WELCOME

History Report of a Confidential Enquiry into Perioperative Deaths -published Dec 1987 Quality not causation

History National Confidential Enquiry into Perioperative Deaths Became the National Confidential Enquiry into Patient Outcome and Death in 2003 Contract managed by NICE then the NPSA and now HQIP under the Clinical Outcome Review Programme Undertake the Medical and Surgical CORP and the Child Health CORP

Remit To review clinical practice to improve the quality of the delivery of care - by undertaking confidential surveys covering many different aspects of clinical care and making recommendations for clinicians and management to implement.

Coverage England, Wales, Northern Ireland and Scotland Jersey, Guernsey and the Isle of Man Independent sector Acute/Mental/Primary/Community/Social Care

NCEPOD supporting bodies Royal College of Emergency Medicine Association of Anaesthetists Association of Surgeons Royal College of Anaesthetists Royal College of Radiologists Royal College of Ophthalmologists Royal College of Surgeons Eng Faculty of Public Health Medicine of RCP Lay Representatives Royal College of Psychiatrists Faculty of Intensive Care Medicine Royal College of Pathologists Royal College of Obstetricians & Gynaecologists Royal College of Physicians Royal College of General Practitioners Royal College of Nursing Royal College of Paediatrics and Child Health Royal College of Surgeons Ed Royal College of Physicians & Surgeons Glasgow Faculty of Dental Surgery of RCS

Independent Advisory Group Academy of Medical Royal Colleges Funding organisations Lay representatives Royal Colleges

Local Reporters/Ambassadors Wider structure NCEPOD Steering Group Chief Executive Clinical Co-ordinators Study Advisory Group Case Reviewers Researchers Scientific Advice Local Reporters/Ambassadors All clinicians Researchers/IT Admin Team Trustees HQIP CORP IAG Lay Representatives

Structure 16 Non-clinical staff 10 Clinical Co-ordinators 550+ Local Reporters 100+ Ambassadors

The role of the Local Reporter History and evolution of the role What the role involves Handing on the baton

The role of the Ambassador History of the role What the role involves Support provided

Why it works Peer review Independence Put into a report what people already suspect…

Participation Hospital participation is encouraged by NCAPOP NHS Quality Accounts Quality Delivery Plan for Wales Doctors’ participation is encouraged by GMC - Good Medical Practice/Good Surgical Practice CPD

Reports

Reports

Trauma: Who cares?

Local impact Stakeholder survey NCEPOD talks Poster competitions Checklists/audit tools

Topic selection Call for topics made to all our stakeholders 1st review made by NCEPOD Co-ordinators 2nd review made by NCEPOD Steering Group Top four topics are taken to the IAG

Questionnaire development Study Advisory Group Identify study themes Determine what questions need to be asked Clinical q. or case reviewer assessment form Questionnaires developed Testing*

Running the main study Main study Cases are identified to us Clinical questionnaires sent to the LR or clinician Extracts of the case notes requested Organisational questionnaire

Questionnaire and case note return Qs sent with FREEPOST envelope Recorded delivery Patient data should always be password protected even if it is sent from an NHS account to our NHS account Always phone with a password rather than email

Questionnaire and case note return Questionnaires and case notes are logged on arrival Notes are checked Anonymisation of patient data Case notes /questionnaires stored in locked cupboards Clinical Co-ordinators, Reviewers don’t have access

Who are NCEPOD reviewers? Active working clinicians, nurses and other relevant healthcare workers Review other clinicians work Assess cases Common themes Recommendations

Case reviewers Multidisciplinary group Specialties Hospitals Recruitment *

Case Reviewer meetings Case Reviewer Training Day 8-10 Reviewers 5 cases - case notes and questionnaire Assessment form

Case Reviewer meetings Overall quality of care assessed on a 5 point scale Cause for concern Group discussion Chief Executive & Lead Co-ordinator Letter to Medical Director

Analysis Not statistical research Qualitative analysis of Reviewer opinion of quality of care- AF Supplemented by data from OQ & CQ

Analysis Data scanned into preset database and validated/cleaned Strategy of analysis Data analysed using descriptive statistics in MS Excel Results reviewed by Reviewers, Steering Group and Study Advisory Group

Report writing Report written by Clinical Co-ordinators and NCEPOD staff 2 Drafts: Reviewed by Steering Group, Study Advisory Group & Reviewers Ensure recommendations are up-to-date Final draft of report sent to designers

Report launch/dissemination PDF of the full report and a summary document Disseminated to stakeholders* Report Launched at day event with representative speakers from relevant associations

Confidentiality It applies to the patient data It applies to the doctor and the hospital Section 251 DPA 1998 Ethics

What we do… Information Security policy document (ISO/IEC 27001:2005) Information Security Procedures Assign Information Asset Owners Information Security Forum Improved data security by encryption, passwords, and confidential disposal of paper NHS mailbox for receiving data and emails from Local Reporters Polythene envelopes and considered using DX boxes

Current Studies

Non-Invasive Ventilation

Objectives To identify whether NIV was an appropriate treatment intervention and whether it was used in the most appropriate location. To identify whether NIV was initiated at an appropriate time and whether any factors compromise the timing of care. To examine organisational aspects of care including local and national guidelines and protocols, staff training and delivery of NIV in hospitals.

Current status

Acute Heart Failure 43

Objectives Aims/Objectives Aim To identify and explore avoidable and remediable factors in the process of care for patients admitted to hospital with acute heart failure Objectives Prompt recognition and diagnosis of heart failure and rapid initiation heart failure pathway Appropriate documentation and management of heart failure Prompt senior review and follow-up throughout admission Escalation of care decisions and planning including admission to critical care

Objectives Objectives continued Assessing MDT approach Communications with patient, families and carers Management of acute end of life pathway and ceilings of treatment Equity of access for mechanical support/transplant centre Organisational aspects

Method Sample/Method HES (2012): 63110 admissions for heart failure, 56901 of which were emergency admission; Mean age of 79 HES (2010) ~9500 deaths in hospital (within 30 days) Retrospective identification via ICD10 codes (I50) Organisational, clinician questionnaires, case note review:

Method Patient identification All adult patients (aged 16 and older) that were admitted as an emergency between 1st January 2016 and 31st December 2016 inclusive and died in hospital with a primary diagnosis of Heart Failure.

Current status LR reporter packs disseminated Patient identifier spreadsheets Questionnaires being finalised Dissemination end of May/June Case Reviewers have been recruited Training day 18th May Report due in July 2018

Cancer in Children, Teenagers and Young People 49

Study Overview Aims To identify remediable factors the care of children/ young adults who died or were admitted to ICU within 60 days of receiving systemic anti-cancer therapy: 1)Look at the decision making and consent process around the prescription of SACT 2)Explore remediable factors in the quality of care provided to patients during the final protocol of SACT prior to death/ICU admission 3)Look at preventable causes of treatment-related mortality in this group of patients 4)Look at the configuration of the service and organisational structures in place for the safe delivery of SACT to children, teenagers and young adults (0-25)

Sample Children, teens and young adults aged 25 and younger Diagnosed with solid tumour/ haematological malignancy Received systemic chemotherapy Died or admitted to ICU within 60 days of receiving chemotherapy

Method Case identification spreadsheet has been sent out containing 2 tabs which should be completed separately SACT data collection ICU/death data collection Patient aged 25 years or younger and has ICD10 code as listed on spreadsheet Received SACT during time period 1st March 2014 – 31st May 2016 Admitted to ICU or died during time period 1st June 2014 – 31st May 2016 Initial deadline has passed but still accepting spreadsheets

Data collection Clinician questionnaire QA QB Form for intensivist Case notes Final Admission to hospital Prescription of SACT – start of last protocol, final cycle Organisational questionnaire Sites participating Assessment form Completed by Case Reviewers assessing casenotes

Current status Questionnaires are out Meetings are running Study launch may be delayed

Peri-operative Diabetes 55

Current status Aim to look at the process of care in the peri-operative management of surgical patients with diabetes across the whole patient pathway from referral for surgery to discharge. Population Patients aged 16 and over Who are admitted as an elective or emergency admission Who have a ICD10 code for Diabetes Mellitus (E10.0 – E11.0) Who have had a length of stay in hospital of at least 1 night post surgery All major OPCS codes will be included in the study Data collection will start in June

Child Health Review 57

Child Health Previously run by RCPCH Topics suggested by previous child health review report Two studies: Chronic neurodisability (cerebral palsy) Young people’s mental health Report to be published March 2018 58

Chronic Neurodisability - Aims To identify remediable factors in the quality of care delivered to those up to the age of 25 who have a chronic disabling condition, focusing on cerebral palsy Interface between care settings Transition

Method All patients up to the age of 25 who were admitted to hospital with a diagnosis of CP (G80 ICD10s) All ACUTE, COMMUNITY and INDEPENDENT providers of healthcare Case ID deadline 20th May Sample will be selected June and case notes requested immediately

How are we collecting data? Organisational questionnaire Clinical questionnaires Admission (yellow) Lead clinician/ongoing care (blue) Case note reviewer meetings

Data collection All admission questionnaires have been sent out – final deadline 16th of June 2017 Lead clinician questionnaires being sent out as we collect contact details – final deadline 4th August 2017 All organisational questionnaires have been sent out – final deadline end of May

Patient/Parent Carer Questionnaires Questionnaires available for patients and parent carers to complete on NCEPOD website

What’s coming next? Case note review meetings (600 cases assessed so far) Lead clinician questionnaires Report launch 8th March 2018

Young People’s Mental Health The aim of this study is to identify the remediable factors in the quality of care provided to young people aged 11 – 25 treated for: Depression and anxiety Eating disorders Self harm Interface between care settings Quality of care Transition

Participating Sites Acute Trusts Mental Health Trusts Health boards Independent providers Community providers of mental health care Adult and child & adolescent services Case ID deadline 20th May OQs – link sent when? Sample will be selected July/August and case notes requested immediately

How are we collecting data? 2 organisational questionnaires 2 spreadsheets – for non-routine emergency admissions and for routine admissions 4 clinical questionnaires and request for case notes: general hospital inpatient (green) mental health inpatient (purple) mental health services in the general hospital (including mental health liaison) community mental health questionnaire

What’s coming next? Admission questionnaires ongoing One set of Emergency Department notes Mental health liaison questionnaires CMHT questionnaires Reminders coming soon

Case Reviewers Needed Psychiatry Psychotherapy Nursing Psychology Psychotherapy and counselling Liaison Psychiatry Paediatrics Emergency care

Service User/Carer Questionnaire Questionnaire available for service users and carers to complete on NCEPOD website

Checklists 71

Gap analysis tool

Benchmarking data 73

Benchmarking data

Audit Tools 75

Audit tools

Audit tools

Audit tool

The Surgical Outcome Risk Tool (SORT)

The Surgical Outcome Risk Tool (SORT)

The Surgical Outcome Risk Tool (SORT) Mortality within 30 days of inpatient surgery % A truly preoperative risk assessment tool Rapid, simple data entry of 6 solely preop variables App is offline – can be used in any location New predictive text search in app

The Surgical Outcome Risk Tool (SORT) Clinical judgment and overall tool kit Pre-assessment clinics, high risk clinics, surgery and emergency departments Might contribute to identifying high risk patients (plan for CCU or other interventions; resource planning) Preoperative assessments, the consent process, and shared decision making

The Surgical Outcome Risk Tool (SORT) Strength of the SORT is underpinned by large data set from which tool was derived: NCEPOD’s “Knowing the Risk” study +19,000 patients from 326 hospitals in UK NHS, independent sector, and public hospitals (Channel Islands) Paper in British Journal of Surgery (2014) Collaboration: NCEPOD and SOuRCe (UCL/UCLH)

Have we missed anything? Thank you Have we missed anything? 84