1. TRUST BOARD Tuesday 27th February CLINICAL HARM REVIEW Richard Sunley – Deputy Chief Executive Louise Glover – Project Director

2. CONTENTS Introduction Background
How have we got to the current position?
Current position
Progress
Dashboard
GP support
Trajectories
Trajectories per speciality
COBRA
COBRA Reporting
Duty of candour
Risks
Next steps and Recommendations
07/11/2018
Project Director - Louise Glover

3. INTRODUCTION The purpose of the clinical harm review is:
To identify any harm which may have arisen as a result in a delay in waiting for appointments and/or treatment.
To ensure any harm is recorded and appropriate action taken in regard to any patient affected
To implement change from lessons learned
To minimise any risk of recurrence
To mitigate any risks to patients that could occur.
The main focus of the work is at the Trust, with involvement and support from the three local CCGs
07/11/2018
Project Director - Louise Glover

4. BACKGROUND
Excessive waiting for a follow-up outpatient appointment or other elective intervention at North Lincolnshire and Goole NHS FT have been a recurring issue for the Trust for several years.
To address this the current review was initiated in April 2017.
The priority cohorts for review are: 
1. Cancer patients waiting 104 days +
2. Pathways on an incomplete RTT pathway, who have waited more than 40 weeks for treatment.
3. Pathways which are more than 6 months past their review date for follow-up (with/without ED intervention)
Project Director - Louise Glover
07/11/2018

5. HOW HAVE WE GOT TO THE CURRENT POSITION?
The journey from initial patient pathways identified to
7359 patient pathways uploaded into COBRA
Starting Point (08/08)
Removal of Duplicates
Cohort Errors/Adaptions
Further Duplicate
Removal
RTT Discharged after
Treatment
Total added to Cobra
Total Numbers of Pathways Closed - 357
Number submitted for Clinical Review -6239
Total Left to Validate - 2
07/11/2018
Project Director - Louise Glover

6. CURRENT POSITION As at 19th February 2018 Completed GP Reviews 461
Awaiting DQ Validation
Awaiting GP Review
Awaiting Clinical Health Records Review by Consultant
Awaiting Clinical Review (OPA) 2
409
3891 21
Completed GP Reviews
461
Completed Consultant Reviews at Clinical Health Record Stage 21
No harm identified at Consultant Reviews at Clinical Health Record Stage – Pathway to continue 11
07/11/2018
Project Director - Louise Glover

7. Full cohort uploaded for review onto COBRA – 7359 patient pathways
PROGRESS
Full cohort uploaded for review onto COBRA – 7359 patient pathways
Current progress
(as at 19th February 2018
Number of patient pathways
Following DQ validation by Source ( ) awaiting validation)(= 1120)
7359
1120(a)
Number submitted for clinical review
6239
Awaiting review by GPs
409(b)
Submitted for review by Consultants
3891(c)
Removed post Clinical review due to quality issues
1822(d)
Awaiting clinical health record review by consultants
2043
Moving through stages of the review process
117(e)
TOTAL (a+b+c+d+e)
07/11/2018
Project Director - Louise Glover

8. DASHBOARD To date no incidences of potential harm have been identified
Specialty/Pathway
Overall Cohort Size
1 - Validation Stage
2 - GP Review
3 - Clinical Health Records Review
4 - Clinical Review
Cobra Incidents Raised
Incidents of harm raised via routine governance processes
Awaiting Validation
DQ Reviews Completed
Awaiting GP Review
GP Reviews Complete
Awaiting Clinical Health Records Review
Clinical Health Records Review Completed
Awaiting Clinical Review
Clinical Reviews Completed
Removed due to DQ issue
Send for Further Review
No Harm - Pathway Discharge
No Harm - Pathway to Continue
Send for face to face review
Identified Low Harm
Identified Moderate Harm
Identified Severe Harm
 Cardiology
852
217
426 46
378 2
 C Rectal surgery
1684
134
1194
324
855 1 14
 Ent
687 31
490
484 5
 Gastro
148 11 82 6 75
 General surgery
218 30 95 94
 Ophth
1051 33
643 4
 Resp
medicine
252
138
127
 T & O
193
149
 Urology
264
171
135
A snapshot of the specialities with the highest number of reviews
To date no incidences of potential
harm have been identified
07/11/2018
Project Director - Louise Glover

9. GP SUPPORT
A local GP piloted reviewing a list of patients at the practice who were in the priority cohorts to ascertain if this would be helpful in risk stratifying patients in order to make best use of the clinical resources available at the trust.
The pilot also helped determine the time required to do the work and assess if this is a good use of GP time.
The pilot demonstrated that GP notes review can identify some patients with an urgent need and some who may be suitable for discharge without further follow up.
All the CCGs were asked to commission this from their GPs.
This appears to have been a practical and deliverable method of rapidly triaging patients waiting to identify those with a potentially urgent need for care and to therefore minimise avoidable harm.
In addition, identifying patients for discharge will release capacity and is resource saving.
East Riding of Yorkshire CCG have confirmed that they were unable to support this process.
GPs Reviews for colorectal, ENT, urology, Ophthalmology, Gastroenterology, Cardiology Respiratory commenced on Monday January 8th with excellent engagement from GPs within NELCCG and NLCCG
07/11/2018
Project Director - Louise Glover

10. TRAJECTORIES
Based upon proposed methodology of 15 minutes per set of case notes, 4 to be reviews completed per hour using 1 SPA per week by each Consultant, the reviews for the current cohort would be completed by end April except for Colorectal which due to high numbers would complete by September 30th 2018
Total number of SPAs per speciality divided by number of Consultants gives the total number of weeks for completion of the reviews.
The use of SPAs can be aligned with local governance activities as described in “A Guide to Consultant Job Planning (BMA – 2011)”
Assumptions:
The specialities reviewed by GPs may reduce numbers for consultant review by 10% based upon the pilot phase.
The number of consultants per speciality is accurate
07/11/2018
Project Director - Louise Glover

11. Trajectories per Speciality
5/2/18
12/2/18
19/2/18
26/2/18
5/3/18
12/3/18
19/3/18
26/3/18
2/4/18
9/4/18
16/4/18
23/4/18
30/4/18
7/5/18
14/5/18
21/5/18
28/5/18
4/6/18
11/6/18
18/6/18
25/6/18
2/7/18
9/7/18
16/7/18
23/7/18
30/7/18
6/8/18
13/8/18
20/8/18
27/8/18
3/9/18
10/9/18
17/9/18
24/9/18
Surgery and Critical Care
Anaesthetics
Breast surgery
Colorectal
Ent
General surgery
Ophthalmology
Oral surgery
Orthodontics
Plastic surgery
T&O
Upper GI
Urology
Medicine
Cardiology
Diabetic medicine
Endocrinology
Gastroenterology
General medicine
Medical oncology
Neurology
Respiratory
Rheumatology
Other Specialities
Paediatrics
Pain management
Orthoptics
Obstetrics
07/11/2018
Project Director - Louise Glover

12. All patients identified within cohorts are uploaded onto the system
COBRA
COBRA is the electronic recording system designed in – house by members of the Information Team
All patients identified within cohorts are uploaded onto the system
The progress of each individual patient record can be tracked at each stage
Clinicians have described it as an intuitive system. Patient details are pre –populated so the reviewer needs to only add their outcome
Training has been offered and rolled out across the trust in group or individual sessions for managers and clinicians
NHSI have invited the Team to present COBRA at their National Conference in April 24th
07/11/2018
Project Director - Louise Glover

13. HARM Cancer Prospective HARM Cancer Retrospective
COBRA REPORTING
A snapshot of the level of detail recording all cohorts in COBRA. The current cohorts of patient records being reviewed by Trust Consultants are
HARM Cancer Prospective
HARM Cancer Retrospective
HARM Retrospective
07/11/2018
Project Director - Louise Glover

14. DUTY OF CANDOUR
The Duty of Candour is a legal duty on hospital, community and mental health trusts to inform and apologise to patients if there have been mistakes in their care that have led to significant harm
Communications to the public about the Clinical Harm Review has to date been minimal. This current approach has been agreed with Dr. David Black, NHSE Regional Medical Director
Progress is being made within the Clinical Harm Review, however, the degree of risk and extent of harm to patients that may have arisen due to excessive waiting is not yet clear. Therefore we do not wish to cause patients unnecessary worry at this point in time, and monitor the situation continually.
Position statement finalised and with Head of Communications as a standby statement ready to be used depending on specific inquiries, should the Trust receive any.
Should moderate or severe harm be identified the Serious Incident process will automatically be initiated
07/11/2018
Project Director - Louise Glover

15. RISKS
Lack of clinical engagement enabling the Clinical Harm Review to be completed at pace
A major risk is that the number of patients needing face to face clinical review and the degree of urgency for this to take place is not compatible with the clinical resources available at the Trust.
There are several specialties where there is a serious shortfall of capacity to meet the needs of patients currently in the care of the Trust and prevent the Trust being in this position in the future.
This will require the Trust and 3 CCGs to work together to identify and implement solutions.
07/11/2018
Project Director - Louise Glover

16. NEXT STEPS and RECOMMENDATION
The Trust needs to continue to minimise unnecessary patient follow up and agree with commissioners how this is managed and communicated.
Ensure that electronic referral is in place and used from October 2018
Clear communications on the reasons for follow-up / discharge; patient initiated follow-up and clarifying reasonable expectations of GPs in monitoring and managing patients according to advice from Trust clinicians, through the use of advice and guidance arrangements.
Working on commissioning priorities – Clear referral thresholds and follow up criteria in many specialties, poorly commissioned pathways (for example the MSK pathway), some ‘one consultant’ services which need re-commissioning and examples (such as the commissioning of optometrist to provide care to some patient groups who otherwise need to use ophthalmology services) where progress would both improve access to care, quality of care and save money.
Working with Commissioners to implement RightCare methodology Getting It Right First Time (GIRFT) Procedures of Low Clinical Value (PLCV)
Recommendation
Trust Board are asked: To Note progress to date
07/11/2018
Project Director - Louise Glover