
95 PRF
PR4 Identities of clinicians (ID Number) 95
PRF
PR5 Vehicle Call Sign 95
PRF
PR6 Is the PRF legible? 95
PRF
PR7 Chief Complaint 95
Patient refusal
Patient absconded
PRF
PR8 Primary observations recorded? AVPU, Pulse, Resps, BP
95
Patient refusal
Patient contaminated
Violent or abusive patient
Patient absconded
PRF
PR9 Signature of attending clinician 95
PRF
PR10 Ethnic monitoring form completed 95 Patient unable to respond
Patient refusal
PRF
Quality Management Procedure for Patient Report Forms Page: Page 11 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
Appendix 2: Trust CPI Process Overview
SENIOR
PARAMEDICS
Clinical
Performance
Indicators CLINICAL PRFs
Stored data
on
IM& T Server
Manual input into Web based
application on Networked
station PC
INTRANET CPI REPORTS
Trust Board
Quality Committee
Clinical Governance
Management Group
etc
LOCAL MANAGEMENT
& STAFF
ALL STAFF
ACTION
PLANNING &
QUALITY
IMPROVEMENT
Quality Management Procedure for patient Report Forms Page: Page 12 of 12
Author: Senior Clinical Quality Manager Version: 2.2
Date of Approval: July 2015 Status: Final
Date of Issue: July 2015 Date of Review July 2017
Monthly review of NWAS CPI and Care
Bundle Reports
Produce Care Bundle Quality Improvement
(QI) Reports by Clinical Quality team
Monthly review and
approval at Trust EMT
Monthly review at
Organisational
Performance Group
Heads of Service, Consultant Paramedics
& Sector Managers review report,
performance and local actions by Advanced
Paramedics
Advanced Paramedics review Sector Reports and develop quarterly prospective QI Plan at sector or station level
Communication and implementation of
actions
Monthly Integrated Performance report for
Trust Board.
CPI Assurance reporting to Quality
Committee
CPI Quality Improvement Report
to Clinical Governance Management Group
Standing agenda item review of Sector Reports and progress
made against the Quality Improvement Plan at Emergency Service Clinical Quality Business Group and local clinical quality
improvement meetings
Production of monthly comparator
performance QI reports by Clinical Quality team
Clinical Performance Indicator care bundle Quality Improvement Process
2015
Reporting & Assurance
Contracted CPI
Performance Report
submitted to
Commissioning Quality
Group.
Appendix 3:
Quality Improvement Process