1. WELCOME

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

3. 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

4. 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.

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

6. 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

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

8. 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

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

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

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

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

13. 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

14. Reports

15. Reports

17. Trauma: Who cares?

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

23. 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

24. 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*

25. 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

26. 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

27. 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

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

29. Case reviewers Multidisciplinary group Specialties Hospitals
Recruitment *

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

32. 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

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

34. 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

35. 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

36. 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

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

38. 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 s from Local Reporters
Polythene envelopes and considered using DX boxes

39. Current Studies

40. Non-Invasive Ventilation

41. 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.

42. Current status

43. Acute Heart Failure 43

44. 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

45. 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

46. Method
Sample/Method
HES (2012): admissions for heart failure, 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:

47. 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.

48. 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

49. Cancer in Children, Teenagers
and Young People 49

50. 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)

51. 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

52. 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

53. 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

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

55. Peri-operative Diabetes55

56. 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

57. Child Health Review 57

58. 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

59. 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

60. 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

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

62. 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

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

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

65. 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

66. 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

67. 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

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

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

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

71. Checklists 71

72. Gap analysis tool

73. Benchmarking data 73

74. Benchmarking data

75. Audit Tools 75

76. Audit tools

77. Audit tools

78. Audit tool

79. The Surgical Outcome Risk Tool (SORT)

80. The Surgical Outcome Risk Tool (SORT)

81. 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

82. 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

83. 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)

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