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Quality Management Procedure for Patient Report Forms Page: of 12

Author: Senior Clinical Quality Manager Version: 2.2

Date of Approval: July 2015 Status: Final

Date of Issue: July 2015 Date of Review July 2017

Patient Report Forms:

Quality Management Procedure





Recommended by Executive Management Team

Approval date July 2015

Version number 2.2

Review date July 2017

Responsible Director Medical Director

Responsible Manager (Sponsor) Head of Clinical Quality

For use by All Trust employees

This policy is available in alternative formats on request.

Please contact the Senior Clinical Quality Manager

on 01204 498392





Change record form

Version Date of change Date of release Changed by Reason for change

2.0 October 2012 S Barnard

2.1 July 2013 M Peters Review

2.2 July 2015 M Peters Final





Quality Management Procedure for Patient Report Forms

1. Introduction ............................................................................................................................ 5

2 Purpose ................................................................................................................................... 5

3 Duties ...................................................................................................................................... 5

4. Scope ....................................................................................................................................... 6

5. PRF Quality Completion Standard ........................................................................................... 7

6. Reporting................................................................................................................................. 7

7 Quality Improvement and Action planning............................................................................. 8

8. Equality impact Assessment ................................................................................................... 8

9 Monitoring and Review of the Procedure .............................................................................. 8

Appendix 1: PRF Completion Standard Care Bundle .................................................................... 10

Appendix 2: Trust CPI Process Overview ...................................................................................... 11

Appendix 3: ................................................................................................................................... 12

Quality Improvement Process ....................................................................................................... 12





1. Introduction

1.1 Patient Report Form (PRF) completion is a legal requirement for the organisation and

the individuals; and constitutes a public record and legal document. The NHS code of

Practice (2006) states: ‘All individuals who work for an NHS organisation are

responsible for the any records which they create or use on the performance of their

duties. Furthermore, any record that an individual creates is a public record’.

1.2 The PRF may be called upon as evidence in a law court of a coroner’s inquiry and

therefore must be a full and contemporaneous record of the care given to the

patient.

2 Purpose

2.1 The purpose of this procedure is to ensure that the Trust has effective systems in

place to monitor and manage the quality of Patient Report Form (PRF) completion

across the organisation.

2.2 Appendix 2 provides an overview of the procedure in flow chart form.

3 Duties

3.1 The Chief Executive has overall statutory responsibility to ensure systems are in

place for the accurate completion of records; for all patients that are assessed and

treated by NWAS NHS Trust.

3.2 The Chief Executive of the Trust has delegated responsibility to the Trust’s Medical

Director who is responsible for ensuring effective systems are in place.

3.3 The Chief Consultant Paramedic has responsibility for ensuring there are systems in

place to monitor and manage the quality of PRF completion; including monitoring

and performance management of the process.

3.4 The Head of Clinical Quality is responsible for the development and implementation

of a system to monitor and manage the quality of PRF completion.





3.5 The Clinical Quality Manager and Clinical Quality Officer are responsible for

supporting local implementation and performance management of the procedure;

including the provision of advice and support in relation to quality improvement.

3.6 Advanced Paramedics and Service Delivery Management are responsible for the

local operational implementation of the procedure; ensuring the correct action is

undertaken within agreed timescales.

3.7 The Trust management have a responsibility to provide advice and support as

necessary regarding the procedure.

3.8 It is the responsibility of the Senior Paramedics to ensure that PRFs are collected and

audited as per the procedure; including supporting of local quality improvements.

3.9 It is the responsibility of all Trust personnel to ensure they follow and support this

procedure.

3.10 The Clinical Leadership Board is responsible for monitoring and reviewing the

implementation of the procedure.

3.11 The Trust Board and Executive Management Team are responsible for reviewing

reports received in relation to this procedure.

3.12 The Trust Clinical Governance Management Group is responsible for reviewing

reports received in relation to this procedure; including monitoring compliance with

the procedure.

3.13 The Emergency Service Clinical Quality Business Group is responsible for supporting

and monitoring the local implementation of the procedure and ensuring quality

improvements occur when necessary at a Sector level.

4. Scope

4.1 The procedure refers to all paper based PRFs and electronic PRFs used within the

organisation by Service Delivery staff.





5. PRF Quality Completion Standard

5.1 The Trust will use the PRF Completion Standard Care Bundle (Appendix 1) to define

the minimum standard for all completed PRFs.

5.2 All completed PRFs will be audited on a monthly basis, using the sample defined in

the PRF Completion Standard Care Bundle (Appendix 1).

5.3 The Trust Clinical Performance Indicator (CPI) process will be used to collect and

report data in relation to the PRF Completion Standard Care Bundle. An overview of

this process can be found in appendix 2.

6. Reporting

6.1 The Trust Care Bundle and CPI reporting process will be used to provide performance

information in relation to the quality of PRF completion.

6.2 Care Bundle and CPI reports will be produced using the Trust web-based reporting

tool with a pre-set reporting format.

6.3 Care Bundle and CPI reports will be produced on a monthly basis at station, sector

and area level.

6.4 A Trust and Area level Care Bundle and CPI exception report will be presented to the

Emergency Service Clinical Quality Business Group on a monthly basis.

6.5 Trust Care Bundle and CPI reports will be produced on a quarterly basis for the Trust

Board and Executive Management Team.

6.6 Trust Care Bundle and CPI reports will also be produced on a bi-monthly basis for the

Trust Quality Committee and Clinical Governance Management Group.





7 Quality Improvement and Action planning

7.1 The Trust will use an agreed Quality Improvement Process to manage the quality of

PRF completion (appendix 3).

7.2 Sector Managers and Advanced Paramedics will be responsible for agreeing and

overseeing the action planning process at Sector level.

7.3 The action planning process will be reviewed on a quarterly basis informed by CPI

quarterly reports.

7.4 All staff involved in the CPI process will be issued with a CPI resource that contains

guidance on the process and a range of quality improvement tools.

7.5 Advanced Paramedics and Senior Paramedics are responsible for acting on and

supporting the quality improvements at local level.

8. Equality impact Assessment

8.1 It was found that the Quality Management Procedure for the PRFs has a positive

assessment as it supports the equality agenda.

9 Monitoring and Review of the Procedure

9.1 This procedure will be reviewed every two year; however, if national guidance or

legislation changes, then the procedure may be reviewed at an earlier date.

9.2 As part of the procedure review process, the effectiveness of the procedure and its

application will be assessed. Information and results from audit systems, adverse

incidents, user feedback and external audits/reviews will be used to inform this

assessment.

9.3 The procedure will be monitored through the following systems:





Area for Monitoring Monitoring Process

The Clinical Quality Data Hub will be responsible for producing and managing the reporting

defined below.

Fulfilment of duties/responsibilities Presentation and review of reports at least

four times a year to the Trust Board and EMT

including assurance regarding Sector Level

action plans.

Criteria against which the clinical records

must be audited for all healthcare

professionals

Presentation and review of reports at least

four times a year to the Trust Board and EMT


action plans; specifically return rates for the

audit.

Frequency of audit of clinical records Presentation and review of exception

reports on return rates to the Emergency

Service Clinical Quality Business Group on at

each meeting.

Minimum content of audit reports Presentation and review of reports at least 4

times as year to the Trust Board and EMT


action plans

Arrangements for the development and

review of action plans

Audit of Sector Level action plans twice a

year by the Clinical Quality Manager

including presentation of an exception

report to the Trust Board, EMT and Clinical

Governance Management Group.





Appendix 1: PRF Completion Standard Care Bundle

PRF Completion

Short Description Percentage of patients with a completed Patient Report Form

Reason for this indicator Healthcare Professionals Code of Practice

NHSLA Ambulance Standard

Full indicator description 100% of patients should have a completed PRF with at least a minimum of

data attached

Definitions All patients that receive ambulance attendance

Target 100%

Measurement Method Any patient recorded by Emergency Service Staff

Sample 30 patient report forms per location (station)

Frequency Monthly

Additional Actions A separate PRF completion standard is applicable for Urgent Care Desk staff

Metric Standard %

Exception Data Source

PR1 Incident Number

95 Failure of Alert/MPDS PRF

PR2 Date 95

PRF

PR3 Response times – including time arrived at patient (excluding Triage, handover and Clear Hospital time)

95 PRF

PR4 Identities of clinicians (ID Number) 95

PRF

PR5 Vehicle Call Sign 95

PRF

PR6 Is the PRF legible? 95

PRF

PR7 Chief Complaint 95

Patient refusal

Patient absconded

PRF

PR8 Primary observations recorded? AVPU, Pulse, Resps, BP

95

Patient refusal

Patient contaminated

Violent or abusive patient

Patient absconded

PRF

PR9 Signature of attending clinician 95

PRF

PR10 Ethnic monitoring form completed 95 Patient unable to respond

Patient refusal

PRF





Appendix 2: Trust CPI Process Overview

SENIOR

PARAMEDICS

Clinical

Performance

Indicators CLINICAL PRFs

Stored data

on

IM& T Server

Manual input into Web based

application on Networked

station PC

INTRANET CPI REPORTS

Trust Board

Quality Committee

Clinical Governance

Management Group

etc

LOCAL MANAGEMENT

& STAFF

ALL STAFF

ACTION

PLANNING &

QUALITY

IMPROVEMENT

Quality Management Procedure for patient Report Forms Page: of 12




Monthly review of NWAS CPI and Care

Bundle Reports

Produce Care Bundle Quality Improvement

(QI) Reports by Clinical Quality team

Monthly review and

approval at Trust EMT

Monthly review at

Organisational

Performance Group

Heads of Service, Consultant Paramedics

& Sector Managers review report,

performance and local actions by Advanced

Paramedics

Advanced Paramedics review Sector Reports and develop quarterly prospective QI Plan at sector or station level

Communication and implementation of

actions

Monthly Integrated Performance report for

Trust Board.

CPI Assurance reporting to Quality

Committee

CPI Quality Improvement Report

to Clinical Governance Management Group

Standing agenda item review of Sector Reports and progress

made against the Quality Improvement Plan at Emergency Service Clinical Quality Business Group and local clinical quality

improvement meetings

Production of monthly comparator

performance QI reports by Clinical Quality team

Clinical Performance Indicator care bundle Quality Improvement Process

2015

Reporting & Assurance

Contracted CPI

Performance Report

submitted to

Commissioning Quality

Group.

Appendix 3:

Quality Improvement Process

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