8th mortality and harm reduction in cwm taf health board · 2015-11-14 · gtt each acute site...

Cwm Taf Health Board Insert name of presentation on Master Slide

Mortality and harm reduction

in CWM TAF HEALTH BOARD

8th November 2011

Cwm Taf Health Board

Leadership

Improve

information &

communication

Review quality of coding data

Review standard of record keeping

Share Learning from mortality and Global

Trigger tool (GTT) reviews

Establish Quality Improvement & Safety

Steering Group

Improving

Leadership

Reduce Mortality

& harm

GTT each acute site monthly

PCCT Pilot in 1 local GP practice

Undertake 50 mortality reviews consecutively

Take forward GTT findings for year 2009/10

with specific reference to quality of record

keeping

Pilot shared notes within community hospital

setting

Using Trend data to target mortality reviews to

areas of apparent concern

Expand mortality and GTT review teams


Leadership • Quality Improvement &

Safety Steering Group being embedded into Governance arrangement

– Primary & Secondary Care Representation

• Director Walk rounds continued to take place on a Friday to both Acute & Community Hospital Setting (July 2010 to September 2011 - 54

• Walk round process currently under review

Monthly Number of walkrounds undertaken


0

1

2

3

4

5

6

7

8

9

May

2010

Jul 2010 Sep

2010

Nov

2010

Jan

2011

Mar

2011

May

2011

Jul 2011 Sep

2011


Mortality

• Improved Quality of Coding

• Mortality reviews are undertaken on a weekly basis alternating between the two district hospitals using Global Trigger Tool

• Fully engaged with CHKS to gain a full understanding of the data and to inform priorities and reviews.

• Using trend data to target areas of apparent concern

• The reviews have highlighted effective use of the outreach team, appropriate use of the end of life pathway and Do not resuscitate process.

• Monthly speciality multi disciplinary reviews of mortality and morbidity cases continue to be held as part of the clinical auditprogramme - Trauma & Orthopaedics , General Surgery & 30 day mortality after anaesthetic

Reduce Harm & Mortality


Global Trigger Tool

• A weekly review of 10 randomly selected notes continues to take place on a weekly basis alternating between Prince Charles Hospital and the Royal Glamorgan Hospital.

• The review team has been expanded and now includes senior nurses on a rotational basis. Reviews are complete to July 2011 discharges.

• The reviews have demonstrated an improved compliance with the MEWS chart and appropriate and effective use of the outreach service.

• The top triggers for the Health Board are currently readmission within 30 days and complication of procedure or treatment

Reduce Harm & Mortality


Surgical Complications • The WHO/NPSA Surgical Checklist has been

implemented across the Health Board.

• Normothermia measures are in place and data captured and reported on a monthly basis.

• Appropriate Hair removal introduced across the Health Board with monitoring and reporting processes developed.

• Walking patients to theatres as per NICE guidelines has been implemented at Prince Charles Hospital from August 2011.

Compliance with peri-operative normothermia


0%

10%

20%

30%

40%

50%

60%

70%

80%

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011

May

2011

Jun

2011

Jul

2011

Aug

2011

Sep

2011

Compl iance Average (45%) Lower l imit 15%) Upper l imit 75%)

Compliance with appropriate pre-operative hair removal


0%

20%

40%

60%

80%

100%

120%

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011

May

2011

Jun

2011

Jul

2011

Aug

2011

Sep

2011


Compliance with WHO / NPSA Surgical Checklist


0%

20%

40%

60%

80%

100%

120%

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011

May

2011

Jun

2011

Jul

2011

Aug

2011

Sep

2011



Clostridium Difficile

• Achieved 46% reduction 2009/2010

• Achieved >20% reduction in 2010/2011

• Achieved lowest Clostridium difficile rate/1000 admission in Wales 2010/2011

• Monthly RCA performed and shared with Directorates

Healthcare Associated Infections

CWM TAF HEALTH BOARD

CLOSTRIDIUM DIFFICLE INCIDENCES

0

1

2

3

4

5

6

7

8

9

10

11

12

13

Oct

201

0

Nov

201

0

Dec

201

0

Jan

2011

Feb

2011

Mar

201

1

Apr 2

011

May

201

1

June

201

1

July

201

1

Aug

2011

Sept

201

1

MONTH

NU

MB

ER

Merthyr/Cynon

RCT

Non-Inpatients

CTHB


Hand Hygiene

• Weekly Hand Hygiene Audits undertaken by ward/department.

• Verification Audits undertaken by Infection Prevention & Control Team

• Audit repeated if score below 85%

• Feedback provided to Clinical Teams at time of audit on a weekly basis


CWM TAF HEALTH BOARD

IPC HAND HYGIENE

VERIFICATION AUDIT RESULTS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct 2010

Nov 2

010

Dec 2

010

Jan 2

011

Feb 2

011

Mar

2011

Apr

2011

May 2

011

June 2

011

July

2011

Aug 2

011

Sept 2011

MONTH

______ Average Monthly Score

_____ Compliance with hand hygiene


CAUTI Care Bundle

• Insertion and maintenance care bundle in use in Dewi Sant Hospital and Surgical wards at Royal Glamorgan Hospital (RGH)

• Surveillance set up to identify catheter associated urinary tract infections based on WHAIP/CDC definition

• Regular multi disciplinary meetings held

• Spread to other wards planned – 12 areas identified

• Compliance data submitted monthly via AQF data collection tool

HAI - Compliance with urinary catheter maintenance

bundle


0%

20%

40%

60%

80%

100%

120%

May

2010

Jul 2010 Sep

2010

Nov

2010

Jan

2011

Mar

2011

May

2011

Jul 2011 Sep

2011

Compliance Average (99%) Lower limit 97%) Upper limit 100%)

HAI - Compliance with urinary catheter insertion

bundle


0%

20%

40%

60%

80%

100%

120%

May

2010

Jul 2010 Sep

2010

Nov

2010

Jan

2011

Mar

2011

May

2011

Jul 2011 Sep

2011




PVC Care Bundle

• Draft care bundle implemented on 3 pilot wards within Royal Glamorgan Hospital and Prince Charles Hospital

• Insertion and maintenance bundle being revised to aid completion at ward level

• Surveillance set up across Health Board to identify line associated bacteraemia‟s

• MRSA, MSSA & line associated bacteraemia‟s investigated by IPCT

• Root Cause Analysis performed monthly and data to be shared with Directorates



• A fully established multidisciplinary Thrombosis Committee

• Thromboprophylaxis Policy approved June 2010

• Hospital Acquired Thrombosis is now an agenda item on Directorate Clinical Governance Meetings

• Thromboprophylaxis Risk Assessment Forms localised and launched in December 2010

• Full engagement of the Nursing Staff in the implementation of reducing Hospital Acquired Thrombosis initiatives

• Thromboprophylaxis education programme developed

• Audit programmes are being developed and implemented

• Mechanisms for establishing the Hospital Acquired Thrombosis rate are currently being formulated.

Hospital Acquired Thrombosis


Critical Care

Both the Ventilator bundle and Central Line Insertion / Maintenance bundles have been fully implemented in ITU on both sites. Data is captured on a monthly basis. A plan for spread is required.

ICC - Compliance with ventilator care bundle


0%

20%

40%

60%

80%

100%

120%

May

2010

Jul 2010 Sep

2010

Nov

2010

Jan

2011

Mar

2011

May

2011

Jul 2011 Sep

2011


ICC - Compliance with central line insertion bundle

(Adult ITU)


0%

20%

40%

60%

80%

100%

120%

May

2010

Jul 2010 Sep

2010

Nov

2010

Jan

2011

Mar

2011

May

2011

Jul 2011 Sep

2011


ICC - Compliance with central line maintenance

bundle (Adult ITU)


0%

20%

40%

60%

80%

100%

120%

May

2010

Jul 2010 Sep

2010

Nov

2010

Jan

2011

Mar

2011

May

2011

Jul 2011 Sep

2011



• MEWS – On all wards in Cwm Taf PCH/RGH adults and audited monthly.

• RRAILS – Currently Implemented On Ward 4 PCH Orthopaedics (Admission Bundle, Recognition Bundle, Response Bundle, Sepsis Six and SBAR) Ward 20 RGH

• RRAILS 2 minute safety briefing and handover checklist introduced on ward 4 PCH

• OUTREACH service implemented currently 9-5, 7 days a week

• SEPSIS SIX currently implemented in A&E PCH

• MEWS/NEWS comparison completed

• Outreach currently auditing score- to- door

• In the process of organising the introduction of NEWS

Rapid Response to

Acute Illness


Rapid Response to

Acute Illness• RRAILS working well on ward 4 PCH, working towards

releasing time to care

• 2 minute safety briefing has been a success and therefore staff are keen to roll out

• Need to roll out RRAILS to other wards

• MEWS Compliance still an issue, however observations are recorded and scored, outreach offers continual training on mews and is currently focusing on obstetrics and gynae

• SEPSIS SIX in use but needs to be updated

• Outreach is working really well, good feedback from all staff, ongoing training is essential on MEWS and sepsis

Rapid Response to Acute Illness


Main aims of

outreach service• Identifying the deteriorating patient and

averting/facilitating timely admissions to ITU

• Support and seamless care to patients

transferred from ITU to the wards

• Education of ward staff in the identification

and management of the deteriorating patient



MEWS Scores on

initial referral:

0

10

20

30

40

50

60

MEWS 0

MEWS 1

MEWS 2

MEWS 3

MEWS 4

MEWS 5

MEWS 6

MEWS 7

MEWS 8

MEWS 9

MEWS 1

0

MEWS 1

1

MEWS 1

2



Appropriate Referral

To Outreach

0

20

40

60

80

100

120

140

Gen

eral con

cern

High

Mew

s

Ass

ista

nce

Pot

ensial fo

r det

erea

tion

Res

p Fai

lure

Sep

tic

Fluid M

anag

men

t

Low B

P

<Not

ent

ered

>

Fluctua

tion

GCS

Low U

rine

Out

put

Con

sulta

nt R

eq

Reason Ref erred



Impact of Outreach

Cardiac Arrest Data• 7 months prior to outreach

– Total arrests: 70

– Arrests at night: 43 (61%)

– Arrests 09:00-17:00: 27 (39%)

• 7 months with outreach presence (09:00-17:00 minimum)– Total arrests: 79

– Arrests at night: 62 (78%)

– Arrests 09:00-17:00: 17 (22%)

• Outreach pts; 3 Arrest call after-hours(2x unexpected, 1x potentially preventable, although awaiting clarification resus

status)



SEPSIS 6

• Initial Management prior

to ITU referral

0

2

4

6

8

10

12

O2 Cultures iv Abx iv fluids Lactate Urine

output

Intervention

No o

f pati

en

ts

Surgery

Medicine


Diagnosis of Sepsis prior to ITU Referral?

Yes

32%

No

68%

Blood Cultures before Antibiotics?

Yes

11%

No

68%

Unclear

21%


NEWS x x x x

x x x

x x x x

x x x x

x

x

x x

7 x x x x

x

6 x x

5 x x x

4 x x

3 x x

2 x x x

1 xxx x x

x

1 2 3 4 5 6 7 8 9 10 11

10

9

8 New + Ve Responding To Both

7

6 trigger point NEWS

5

Missed By Both Not Intervening

4 When Using News

3

2

1

1 2 3 4 5 6 7 8 9 10 11

MEWS Trigger point

NEWS MEWS

MEWS/NEWS COMPARISON



Main Problems

Identified

• Failure to recognize sepsis

• Poor initial investigation and management

• Late referral to ITU

• Even when antibiotics, fluids prescribed,

often delay in administration



Learning

• Presentation to each group of F1

• Presentations to Student Nurses

• Medical Students on Outreach ward

rounds

• Establishment of a Critical Care Delivery

Group to review RRAILS.



ACTION BY WHOM BY WHEN PROGRESS

Complete comparison of MEWS/NEWS using set methodology Outreach Team October 2011 2x2 comparison grid completedActions identified

Identify changes needed to current documentation Outreach Team November 2011

Substitute MEWS for NEWS in 2 areas (1 PCH & 1 RGH) to pilot and gain local champions

Implementation Team November 2011

Evaluate changes Implementation Team January 2012

Awareness raising sessions / add to induction programme Medical / Nursing

Implementation Team February 2012 and ongoing

Student nurse awareness sessions Implementation Team November 2011

Global introduction Implementation Team March 2012

NEWS

Implementation Plan



MR

SA

c.D

iff

Me

d E

rro

rs

Fa

lls

Pre

ssu

re

Ulc

ers

Co

mp

lain

ts

609 609 609 199 419 429

Transforming Care

Highest Days since

Transforming Care


The Targets

Increase Direct Care Time [DCT] to at least 70%

-Average increase of 19%-Highest DCT to date is 80%

Increase Patient satisfaction to at least 95%

-Average increase of 7%-Highest result to date is 98%

Increase Staff satisfaction to at least 95%

-Average increase of 5%-Highest result to date is 92%

Transforming Care


0

1

2

3

4

5

6

7

8

9

10

Dec-0

9

Jan-1

0

Feb-1

0

Mar-

10

Apr-

10

Ma

y-1

0

Jun-1

0

Jul-10

Aug-1

0

Sep-1

0

Oct-

10

Nov-1

0

Dec-1

0

Jan-1

1

Feb-1

1

Mar-

11

Apr-

11

Ma

y-1

1

Nu

mb

er

of

Incid

en

ce

Month

Pressure Ulcers

Example

Introduced Skin

Bundle

Transforming Care


Falls

• The day hospitals, district nurses, ward nurses and rehabilitation teams have been working on trigger and assessment bundle with the NLIAH collaborative. An action plan has been developed for 2011/12 that include the following key actions: – implementation of the trigger/assessment bundles for

inpatients

– working with NPSA for those who have fallen in our care

– developing skills in multi factorial assessments, for those who carry out interventions and those who assess.

– Participating in SAFER 2 research with Ambulance services using trigger, assessment and if sufficient patients, intervention bundle.


0

1

2

3

4

5

6

7

8

9

10D

ec-0

9

Jan-1

0

Feb-1

0

Mar-

10

Apr-

10

May-1

0

Jun-1

0

Jul-10

Aug-1

0

Sep-1

0

Oct-

10

Nov-1

0

Dec-1

0

Jan-1

1

Feb-1

1

Mar-

11

Apr-

11

May-1

1

Nu

mb

er

of

Incid

en

ce

Month

Patient Falls

Example

Introduced patient Care

Rounding

Transforming Care


0

1

2

3

4

5

6

7

8

9

10

Feb-1

0

Mar-

10

Apr-

10

May-1

0

Jun-1

0

Jul-10

Aug-1

0

Sep-1

0

Oct-

10

Nov-1

0

Dec-1

0

Jan-1

1

Feb-1

1

Mar-

11

Apr-

11

May-1

1

Nu

mb

er

of

Incid

en

ce

Month

Medication Errors

New Process was introduced

Staff member returned to work

and not aware of new process

Example

Transforming Care


0%

10%

Ward 3, PCH Ward 11, PCH Dare Ward, AGH C Ward, AGH

8%

11%

27%14%

3%

7%

1% 1%

% Time Spent Looking, Collecting and Returning - Pilot Wards

Before

After

Transforming Care


0%

10%

20%

30%

40%


28%26%

28%

37%

17%20%

0%

23%

% Interruptions regarding Patient Status - Pilot Wards

Before

After

Transforming Care


0%

10%


12%

9%

7%

13%

6%

3% 3%

9%

% Time Spent in Handovers - Pilot Wards

Before

After

Transforming Care


0

20

40

60

80

100

120


52

109

22

59

24

55

6

35

Total Interruptions to nursing Staff Results - Pilot Wards

Before

After

Transforming Care

Cwm Taf Health Board Transforming Care

Achievements

• 50% reduction in time taken for handovers

• 28% reduction in time wasted locating

equipment and information

• 45% reduction in interruptions to nursing staff

• 69% reduction in time spent in medicines

administration

• 68% reduction in Admin


•„This is Me‟ –This leaflet was developed by the Alzheimer's Society , it aims to provide professionals with

information about the person with dementia as an individual. This will enhance the care and support

given while the person is an unfamiliar environment

•Patient Care Round [PCR]–is the scheduling of regular nursing rounds, at least once every two hours ,that incorporates

specific actions linked to the Fundamentals of Care. The intended outcome of PCR is improved

patient safety and experience.

•Relative Rounding -This is dedicated time for patient/relative/carer communication,

whereby nursing staff actively seek out relatives/carers,

giving them the opportunity to ask any questions.

•Patient Rest Time - Being in hospital can be physically and emotionally tiring for patients, an undisturbed

rest period gives them the opportunity to recuperate.

•Nursing Documentation

•at the bedside -

Patient documentation is often time consuming and frequently performed at the nurses

station .Moving patients documentation to the bedside puts nursing staff back at the patients

bedside.

Relatives are asked to contact the ward between 10am and 12pm midday with all non-urgent

telephone enquiries. This ensures that the nursing staff can give the information and time

needed and are not being pulled away from patient care activities.

•Phone Calls after 10am -

Other Initiatives


Anticoagulation: INR

Cwm Taf Total % of INR tests >5 and >8

(inpatients & outpatients)

Medicines Management

MMA - % patients (or results) with INR >5 in hospital &

community


0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

May

2010

Jul 2010 Sep

2010

Nov

2010

Jan

2011

Mar

2011

May

2011

Jul 2011 Sep

2011

Percentage

Value Average (2.7) Lower limit (n/a) Upper limit (n/a)

MMA - % patients (or results) with INR >8 in hospital &

community


0.0

0.2

0.4

0.6

0.8

1.0

1.2

May

2010

Jul 2010 Sep

2010

Nov

2010

Jan

2011

Mar

2011

May

2011

Jul 2011 Sep

2011

Percentage

Value Average (0.7) Lower limit (n/a) Upper limit (n/a)


Patient leaves with

all information

and next

appointment date

Patient arrives at

RGH just before

appointment time

Receptionist

books patient into

clinic on PAS

system

Patient waits to be

called in

Patient called in

clinic and finger

prick blood test,

result,

consultation and

new date given

Process map –

Re-designed POCT service



Patient Experience

How does service compare with previous

arrangements?

much better

better

no difference

worse



Patient Experience –Hospital or GP monitoring?

A Pie Chart Showing Patients' Preference for a GP- or RGH-

Provided Anticoagulation Clinic

GP

28%

RGH

35%

No Preference

37%



Patient Story• Mrs M, age 52

• Warfarin for 6 years following heart valve replacement

• Originally unstable INR, monitored in UHW, then transferred to RGH out-patients

• Experience was of long waiting times, often here all morning (“Warfarin day out”)

• INR was quite unstable, sometimes required injections to stop it going too low.

• At first was apprehensive about change in service but quickly re-assured

• Biggest improvements are – Much lower waiting times

– Immediate INR result

– Finger prick test (patient also has own machine)

– Keeps own Yellow Book and new dose given there and then

• Mrs M feels INR control is now much better

• Attends clinic every 3-4 weeks

• Reassured that back up advice always available from clinic staff if needed (feels more “in control” herself)

• Discusses medication changes with pharmacists in clinic



Patient Story

“I FEEL AS THOUGH I HAVE GOT MY

LIFE BACK – WARFARIN IS NOW A

PART OF IT”



StrokeBundle Compliance – Prince Charles Hospital

April 2010 September 2011

Bundle 11st Hours

23% 100%

Bundle 21st Days

31% 82%

Bundle 31st 3 days

77% 64%

Bundle 41st 7 Days

0% 100%


StrokeBundle Compliance – Royal Glamorgan Hospital

April 2010 September 2011

Bundle 11st Hours

0% 100%

Bundle 21st Days

5% 91%

Bundle 31st 3 days

10% 100%

Bundle 41st 7 Days

0% 100%


1st Hours Bundle

% compliance with First Hours bundle

Cwm Taf Stroke patients

from Jan 2010 to Apr 2011

0

10

20

30

40

50

60

70

80

90

100

Jan

2010

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011Months


First Days Bundle

• CT scan – 82%

• Weekend admissions. Since whiteboard has been in use on AMU, all patients have been compliant

% compliance with First Days bundle



0

10

20

30

40

50

60

70

80

90

100

Jan

2010

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011Months

Stroke


First 3 Days Bundle

% compliance with First 3 Days bundle



0

10

20

30

40

50

60

70

80

90

100

Jan

2010

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011Months

Stroke


First 7 Days Bundle

% compliance with First 7 Days bundle



0

10

20

30

40

50

60

70

80

90

100

Jan

2010

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011Months

Stroke


Chronic Heart Failure

• Initial audit October 2010

• 1000 lives implementation January 2011

• Repeat audit February 2011

Heart Failure

• Collect information about:– Accuracy of documentation in

notes

– Referrals to heart failure service

– Prescribing of ACE/ARB and

betablockers

– Warfarin prescribing in AF

– Impact of prompt stickers


Audit• Baseline Audit

– 100 patients randomly selected with a discharge diagnosis of heart failure

(ICD coding 150.0 – 150.9)

• Repeat Audit

– 41 consecutive discharges from cardiology ward (44% documented heart failure)

Chronic Heart Failure

Diagnosed Heart Failure Baseline Repeat

Echo 67% 100%

Referred to Heart Failure nursing

service

42% 78%

ACE Inhibitor 90% 89%

Betablocker 68% 67%

Warfarin for AF 74% 100%


Enhanced Recovery

After Surgery

• A national audit has been developed for LHBs to understand where the process is non-

compliant and it‟s overall reliability. In order to complete this tool, data needs to be collated,

input and then analysed on an individual patient basis. The tool is being populated across

both DGH sites but only the PCH data has been submitted to the 1000 Lives Programme.

• The data gathered so far indicates that the re-focus on ERAS is giving us the momentum to

deliver improvements in ALOS outcomes. In RGH ALOS has reduced from 9.7 days to 8.2

days. PCH whilst fairly static, is maintaining a downward trend with the ALOS

reducing to 6.4 days from 6.7 days. By comparing this ALOS data alongside programme

compliance it can be concluded that the more compliant the programme, the shorter the

length of stay.

• There is considerable variability in the current bundle compliance rates. However in order to

use this information effectively, there is a need to distinguish between our non-compliance

through incomplete data collection and non-compliance through practice


ERASOctober 2010 to April 2011

Patients re-admitted within 28 days of surgery = 6

Procedure Length of stay Reason for re-admission Re-admitted

within

Lap. right hemicolectomy 7 days Bowel obstruction 3 days

Lap Anterior Resection +-

ileostomy

4 days Pr bleeding 3 days

Anterior Resection +/-

Ileostomy

5 days No reason 3 days

Lap Right hemicolectomy 4 days Nausea 3 days

Lap Anterior Resection 7 days Nausea 1 day

For Anterior Resection +/- 8 days Abdominal pain

/constipation

3 days

Enhanced Recovery After surgery


Work streams

• Executive Leads & Operational Leads Identified

• Work stream groups being established

• Baseline audits & scoping exercises being undertaken

• Enhanced Recovery After Surgery

• Mental Health

• Improving Maternity Services

• Reducing Falls in the Community


First Episode Psychosis

• A position statement has been presented to the Clinical Governance (Mental Health) meeting where the next steps were agreed.

• The DUP calculations have been submitted to All Wales FEP group.

• Feedback on Cwm Taf position within Wales from All Wales review group is currently awaited.

• Key staff have been nominated in appropriate clinical areas who will coordinate and feedback information on FEP uptake.

• Project leads attended the All Wales update workshop on 12th September to review outcomes across Wales.


Key Contact Information

Dr David Cassidy – Assistant Medical Director for Governance & Quality Improvement

Arlene Shenkorov – Clinical Audit & Effectiveness Manager

Kellie Jenkins-Forrester – Clinical Governance Manager

Patient Care & Safety Unit


Administration Block

Dewi Sant

Pontypridd

CF37 1LB

[email protected]

[email protected]

[email protected]

mailto:[email protected]





8th mortality and harm reduction in cwm taf health board · 2015-11-14 · gtt each acute site...

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