Quality & Safety: Annual Clinical Audit & Effectiveness Report
Quality & Safety:Annual Clinical Audit & Effectiveness ReportQ1 2014/15 – Q4 2014/15 (April 2014 - March 2015)Presented by: Melanie HingoraniClinical Director for Quality and SafetyProduced by:Andy Dwyer, Head of Clinical GovernanceMelanie Hingorani, Clinical Director for Quality and SafetyAamir Khan, Asst. Clinical Audit FacilitatorTMB August 2015
1.0 IntroductionThis report presents an overview of clinical audit and effectiveness activities withinthe Trust between 1st of April 2014 and 31st March 2015. It informs the Board of howthe Trust works to ensure delivery of excellent care to patients (high quality evidencebased care, following recommended guidelines) and achieve good outcomes (betterhealth, fewer symptoms) for patients.The Department of Health explains clinical effectiveness as 'the extent to whichspecific interventions, when deployed in the field for a particular patient orpopulation, do what they are intended to do, for example, maintain and improvehealth and secure the greatest possible health gain from available sources'.Clinically effective care is based on adherence to evidence based guidelines toprovide the best possible outcomes for patients. Clinical audit is defined by theHealthcare Quality Improvement Partnership HQIP as 'a quality improvementprocess that seeks to improve patient care and outcomes through systematic reviewof care and implementation of change. It is an essential tool in the delivery ofclinically effective care, allowing professionals to measure their performance,recognise good practice and bad practice, and to make improvements in areaswhere practice does not reach appropriate standards.2.0 Organisational StructureMoorfields Eye Hospital (MEH) clinical quality team is led by Mrs Melanie Hingorani,a Consultant Ophthalmologist and Clinical Director for Quality and Safety and theHead of Clinical Governance (Andy Dwyer) and it includes the Clinical AuditFacilitator (recently appointed Carol Kibble), the Assistant Clinical Audit Facilitator(Aamir Khan) and the Clinical Audit Clerk (until recently Christopher Smith, currentlyout to advert). The team works closely with the Corporate Governance, Risk andCompliance Teams.There are two committees for implementation and monitoring of clinical audit andeffectiveness processes: the Clinical Audit Assessment Committee (CAAC) whichmeets 2 weekly to assess and approve clinical audit proposals and reports; and theClinical Audit Effectiveness Committee (CAEC) which meets 2 monthly and oversees2
clinical audit and effectiveness work. The CAAC reports to the CAEC, which in turnreports to the Clinical Governance Committee (CGC).The Trust’s intranet site contains a number of resources: CLAW (Clinical AuditWebtool) for online registration and management of the audit process and reportingof audit activities in the Trust; the Clinical Audit Policy; a simple “how to” guide toclinical audit; training materials; and other information regarding the department. Toensure coordination of clinical audit in the services, all major departments andsatellites have an identified consultant or equivalent clinical audit lead who workswith the quality team and are invited to attend the CAEC to present theirdepartment’s audit and effectiveness work at least annually.Moorfields continues with its program of multidisciplinary clinical governance (CG)half days, with good recorded attendance by 400-500 staff per meeting. CG halfdays provide a forum for presentation and discussion of quality activities and thereare standing agenda items to ensure that key effectiveness topics such as auditresults and actions, clinical outcomes and progress against the annual audit arediscussed, minuted and fed back to the quality team. The major satellite sites holdtheir own local meetings three to six times yearly. The smaller satellites and the CityRoad site hold four sessions per year, of which three are service specific and one isrun jointly attended by all the services. However due to a failure in achieving theReferral-to-Treatment (RTT) 18 week pathway, a decision was made by the Trust tocontinue extra clinics on the CG date planned for September 2014. Therefore theTrust conducted only three CG half day sessions in 2014-15 for City Road. Membersof the corporate and clinical governance teams attend each CG meeting as agovernance “buddy” to provide support and guidance. The emphasis onmultidisciplinary clinical audit participation and multidisciplinary attendance at CGhalf day meetings is designed to embed clinical audit in practice for all staff andensure all clinical staff have the knowledge and skills to do so.The annual joint CG meeting in November welcomed the Chief Inspector ofHospitals at the Care Quality Commission (CQC), Professor Sir Mike Richards, toopen with a keynote speech followed by a question and answer session. The eventwas well publicised with posters and emails and was recorded on video for sharing3
with other Moorfields sites and services unable to attend. The involvement of anational figure from the CQC was well received by the 500 staff who attended.3.0 Clinical Audit3.1 Clinical Audit PolicyThe Trust’s Clinical Audit Policy, which is currently being updated, outlines thestrategic direction of clinical audit and aims to ensure that: Clinical audits focus on high priority areas There is a clear simple procedure for approving and conducting audits Clinical audit is conducted against appropriate standards, presented in theapproved format and contains a suitable action plan Progress against action plans is monitored and re-audited to demonstratesustained improvement; it is crucial that lessons are learned, acted on and sharedacross the organisationClinical audit in the Trust has three main themes: Quality improvement Patient safety Demonstrating consistent achievement of key clinical outcomes in each service:the “core outcomes”.Audits that are accorded high priority include those against national standards suchas National Institute for Health and Care Excellence (NICE), National ConfidentialEnquiry into Patient Outcome and Death (NCEPOD), Care Quality Commission(CQC), Royal College of Ophthalmologists’ (RCO) related audits. Other importantareas include concerns from incidents or complaints, new research evidence, newservice developments, audits assessing training and compliance with key policiesand procedures and re-audits. Table 1 shows the number of audits proposed andapproved (195) during the year 2014-15 associated with these priorities/triggers.The Trust’s quest to use the new electronic patient record, OpenEyes, for moreautomated audit continues, although the progress achieved has been less thanhoped. So far only Glaucoma, Medical Retina and Cataract services’ modules are inregular use and are being used to support clinical audit activities but the process forautomated audit accessible directly by clinicians is not yet available and the majority4
of clinical audits require the paper health records. The OpenEyes team are currentlydeveloping software which will allow the Trust to submit historical data to the RCONational Cataract Audit later in 2015 and then submit rolling prospective data from2016 as required. In addition, OpenEyes are developing an audit facility for cataractsurgery outcomes which will be available for clinicians to use to directly examinetheir own and their team’s up to date cataract surgery outcomes and compare resultswith national and Trust outcome standards.Table: Number of audits by priorityReason for auditNoComplaints, claims and litigation3Core Outcome audit21Incidents5Local Guidelines20National Audit5New Research30NICE24National Service Framework (NSF)1Patient Feedback8PROM5Royal College of Ophthalmologists (RCO)6Royal College of Ophthalmologists mGTT(RCOmGTT)Re-audit34Revalidation3Service Evaluation17Survey4Total19593.2 Clinical Audit Activity5
In the period under review, there were 195 clinical audit and 69 completed auditreports presented and approved by the CAAC. Audit activities varied by services withsome services engaging in higher levels of audit activity than others. Medical Retinaand Glaucoma were involved in the highest number of audits, in line with being thebusiest services, but the Paediatrics and Strabismus and Corneal and ExternalDisease services were also very productive. There were nine trustwide audits,related to local guidelines, national audits and incidents, NICE, National ServiceFramework (NSF) and service evaluation.Chart: Audit proposals approved and completed audit reportsChart: Audit activities by service6
3.3 National AuditsAs the Trust is a single speciality hospital, most national audits are not applicable.Therefore the Trust performs audits against relevant national recommendations suchas RCO recommended standards and standards relevant to national guidance orregulators, such as NICE and NSF. During 2014-15, 30 nationally related and 61RCO clinical audits were registered on the Trust’s Clinical Audit Webtool database.The national clinical audits, RCO standards and NICE standards audits thatMoorfields took part in during 2014/15 were as follows:National AuditsAudit Project TitleAuditReasonsSitesServiceIntraoperative monitoring of theelderly at MoorfieldsNICECity RoadEalingHomertonLoxfordMile EndNorthwick ParkPotters BarSt Ann'sSt George'sAnaestheticsAudit of suspected lid cancerpatient referral in adnexal oncologyNICECity RoadAdnexal7
Sprint National AnaesthesiaProjects (SNAP-1): Patient surveyon quality of anaesthesia in UKhospitals and accidentalawareness under generalanaesthesia.NationalAuditBedfordCity RoadEalingMile EndNorthwick ParkPotters BarSt Ann'sAnaestheticsDMO Compliance AuditNICECity RoadEalingLoxfordNorthwick ParkSt Ann'sSt George'sMedical RetinaDMO Lucentis New Referral FormsNICECity RoadMedical RetinaA Prospective Evaluation ofPatient Knowledge of Diabetes,Diabetes Self-care and DiabeticRetinopathy Associated RiskFactors (the Patient Knowledge ofDiabetes Audit, PKDA)NICEEalingMedical RetinaRetrospective Glaucoma OpticNerve Head Imaging AuditNICEBedfordEalingPotters BarQueen Mary'sGlaucomaEvaluation of acute optic neuritismanagement: towards a diagnosticapproach and therapeutic protocolusing up-to-date proceduresNICECity RoadNeuroOphthalmologyPatient Glaucoma AwarenessStudyA retrospective evaluative audit ofvisual and anatomic outcomes ofpatients with refractory or recurrentwet age-related maculardegeneration who were convertedfrom ranibizumab to afliberceptNICEBedfordGlaucomaNICEBedfordMedical RetinaAn Audit of Patients who are 'Lostto Follow Up' in the GlaucomaServiceNICECity RoadGlaucoma8
Audit on intravitreal treatment ofmacular oedema from retinal veinocclusionNICETrustwideMedical RetinaImplantation of an opaqueintraocular lens for intractabledouble vision: adherence to NICEguidanceCauses of clinic non-attendance ofdiabetic patients in the MedicalRetina Service at City Road.NICECity RoadStrabismusNICECity RoadMedical RetinaAn evaluation of A&E childprotection documentation wherethere has been a disclosure ofdomestic abuse.NICECity RoadA&EThyroid eye disease: do we meetstandards?NationalAuditCity RoadAdnexalPrescribing compliance within theAdnexal ServiceNICECity RoadAdnexalDecision making for treatment ofpatients with pigment dispersionsyndrome(PDS) using visual fieldand optic disc imagingComplaint handling (Complainantperspective)NICECity ct Surgery Audit in theGlaucoma Service - PCR rateNICETrustwideGlaucomaIntra-operative DVT prophylaxisCystoid Macular Oedema AfterCataract SurgeryNICENSFCity RoadTrustwideAnaestheticsCataractsNon Diabetic Retinopathy ReferralOutcomes from Tower HamletsPCT'SDiabetic Screening ServiceNICECity RoadHomertonMile EndMedical Retina9
Real- Life Experience withRanibizumab in the Treatment ofMacular Odeama secondary toCentral Retinal Vein Occlusionwithin the NHS: Can we CRUISE?NICECity RoadMedical RetinaVisual outcomes in patientsattending the Surveillance and SlitLamp Clinic of the NationalDiabetic Eye ScreeningProgramme (NDESP) of TowerHamlets PCTGlaucoma service atMoorfields@City Road comparedto Nice guidelinesCG85/2009NationalAuditCity RoadMedical RetinaNICECity RoadGlaucomaA review of the application of theMental Capacity Act in practice atMoorfields Eye Hospital NHSFoundation TrustNationalAuditTrustwideTrustwideAdherence to local protocols forscheduling of aflibercept injectionsin wet AMDNICECity RoadMedical RetinaOcriplasmin for VitreoMacularTraction and Stage II MacularHolesAudit of informed consent forintravitreal therapy in CroydonUniversity HospitalNICECity Road, St.George’s,EalingCroydonVitreo-RetinalNICERoyal College of Ophthalmologists Audits and Core OutcomesAudit Project TitleAuditSitesReasonsR3 referrals from the screeningprogramme to MoorfieldsCataract Outcome SurveyCorneal/External Disease PatientSurvey 2014Modified Global Trigger Tool CityRoad/Medical RetinaModified Global Trigger Tool CityRoad/Trustwide (Inf. Ctrl, Nursing,Pharmacy,etc.)Medical utcomeauditRCOmGTTCity RoadMedical RetinaCity RoadCataractsCity RoadCity RoadCorneal &ExternalDiseaseMedical RetinaRCOmGTTCity RoadTrustwide10
Modified Global Trigger Tool StAnn's/Medical RetinaRCOmGTTSt Ann'sMedical RetinaModified Global Trigger Tool CityRoad/Medical RetinaRCOmGTTCity RoadMedical RetinaModified Global Trigger Tool CityRoad/Medical RetinaRCOmGTTCity RoadMedical RetinaOutcomes of 50 consecutive cataractsurgery casesCoreOutcomeauditCataractsModified Global Trigger ToolBedford/OptometryRCOmGTTCity RoadEalingNorthwickParkPotters BarBedfordModified Global Trigger Tool CityRoad/AdnexalRCOmGTTCity RoadAdnexalOutcome of Baerveldt tubeimplantation in patient with glaucomaCoreOutcomeauditRCOmGTTCity RoadGlaucomaCity RoadMedical RetinaCity RoadCataractsModified Global Trigger ordPaediatricsModified Global Trigger fied Global Trigger ToolEaling/Primary CareRCOmGTTEalingPrimary CareRe-audit of paediatric syringe andprobing core outcomeCity RoadPaediatricsCataract Outcome AuditCoreOutcomeauditRCOCity RoadEalingSt Ann'sCorneal &ExternalDiseaseModified Global Trigger Tool CityRoad/Medical RetinaRCOmGTTCity RoadMedical RetinaSurgical Outcomes of MitomycinAugmented Trabeculectomy in theFirst Two Years of LifeCoreOutcomeauditCity RoadGlaucomaModified Global Trigger ToolBedford/Corneal and External DiseaseRCOmGTTBedfordCorneal &ExternalDiseaseAudit of Paediatric cataract surgeryRCOCity RoadPaediatricsModified Global Trigger Tool CityRoad/AnaestheticsRCOmGTTCity RoadAnaestheticsModified Global Trigger Tool CityRoad/Medical RetinaAudit of cataract surgery outcomesOptometry11
Modified Global Trigger Tool CityRoad/AnaestheticsRCOmGTTCity RoadAnaestheticsModified Global Trigger Tool CityRoad/Neuro-ophthalmologyRCOmGTTCity RoadNeuroOphthalmologyModified Global Trigger Tool UpneyLane/Primary CareRCOmGTTUpney LanePrimary CareModified Global Trigger ToolLoxford/Medical RetinaRCOmGTTLoxfordMedical RetinaCoreOutcomeauditBotulinum toxin for the treatment ofCorepaediatric strabismusOutcomeauditmGTT of patients with external disease RCOcomplaintsmGTTBedfordCataractsCity RoadNorthwickParkCity RoadPaediatricsCore outcome audit of trabeculectomyat 1 year (2013 surgery data)CoreOutcomeauditGlaucomaStop Before You BlockCore Outcomes on Aqueous ShuntDevices (Tube Outcomes III) 2015(tubes done 2013-14)RCOCoreOutcomeauditRetinopathy of prematurity ScreeningMoorfields @ BedfordRCOCity Road,Upney Lane,Ealing,Loxford, MileEnd,NorthwickPark, PottersBar, St Ann's,St George'sCity RoadCity RoadMile EndNorthwickParkSt Ann'sSt George'sBedfordModified Global Trigger Tool CityRoad/OrthopticsRCOmGTTCity RoadOrthopticsModified Global Trigger Tool ticsModified Global Trigger Tool StGeorge's/OrthopticsRCOmGTTSt George'sOrthopticsRetrospective Audit of PrematureBabies for Retinopathy of PrematurityRCOEalingPaediatricsModified Global Trigger ToolLoxford/GlaucomaRCOmGTTLoxfordGlaucomaModified Global Trigger Tool CityRoad/OptometryRCOmGTTCity RoadOptometryModified Global Trigger Tool ryRisk stratification of cataract surgery atBedford, cs12
Modified Global Trigger ToolEaling/OptometryRCOmGTTEalingOptometryModified Global Trigger Tool PottersBar/OptometryRCOmGTTPotters BarOptometryModified Global Trigger Tool StGeorge's/OptometryRCOmGTTSt George'sOptometryA retrospective audit of time fromdiagnosis to surgery in primary retinaldetachments presented in VRECoreOutcomeauditCity RoadVitreo-RetinalFull thickness Macular holes AugustNovember 2014CoreOutcomeauditRCOmGTTCity RoadVitreo-RetinalPotters BarOrthopticsModified Global Trigger Tool odified Global Trigger Tool DarentValley and StratfordRCOmGTTOrthopticsModified Global Trigger Tool MileEnd/GlaucomaRCOmGTTDarentValley,StratfordMile EndReattachment rate following primaryrhegmatogenous retinal detachmentrepair surgeryCoreOutcomeauditCity RoadVitreo-RetinalMoorfields @ Bedford CataractSurgery Outcomes Audit itRCOmGTTBedfordCataractsCity RoadGlaucomaCity RoadGlaucomaCity RoadPaediatricsRetrospective study of anaesthesiaoutcome of cataract surgery doneunder local anaesthesiaRCOCity Road,Mile End, St.Anne'sAnaestheticsPersonal trabeculectomy audit August2013-August itCity RoadGlaucomaCity RoadA&ECity RoadCorneal &ExternalDiseaseRCOmGTTCity RoadMedical RetinaModified Global Trigger Tool PottersBar/OrthopticsTrabeculectomy outcomesCataract surgery outcomesModified Global Trigger Tool CityRoad/PaediatricsAngle closure Glaucoma in A&EOutcomes of therapeutic keratoplastyModified Global Trigger Tool CityRoad/Medical RetinaGlaucoma13
3.4 External Review: CQC and NHSLAA number of key NHSLA and CQC related audits are undertaken annually.Record Keeping AuditThe Trust Record Keeping Audit is undertaken every year by the clinical audit teamand was repeated for 2014-15. With a slight modification to the 2013-14 audit tool,the team reviewed and analysed 15 sets of medical records for each site, tocompare and contrast between satellites. The team visited City Road, NorthwickPark, Ealing, Potters Bar, Mile End, St George’s, St Ann’s, Bedford and Croydon,and the notes were chosen at random and covered various services. The auditstandard was the Trust’s ‘Health Records Management Policy and Procedure V3.3(July 2013)’ and comparisons were made against the results of 2013-14. The auditassessed the condition of the medical notes (securely held and bound, filed correctlyand correct patient details on the outside), and also assessed the last episode ofcare to determine, patient detail, legibility, use of electronic records, appropriate dateand time, written in black ink and amendments noted correctly.The audit showed many improvements since the previous year. The generalcondition of the health records has shown improvements with inclusion of thepatient’s NHS number and the security of documents held and bound in the folder.The majority of sites continue to use handwritten notes as a preference to OpenEyes/Medisoft but Croydon, Bedford and Potters Bar use mainly electronic records.Upon review of the last episode of care, many sites showed improvements on lastyear’s audit. Croydon was not part of the review last year, but demonstratedexcellent documentation standards throughout. Some aspects of the Health RecordsManagement Policy and Procedure V3.3 (July 2013) were impractical and thestandards set unachievable without a hospital bleep system, or changes to theelectronic print-outs for Open Eyes and Medisoft, and a review of the policy isnecessary to achieve further compliance and to also reflect current practice. Therewere also issues with the printing of electronic documents whereby if the documentsprinted continued to a separate page, the patient details were not printed at the topof the second page. The results were shared with the Information Governance teamand Health Records Management team within the Surgical Services directorate toaddress the policy and also with the OpenEyes team to ensure the patient details14
appear on every page. Also, results have been shared with staff across the Trustthrough clinical governance meetings, quality performance reviews and othermeetings, to ensure actions are taken to continuously improve the standard ofrecording keeping by all staff.Being Open AuditIn February 2015 the Head of Clinical Governance undertook an audit of complianceagainst the Trust’s Being Open Policy (July 2014). The audit reviewed all patientsafety events (incidents, complaints and claims) recorded as having a significantlevel of harm (moderate, major, catastrophic, including prolonged psychologicalharm and death). Serious Incidents and Never Events were also included. Data wasassessed between September–December 2014 and identified 11 patient safetyevents (all recorded as clinical incidents).One incident involved a large number of documents that were inappropriately storedand had not been dealt with appropriately, such as patient letters and investigationresults and, although still under review, the investigation has not identified anypatients who have yet come to harm as a result of the documents mishandling.Four incidents graded as moderate harm included two cases of dropped nucleusduring phacoemulsification procedure and two cases of endophthalmitis fromtrabeculectomy procedures. These cases were not discussed at a Serious IncidentPanel as they are recognised complications from surgery for which the patients wereappropriately consented and there was no suggestion of poor practice or care.Documented discussions were present in four sets of notes in varying degrees ofcompleteness and only three patients received correspondence by letter describingthe events and investigation process together with an apology.Further work is clearly necessary to embed a process for reviewing all relevantcommunications with patients who have suffered significant harm from a patientsafety event. Staff will also require further support and guidance to demonstrate fulldisclosure and appropriate documentation of discussions. The report has beendiscussed at the CGC and the Being Open Policy has also been amended to includethe ‘Duty of Candour’ statutory requirements and will be included in future audits.Duty of Candour current requirements and the results of the audit have beendiscussed widely across the Trust, for example in all CG half days, risk management15
training and targeted training for clinical and service directors, and service and sitedirectors have been asked to ensure they review any significant harm incidents andfulfilment of the associated Duty of Candour requirements regularly in their monthlybusiness meetings.Consent AuditThe consent process was not audited in 2014-15 as expected changes to theConsent Policy were delayed until November 2014. The policy was audited in June2015 with a report written in July 2015 and will be included in the report for next year.Audit of Clinical Audit Team-Records HandlingThe clinical audit team are required to handle and store hundreds of patient medicalrecords in a small office and we pride ourselves on ensuring that all notes for clinicalaudit activity are organised and tracked appropriately. The management of healthrecords has proved more difficult in 2014 with a changing clinical audit team, and theuse of temporary and agency staff with various experiences and abilities. This hasalso been compounded by the changes to the administrative and clerical staff andthe closure of the Medical Records Library to all except records staff.The team therefore audited themselves and assessed the tracking of all notes in theclinical audit office. In July 2014, 255 sets of notes were audited and 40 (16%) were not trackedby the temporary audit clerk. The clerk was fully informed of the disappointing resultsand the need to ensure that every set of notes that enter and leave the clinical auditoffice should be tracked. In August 2014, 287 sets of notes were audited and 10 (3%) were not trackedby the clinical audit team. It was also noted that 20 (7%) of case notes that werespecifically borrowed by the Glaucoma Service failed to track notes when acquiringthe notes for their clinics. (Staff in the Glaucoma Service did not track the notes afterremoving them from the clinical audit office, leaving no audit trail which resulted inthe audit department as the last point of contact on PAS). This resulted in case notesbeing misfiled and the audit department held accountable for the notes. A further 20(7%) case notes had not been tracked by various departments borrowing notes fromthe audit office. At this time a new clinical audit clerk joined the clinical audit team16
and was advised to track all notes that leave the office by noting they are ‘on the wayto’ the desired location when removed by staff. In October 2014, 260 sets of notes were audited and 8 (3%) of the case noteswere not tracked by staff in the audit department. All other notes borrowed by thevarious clinics were returned correctly as there has been a greater emphasis madeto staff that notes borrowed from the audit department should be returned back tothe audit team. It was clear to the auditors that those 8 sets of notes that were notcorrectly tracked by the audit team were collected within a bundle of notes boundwith elastic bands. The clinical audit clerk was reminded that he must separate andcheck all notes collected (including those that are already held/bound together). In January 2015, 210 sets of notes were audited and 5 (2.4%) were nottracked appropriately. 1 set of notes had been returned from the clinic after anoutpatient appointment and was not tracked, 1 set was tracked to the library but wasfound on the shelf in the office and 3 sets of notes were tracked to the audit office,but not noted as ‘received’ by the clinical audit team on PAS. In March 2015, 372 sets of notes were audited and 5 (1.3%) of notes were nottracked appropriately. 3 clinical notes were tracked to different departments on PASbut physically present in the audit office. These notes had been in the audit officebefore being taken away for appointments and it was suspected they were returnedwithout the knowledge of the clinical audit staff. 1 set of notes was the wrong volumetracked to the audit office, and 1 set was not tracked to audit department and wasrecorded as still in the library awaiting transfer to the audit department.The clinical audit team will continue to assess compliance with this during 2015-16.GP surveyFollowing a patient complaint in 2014 about the format and addressee information ina patient’s copy of their GP letter, and subsequent discussion at the CGC, a surveyabout GP letters was undertaken. The audit team agreed to review the opinions ofpatients and GPs regarding the format of these letters and developed surveyquestionnaires that were discussed and approved at the CAAC.50 patients were handed a questionnaire in clinic and the top 10 referring GPsurgeries in the Islington area were contacted to complete an online survey.Although it was highlighted on each questionnaire and instruction was given to17
patients, it is suspected from the results that some patients commented on theirappointment letters rather than the copy of their GP letters.Of concern, 20% of patients reported never having received a copy of their GP letter.Although patients who did receive copies of the GP letter reported that theyunderstood them to some extent, the GPs made it clear that handwritten letters (andprescriptions) were illegible and included unknown abbreviations. Patients weregenerally happy with the format of the letters, but some patients agreed with theGPs, suggesting letters could be written for the ‘lay-person’. Although almost allpatients wanted to receive a copy of the GP letter, some would prefer alternativeroutes of receipt including, as well as post (58.7%), email (30.4%), during the clinicappointment (17.4%), and one patient suggested a letter in Braille.Clinical staff who complete GP letters must ensure that the use of abbreviations islimited and, where necessary, explained. Many letters are now completedelectronically; however, handwritten letters and prescriptions should be written moreclearly and legibly for both GPs and patients to be fully informed.The audit was shared with the CGC, CAAC, Patient Experience Committee and theTrust’s GP liaison officer who shared the findings with the GP referrers. The findingswere also shared with a project manager in the Trust looking to develop patient andGP letters and have contributed to the development of a Patient Letter Policy. Theupcoming changes to the OpenEyes administration and prescription modules mayallow much greater and improved use of electronic communications and minimisehandwritten communications. A further audit of this policy this year will identify anyprogress across the Trust.3.5 Commissioner requested audits arising due to Serious IncidentsAs a result of Serious Incidents (SIs) within theatre during previous years, the clinicalaudit team have assisted in undertaking observational audits to assess compliancewith theatre procedures, guided by commissioner requests. A member of the clinicalaudit team will observe the practice undertaken within theatres without disclosing thespecific reasons for the audit.18
Surgical Count Re-auditIn April 2014, the clinical audit team re-audited the swab, needles and instrumentcount procedures in theatres. The communication and documentation of the count intheatres was assessed prior to s
Quality & Safety: Annual Clinical Audit & Effectiveness Report Q1 2014/15 - Q4 2014/15 (April 2014 - March 2015) Presented by: Melanie Hingorani Clinical Director for Quality and Safety Produced by: Andy Dwyer, Head of Clinical Governance Melanie Hingorani, Clinical Director for Quality and Safety Aamir Khan, Asst. Clinical Audit Facilitator
PSI AP Physics 1 Name_ Multiple Choice 1. Two&sound&sources&S 1∧&S p;Hz&and250&Hz.&Whenwe& esult&is:& (A) great&&&&&(C)&The&same&&&&&
Argilla Almond&David Arrivederci&ragazzi Malle&L. Artemis&Fowl ColferD. Ascoltail&mio&cuore Pitzorno&B. ASSASSINATION Sgardoli&G. Auschwitzero&il&numero&220545 AveyD. di&mare Salgari&E. Avventurain&Egitto Pederiali&G. Avventure&di&storie AA.&VV. Baby&sitter&blues Murail&Marie]Aude Bambini&di&farina FineAnna
The program, which was designed to push sales of Goodyear Aquatred tires, was targeted at sales associates and managers at 900 company-owned stores and service centers, which were divided into two equal groups of nearly identical performance. For every 12 tires they sold, one group received cash rewards and the other received
College"Physics" Student"Solutions"Manual" Chapter"6" " 50" " 728 rev s 728 rpm 1 min 60 s 2 rad 1 rev 76.2 rad s 1 rev 2 rad , π ω π " 6.2 CENTRIPETAL ACCELERATION 18." Verify&that ntrifuge&is&about 0.50&km/s,∧&Earth&in&its& orbit is&about p;linear&speed&of&a .
theJazz&Band”∧&answer& musical&questions.&Click&on&Band .
6" syl 4" syl 12" swgl @ 45 & 5' o.c. 12" swchl 6" swl r1-1 ma-d1-6a 4" syl 4" syl 2' 2' r3-5r r4-7 r&d 14.7' 13' cw open w11-15 w16-9p ma-d1-7d 12' 2' w4-3 moonwalks abb r&d r&d r&d r&d r&d r&d ret ret r&d r&d r&d r&d r&d 12' 24' r&d ma-d1-7a ma-d1-7b ret r&d r&d r5-1 r3-2 r&d r&r(b.o.) r6-1r r3-2 m4-5 m1-1 (i-195) m1-1 (i-495) m6-2l om1-1 .
s& . o Look at the poem’s first and last lines (first and last lines may give readers important . it is important to read poems four times. Remind them that the first time they read is for enjoyment; rereads allow them to dive deeper into poems .
27 Science Zoology Dr. O. P. Sharma Amrita Mallick Full Time 18/2009 11.06.2009 Evaluation of Genotxic Effects & Changes in Protein Profile in Muscle Tissue of Freshwater Fish Channa Punctatus Exposed to Herbicides Page 3 of 10. Sl. No. Faculty Department Name of the supervisor Name of the Ph.D. Scholar with Aadhar Number/Photo ID Mode of Ph.D. (Full Time/Part-Time) Registration Number Date of .
