Quality Account 2012/13
“Aiming for high quality care for every person,
every time”
CONTENTS
Contents ............................................................................................................................... 2
1.
PART 1: STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE ........................ 1
2.
PART 2: PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF ASSURANCE ... 5
2.1.
2.1.1.
Progress against quality priorities identified in 2011/12 Quality Account .......... 5
2.1.2.
Quality Priorities for 2013/14 .......................................................................... 21
2.2.
3.
PRIORITIES FOR IMPROVEMENT 2012/13 .......................................................... 5
STATEMENTS OF ASSURANCE FROM THE BOARD ........................................ 23
2.2.1.
Review of Services/ Quality of NHS Services Provided .................................. 23
2.2.2.
Participation in Clinical Audits and National Confidential Enquiries ................ 25
2.2.3.
Participation in Clinical Research ................................................................... 29
2.2.4.
Use of the Commissioning for Quality and Innovation Framework ................. 31
2.2.5.
Registration with the Care Quality Commission ............................................. 32
2.2.6.
Information on the Quality of Data.................................................................. 32
2.2.7.
Quality Indicators ........................................................................................... 33
PART 3: OTHER INFORMATION ............................................................................... 42
3.1.
REVIEW OF QUALITY PERFORMANCE ............................................................. 42
3.1.1.
Patient Safety ................................................................................................ 42
3.1.2.
Clinical Effectiveness ..................................................................................... 46
3.1.3.
Patient Experience ......................................................................................... 49
3.2. PERFORMANCE AGAINST KEY NATIONAL PRIORITIES INCLUDING
INDICATORS AND PERFORMANCE THRESHOLDS IN THE FRAMEWORK ............... 53
3.3.
ADDITIONAL CONTENT FOR QUALITY.............................................................. 54
3.3.1.
CQUIN indicators 2012/13 ............................................................................. 54
3.3.2.
Key staff survey results 2012 and comparison with 2011 ............................... 54
3.3.3.
Responsiveness to patient needs .................................................................. 55
3.3.4.
Complaints ..................................................................................................... 56
2
4.
3.3.5.
Eliminating Mixed Sex Accommodation ......................................................... 58
3.3.6.
Care Quality Commission (CQC) Quality and Risk Profile.............................. 58
3.3.7.
The Patient Voice Group (PVG) ..................................................................... 59
ANNEX ONE: STATEMENTS FROM STAKEHOLDERS ............................................. 61
4.1. NHS HARROGATE AND RURAL DISTRICT CLINICAL COMMISSIONING GROUP
QUALITY ACCOUNT STATEMENT 2013 ....................................................................... 61
4.2.
HEALTHWATCH NORTH YORKSHIRE QUALITY ACCOUNT STATEMENT 2013
61
4.3. NORTH YORKSHIRE COUNTY COUNCIL SCRUTINY OF HEALTH COMMITTEE
QUALITY ACCOUNT STATEMENT 2013 ....................................................................... 62
4.4.
COUNCIL OF GOVERNORS QUALITY ACCOUNT STATEMENT 2013 .............. 63
5.
ANNEX TWO: STATEMENT OF DIRECTORS’ RESPONSIBILITIES .......................... 64
6.
ANNEX THREE: NATIONAL CLINICAL AUDITS ......................................................... 66
7.
GLOSSRAY…………………………………………………………………………………….70
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Harrogate and District Foundation Trust Quality Account 2012/13
1.
PART 1: STATEMENT ON QUALITY FROM THE CHIEF
EXECUTIVE
The purpose of this report is to provide information to the public on the quality of our
services, to demonstrate progress and improvements from last year and to inform you of our
priorities for next year. Where further work is needed on previous priorities, the document
details the clear workplans agreed to make the required progress. The quality priorities have
been agreed through consultation with patients and the public as well as staff, Governors
and other stakeholders.
Harrogate and District NHS Foundation Trust (‘HDFT’ or ‘The Trust’) is a high-performing
Trust, performing well against all national indicators. Quality of care for every patient, every
time, is the first objective of the Trust and we are committed to continuous improvement.
I, as the Chief Executive, am accountable for all that happens within HDFT and am also the
sponsor for ensuring quality of care. The Executive Director lead for Quality is the Chief
Nurse, Mrs Angela Monaghan. Our Board of Directors and Council of Governors are fully
committed to ensuring that the Trust’s top priority is the delivery of high quality care.
The Trust’s Governance structure was reviewed in 2011, as reported in last year’s Quality
Account. This structure remains fit for purpose and ensures that appropriate reporting and
scrutiny takes place in relation to quality matters.
The Quality and Governance Group plays a key role in monitoring the quality priorities and
initiatives that were identified in the Quality Account for 2011/2012 and continues to monitor
and drive a strong programme of quality improvement initiatives for 2013/14. The work plan
includes the identified priorities for next year as well as continuing the work of the priorities
from last year.
The Board of Directors meets in public on a monthly basis and receives performance and
benchmarking reports which include measures of quality. The nursing report includes a
quality and safety dashboard that details a large number of areas that are measured in
relation to the quality of nursing care.
It is acknowledged good practice to review ward nurse staffing levels regularly to ensure that
these are set at an appropriate level to provide high standards of nursing care. Within this
Trust, there has been investment in front line ward nursing in each of the last three years.
Most recently, a full adult ward staffing review has been undertaken leading to significant
investment in 2013/14 and further planned in 2014/15. The Trust is able to describe how
ward staffing levels compare with the Royal College of Nursing best practice standards and
the full attainment of these will guide future ward staffing investment decisions.
In addition a detailed review of the quality and sustainability of core services has been
carried out. This includes Urgent Care including the Emergency Department, Emergency
Surgery, Elderly Care, Maternity and Paediatrics.
The Trust has responded to the Final Report on the Inquiry into Mid Staffordshire NHS
Foundation Trust (Francis Report II) and has carried out a gap analysis against the
recommendations in the report.
We are totally committed to a culture of openness and candour across the organisation and
work hard to communicate efficiently and effectively with people who use our services and
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Harrogate and District Foundation Trust Quality Account 2012/13
staff. We have introduced ‘Listening Events’ led by Directors, at which staff can share good
practice and raise any concerns and be assured that the points they raise will be addressed.
Quality of Care Teams at local level across community and hospital settings provide the
forum for ensuring the delivery of quality care. They are multi-disciplinary and meet
regularly. Some of the teams have a linked Public Governor. The organisation aims to
ensure the values and ethos of the Trust are understood by all staff, and aims to develop
and strengthen the work of the Quality of Care Teams to ensure local actions are taken in
response to feedback and identified risks and to ensure consistent reporting.
There is a programme of safety visits and revisits to hospital departments, wards and
community based settings, reflecting the integration of community based and hospital based
services. Since September 2009, 78 visits have been carried out with 18 return visits and 8
new visits between January 2012 and March 2013. Significant issues raised at the safety
visits are reported to the Directorates for action and lead to resolution in the majority of
cases. Examples of good practice arising from the visits include better maternity staffing and
the organisation of specialist training for staff. Most issues raised on initial visits are resolved
before revisits.
In addition, to drive forward the quality agenda, the Board of Directors undertake Directors’
inspections on a monthly basis. These visits are unannounced and are led by an Executive
and Non-Executive Director and a Matron. The outcomes of the visits are reported to the
Board of Directors on a monthly basis.
HDFT promotes a culture of openness in reporting incidents, claims and complaints,
investigating them and learning from mistakes. Regular meetings are held, which are open
to all, to share good practice and learn from mistakes. The Trust has however identified over
the past year that it could be more responsive to patients who complain to us about the care
they received. In order to achieve this, a major review has been undertaken of the
complaints process and the actions identified to improve the process will be implemented
early in the 2013/14 financial year.
In our Quality Account last year we stated that the Trust would be monitoring its incident
reporting rates. I am pleased to confirm that the reporting rates have increased and our
reporting now matches the average rate for NHS Trusts.
In 2012/13, the Trust reported six serious untoward incidents on the Strategic Electronic
Reporting System (STEIS) and also informed the local commissioner, NHS North Yorkshire
and York (NYYPCT or PCT).
Of the six incidents, four related to delayed diagnosis, one related to an unexpected death
and the other related to a patient who had absconded from the hospital.
Each of these incidents has been thoroughly investigated. Investigation teams include NonExecutive Directors and external professional advice as appropriate. The findings from all
investigations are scrutinised by the Board of Directors and are used across the organisation
to ensure that learning from these events takes place and that the possibility of recurrence of
similar events is minimised. In turn, these incidents have been externally scrutinised by the
PCT and in future will be scrutinised by the Commissioning Support Unit (CSU).
The Quality Account should highlight areas where the Trust needs to improve, as well as our
achievements and one of these areas is discharge. We are working hard to increase
satisfaction levels with our discharge processes; however we know we are not always
getting it right. That is why we have identified it again as a priority for improvement over the
coming year. Further detail is included later in the report.
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Harrogate and District Foundation Trust Quality Account 2012/13
The Trust is appreciative of the patient and public feedback it receives and uses this
proactively to drive improvements in care. HDFT is fortunate to have strong public
engagement through the Trust’s Members and the Governors, the lay representatives who
serve on Trust Committees, the Lay Readers who proof read patient information, the
independent Patient Voice Group which monitors the quality of services provided from a
patient perspective and the large numbers of other volunteers who support HDFT and its
patients so well.
To the best of my knowledge the information presented in this document is accurate. In light
of the Trust’s commitment to openness and transparency and the recommendations of the
Francis II Report, the full Board of Directors has committed to signing the Quality Account to
confirm that the information contained within it is, to the best of its knowledge, accurate and
representative of the Trust’s performance over the past year*.
Signed
Richard Ord (Chief Executive)
Date
Name/Role
Date
Mrs Sandra Dodson (Chairman)
28 May 2013
Dr David Scullion (Medical
Director)
28 May 2013
Mr Jonathan Coulter (Director of
Finance/Deputy Chief Executive)
28 May 2013
Mrs Angela Monaghan (Chief
Nurse)
28 May 2013
Mr Robert Harrison (Director of
Performance and Delivery)
28 May 2013
Mr John Ridings (Non-Executive
Director/Chair of Audit
28 May 2013
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Harrogate and District Foundation Trust Quality Account 2012/13
Committee)
Mr Robert Wivell (Non-Executive
Director/Vice Chair/Senior
Independent Director)
28 May 2013
Mrs Sarah Nattress (NonExecutive Director)
23 May 2013
Mrs Sue Symington (NonExecutive Director)
28 May 2013
Mr Ian Ward (Non-Executive
Director)
28 May 2013
(not present at meeting on 28 May
2013)
*The Board of Directors signed the Quality Account as described above. The signed copy
was submitted to our regulator as part of the Annual Report and Accounts.
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Harrogate and District Foundation Trust Quality Account 2012/13
2.
PART 2: PRIORITIES FOR IMPROVEMENT AND STATEMENTS
OF ASSURANCE
2.1.
PRIORITIES FOR IMPROVEMENT 2012/13
In its Quality Account and Report 2011/12, the Trust set out three key quality priorities for the
coming year:
Improving End of Life Care
Improving Discharge
Improving Fundamental Care
In addition, during 2012/13 the Trust’s Quality and Governance Group has been monitoring
other elements of the quality improvement work plan. The workplan included the following
priorities that were identified by HDFT staff, Governors and external stakeholders, and
supported by the Board of Directors:
Dementia care – to improve the pathway of care for patients admitted into acute care
who also have dementia;
Community equipment and responsiveness of service – systems to ensure
appropriate provision of equipment to support the Care Closer to Home Strategy ;
Stroke care – to include the establishment of a Community Stroke Team;
Outpatient services – reducing waiting times within identified specialty clinics;
The deteriorating patient – to introduce the National Early Warning Score and
escalation process and monitor local practice against this;
Safe prescribing and drug administration – the implementation of the e-prescribing
project and a reduction in drug errors;
Clinical handover – the implementation of a new communication process for
multidisciplinary handover of care particularly out of hours ;
Inpatient falls reduction – to focus on the recording of data, falls prevention and the
minimisation of harm to patients.
This section of the report contains information regarding the progress that has been made
for each of the three key priorities. The additional priorities are reported on in part 3 of this
report.
2.1.1. Progress against quality priorities identified in 2011/12 Quality Account
1. Improving End of Life Care
“How people die remains in the memory of those that live on”.
Dame Cicely Saunders
Founder of the Modern
Hospice Movement
Aims and rationale
The aim of this priority is to improve end of life care for all patients, and to support dignity,
choice and equality. The work is co-ordinated by our End of Life Steering Group which is
chaired by a Non-Executive Director of the Trust. The specific work planned related to:
A clearer understanding of the key concepts involved in care at the end of life
supported by appropriate use of the Liverpool Care Pathway (LCP)
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Harrogate and District Foundation Trust Quality Account 2012/13
Supporting patients to make autonomous decisions about where they choose to die,
with a priority being their usual place of residence
Promoting the implementation of documentation to support conversations and robust
resuscitation decision making processes.
Work done and results
a) Appropriate use of the Liverpool Care Pathway
We wanted to increase the awareness of all professionals delivering end of life care with the
emphasis on compassionate, confident and competent communication and assessment
skills to enhance best practice. This will ensure that end of life care is supported by the LCP
when that is appropriate. The aim is to introduce the end of life pathway to the organisation
through an updated version that fully supports patients, carers and staff with all aspects of
end of life care. The pathway was recommended as a model of best practice in the last
hours or days of life in National Policy (DH 2006, 2008) and in the End of Life Care Strategy:
Quality Markers and Measures for End of Life Care (2009). In addition, the Trust aimed to
continue the improvement previously achieved in completion of the documentation of the
LCP within the hospital setting, and wanted to audit for the first time the completion of the
LCP for patients cared for by its community staff.
Achieving these goals would be supported by increasing the number of staff trained in the
use of the LCP.
During the year, the latest version of the LCP has been introduced across all hospital wards
within HDFT, and 52% (156/300) ward-based registered nurses are now trained in its use. In
addition, approximately 53% (134/252) relevant doctors have received some training in
selected aspects of end of life care during the year. The End of Life Facilitator and the
Chaplains hold four seminars a year about end of life care and staff report increased
confidence in the use of the LCP following training.
The use of the LCP on the hospital wards to support patients at the end of life is monitored
and the results show that 39.2% of patients who died in 2011/12, and 37.5% of patients who
died in 2012/13 were supported by the LCP in the last days or hours of life. The use of the
LCP during 2012/13 was lower than we hoped to achieve, given that audits within the Trust
have indicated that approximately 65% of patients who died in hospital would have benefited
from being supported by the use of the LCP. Wards with significantly low use have been
identified and supported to understand the rationale for use.
It is relevant to note that use of the LCP received negative national media coverage in
November 2012, and following this, the use dropped to 20%. In response to this, two
‘Medicine for Members’ events were held to provide members of the Trust with greater
understanding of the LCP and address any questions and concerns.
Regarding the complete documentation of care using the LCP, audits have been undertaken
since 2011. Earlier results are difficult to compare because they were undertaken when
using version 11 of the LCP. The following results are all since version 12 of the LCP was
implemented on the hospital wards.
Quarter 4
2011/12
Quarter 1
2012/13
Quarter 2
2012/13
Audited pathways with at least 80% LCP goals completed
40%
78%
83%
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Harrogate and District Foundation Trust Quality Account 2012/13
Documentation of care on the LCP by the Trust’s community staff has been audited for the
first time during 2013/14 and the average baseline goal completion was 77%.
Next steps
The Trust will undertake an organisational response to the LCP review with the aim of
increasing public confidence in all aspects of end of life care.
The Trust will continue to establish clarity and frameworks to enhance patient dignity, choice
and equitable care, and improve communication, coordination and collaboration in all
settings.
The Trust now aims to introduce the latest version of the LCP in the community together with
training, and introduce effective monitoring of the use of the LCP to support patients at the
end of life in the community.
b) Supporting patients to die in their preferred place
The ability for patients to die in their preferred place is a key indicator of quality care, but the
ability to establish care services for such patients in a timely way is frequently reported as
challenging. It is equally recognised that patients can ‘miss the opportunity’ to go home as
they may deteriorate and be too ill to travel once discharge plans are in place. Initial work
was to establish the current baseline for timeliness of discharges.
The Trust has undertaken a detailed audit of the discharge of patients with a rapidly
deteriorating condition which may be entering a terminal phase. We aim to achieve
discharge within 48 hours of the decision for discharge for these patients, but the results
revealed a median time of 4 days, and only 2 of the 9 patients audited were discharged
within 2 days.
Next steps
The factors causing delay have been identified and a “Rapid Improvement Event” will be
delivered in the coming year to identify opportunities to reduce delays.
c) Promoting good resuscitation decision making
Cardio pulmonary resuscitation (CPR) could be attempted on any individual in whom cardiac
or respiratory function ceases. Such events are inevitable as part of dying and thus,
theoretically, CPR could be used on every person prior to death. It is therefore essential to
identify patients for whom CPR is inappropriate, or who have requested that CPR is not
attempted at the end of their life, in order to ensure dignity, quality of care and patient
choice. This involves sensitive and skilled communication with patients and their families.
The decision making is documented on a “Do Not Attempt CardioPulmonary Resuscitation”
(DNACPR) form.
In 2011 HDFT adopted a new regional DNACPR form and implemented a revised Trust
DNACPR policy to support this. The results of an audit early in 2012 were disappointing and
significant work was undertaken to communicate with clinicians and to clarify the Trust policy
in relation to good resuscitation decision making and completion of “do not attempt
cardiopulmonary resuscitation” (DNACPR) documentation. This included:
Improving endorsement of any decision made by a non-consultant by a Consultant
within 24 hours
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Harrogate and District Foundation Trust Quality Account 2012/13
Improving the sharing of a DNACPR decision with the patient and family (where
appropriate)
Ensuring forms travel with the patient from the hospital to the community (where still
relevant)
The audit results were shared at audit and governance meetings, the Consultants’ Forum
and Sisters/ Matrons meetings. The Medical Director communicated with all consultants to
clarify expectations, and two practical sessions were held for consultant staff on how to have
DNACPR discussions.
Initial data from monthly audits appeared to demonstrate an improving position but the
number of forms reviewed was small. The annual audit in December 2012 looked at all
inpatients with DNACPR on a single day, which amounted to a sample size of 67.
Disappointingly this revealed that there are still significant problems with the DNACPR
process, most notably around consultant endorsement, the documentation of sharing the
decision with the patient and their family, setting review dates for the decision, and effective
awareness of decisions amongst nursing staff. On a positive note processes at discharge
were much improved. The results of audits are given in the following table:
Objectives
Standards
2012
(Dec)
2012
(Jan)
New DNACPR
form
2011
2010
2009
Old style DNACPR form
1.
DNACPR orders are filed correctly
at the front of the notes.
100%
94%
100%
99%
93%
2.
DNACPR orders completed by a
non-consultant grade should be
endorsed by a Consultant within 24
hours.
DNACPR
orders
contained
adequate patients demographics.
100%
38%
52%
55%
51%
30%
100%
100%
100%
4.
DNACPR order contains relatives’
details in full.
100%
45%
5.
Nursing documentation contained
information about the presence of a
DNACPR.
100%
62%
86%
77%
1%
6.
All DNACPR forms must have at
least one of the boxes ticked in
Section one (Reason for DNACPR).
100%
100%
7.
Documentation
in
the
notes
regarding a discussion about the
DNACPR order.
The Review section of the
DNACPR form must be completed.
100%
35%
100%
16%
9.
Discharged patients had the
DNACPR form sent home correctly.
(Documented
on
the
GP
letter/discharge checklist).
100%
80%
35%
10
Section must be complete. (Print,
Sign,
Designation,
Date,
Organisation).
The form must be completed in full.
100%
64%
80%
100%
19%
30%
3.
8.
11
8
2008
78%
20%
36%
31%
Harrogate and District Foundation Trust Quality Account 2012/13
Next steps
An action plan has been produced to address the themes relating to DNACPR, local
education is on-going and the frequency of audit has been increased, however embedding
good DNACPR decision making and practice into the organisation remains a challenge.
A preliminary result from the first quarterly audit in March 2013 has shown a marginal
increase in the percentage of forms being endorsed by a consultant and a marginal
improvement in the discharge processes. Review of the DNACPR form and communication
about DNACPR orders with staff, patients and relatives where appropriate, requires further
improvement. The quarterly audits will be continued and results will be reported directly to
clinical teams as well as to senior clinical groups in the organisation.
Summary
The Trust is working in partnership with Saint Michael’s Hospice and has recently appointed
a full time Macmillan End of Life Facilitator, and this role will support the Trust to continue to
prioritise improvement in the quality of care provided for HDFT’s patients at the end of life.
2. Improving Discharge
Aims and rationale
The aim of this priority is to ensure inpatients are discharged as soon as clinically indicated,
to improve the patient’s experience of discharge and to reduce delays at discharge. In
addition, we have had a local Commissioning for Quality and Innovation (CQUIN) target that
relates to moving from hand written discharge communication with GPs, to increasing the
number of electronic discharge letters, which ensure that information is clear, based on a
standard template, and therefore contain the information required by the patient’s GP.
This work is lead by the Discharge Steering Group, and various measures of discharge are
monitored regularly.
Work done and results
a. Efficient discharge planning
Discharge is an essential part of care management, and should ensure that health and
social care systems are proactive in supporting patients, their families and carers to either
return home or transfer to another setting. Whilst hospitals are the right place for patients
requiring acute (emergency) and elective (planned) care, an efficient discharge to the
appropriate setting is in the best interests of all. Discharge is therefore planned for at the
earliest opportunity, ideally on admission for emergency admissions if appropriate at that
point and prior to admission for elective admissions.
Achieving a safe and timely discharge is a complex activity. Premature discharge can mean
the patient is poorly prepared, may have unmet needs, and readmission is more likely.
Delayed discharge increases the risk of infection, loss of independence and inappropriate
use of hospital resources.
The discharge process should be a multi-disciplinary and multi-agency activity to avoid
unnecessary hospital re-admissions and to ensure the needs and resources of patients and
carers are at the centre of discharge assessment, planning and implementation. We also
aim to ensure a continuity of care between hospital and the agreed on-going care provider
with effective written and verbal communication to achieve a seamless service transition.
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Harrogate and District Foundation Trust Quality Account 2012/13
The work to improve discharge planning has included:
The introduction of best practice discharge planning standards
The assessment of medical need and social circumstances in relation to discharge
planning to be recorded on admission
The use and regular review of target discharge dates
The introduction of electronic whiteboards on all wards to enable communication of
target discharge dates, and other information to the multidisciplinary team.
A patient flow database to identify and proactively manage potential delays
Service development facilitators have been working on Byland and Jervaulx wards to
seek opportunities to improve communication and information flow between ward
rounds, handover and multidisciplinary team meetings
Weekly meetings between the Discharge Liaison Team and representatives from
Leeds and North Yorkshire social care to discuss the progress and discharge
requirements of relevant patients. In addition, the Discharge Steering Group
membership includes a senior representative from each area.
The introduction of a hospital based Discharge Co-ordinator role. This has been a
valuable asset in reducing length of stay (in some cases by 17 days) when delays
are caused by poor communication between the Multidisciplinary Teams and Social
Services. This has also had a positive effect on patient experience as patients are
reporting being more involved with their discharge planning. In comparison to wards
which do not have a Discharge Co-ordinator, patients fed back that they were kept
more up-dated about their discharge. Other wards are keen to adopt this model and
have begun identifying ways in which this role can be supported.
The discharge dashboard is published by the Information Services Team once a
month and is circulated to Directorate leads, General Managers, Director for
Partnerships & Innovation and Ward Managers. It contains key performance
indicators that demonstrate how wards are performing in relation to discharge
processes. Directorate leads are then responsible for identifying actions to address
any performance gaps. This is monitored through the Discharge Steering Group on a
bi monthly basis.
The Trust aims to record a target discharge date (Intended/ Planned Discharge Date (IDD/
PDD)) as soon as a plan of care has been identified and this should be regularly reviewed
and communicated to the patient, relatives and carers and the multidisciplinary team. The
use of the target discharge dates is one of the discharge performance metrics monitored in a
new “discharge dashboard”.
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Harrogate and District Foundation Trust Quality Account 2012/13
The use of the target discharge date has improved during 2012/13 but we have not achieved
our target standard of 95%.
Next steps
The Discharge Steering Group will continue to monitor progress and promote activity and
opportunities to support efficient discharge planning.
b. Improving patient experience of discharge
A telephone survey to capture the experiences of patients within two to seven days following
their discharge was undertaken during February to May 2012. Volunteers collected the
names of patients who consented to receiving a telephone call, and then members of the
Patient Voice Group telephoned these patients at home to ask a set of standard questions
based on the Picker Survey (a national NHS survey co-ordinated by the Picker Institute on
behalf of the Care Quality Commission).
99 patients were surveyed with a ratio of medical: surgical patients of 1:16.
81% of patients said they were completely ready to be discharged, 11% were ready
to some extent and 8% were not ready;
44% were made aware of their planned discharge on the day of discharge. 24% said
they knew a few days before, with only 16% indicating that they were aware of their
discharge date on admission;
73% were discharged from the wards, and 25% from Harrogate District Hospital’s’s
discharge lounge ;
80% of patients said they felt involved in decisions about their discharge plans, 9%
said they did not need to be involved and 11% reported not being involved;
37% felt their discharge was delayed. Of these, 46% were delayed less than 2 hours,
32% were delayed between 2-4 hours and 27% were delayed over 4 hours;
71% of respondents said they were fully informed of the purposes of their medication.
6% indicated they were not informed;
90% of these were told how to take medications in a way they could understand, and
94% were given clear written or printed information about their medications;
83% were informed about who to contact should they have concerns about their
treatment or condition following discharge. 15% said they were not given this
information;
51% said they had received copies of letters sent between hospital doctors and the
GP, 39% said they did not receive them. 86% of those who received a copy of the
latter said that it was written in a way they could understand.
The majority of these patients felt ready to be discharged and involved in their discharge
plans. However they were usually informed of the date of their discharge on the actual day
and often waited more than 2 hours to be discharged after being told they could go home.
This report is predominately representative of the surgical wards, and tends to reflect the
activity of short stay episodes. It reflects the high level of engagement that the Elective Care
Directorate has with the patient experience process.
The Trust implemented an online survey in January 2013 to capture patient feedback
relating to the discharge process. Unfortunately the response rate from the online survey
was poor with only nine responses between January and March 2013 and therefore the
results were not necessarily representative.
Any incidents or complaints that relate to discharge are investigated and any learning is
incorporated into the work to improve discharge.
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Harrogate and District Foundation Trust Quality Account 2012/13
Next steps
Online patient feedback following discharge as a methodology will be reviewed, and other
opportunities to capture patient feedback considered. Improvement targets will be
considered for each Directorate regarding participation in patient experience surveys and
discharge surveys, and the Discharge Steering Group will monitor progress.
c. Reducing delays at discharge
An audit of the discharge process to identify delays was first undertaken in 2010, and
identified various delays in the process, particularly relating to the dispensing of “take out”
medicines from Pharmacy. Since then, the Trust has aimed to reduce these delays and
improve the efficiency of the discharge process. Improvements include the use of electronic
discharge letters and the implementation of sophisticated pharmacy facilities and processes.
The audit was repeated in September 2012 and the results showed an average 30%
reduction in time from the patient being told they could go home, to actually leaving (3 hours
38 minutes, compared to 5 hours and 11 minutes). Although waiting for medications was still
cited by patients as the main cause for this delay in the telephone survey reported above,
the remaining delays are now generally not due to delays in obtaining medications from
Pharmacy. Additional audits have shown that delays are caused by information not being
“handed on” to the next step in the process efficiently i.e. from doctor to Pharmacy to nurse
etc. Facilitators are currently working with the ward teams on Byland and Jervaulx Wards to
make this process more visible and timely.
Next steps
Learning from the work being done by the facilitators will be shared with other wards.
d. Electronic discharge letters
Improving the continuity of care between secondary and primary care with effective
discharge communication has been a local CQUIN indicator for 2012/13. The Trust has been
working to ensure an increased proportion of discharge letters are printed from an electronic
system rather than hand written on paper templates. Electronic letters enable the text to be
clear, and some relevant information to be imported from the system to the letter, hence
improving the clarity and efficiency of the communication.
The Trust has developed further standard electronic discharge letter templates for different
specialties that set out the information required, using our electronic results software. Having
ensured that appropriate templates are available to staff, we have been promoting the use of
the electronic discharge letters and the results have shown a significant improvement during
the year.
12
Harrogate and District Foundation Trust Quality Account 2012/13
In order to focus on the areas that use the software containing the relevant discharge letter
templates, the following areas are excluded from the above data, which is therefore not the
same as our CQUIN data relating to discharge letters: Endoscopy, Ophthalmology, Pannal,
Pannal Babies, Delivery Suite, Mowbray Square, Outpatients, Macmillan Dales Unit, Special
Care Baby Unit, Clinical Investigations Area, Harrogate Heart Centre.
Next steps
Some specialties use different software, and therefore further work is ongoing to understand
how to ensure all patients can be discharged with a high quality electronic letter.
Summary
Significant work is being undertaken to improve effective “patient flow” which in turn the
Trust expects to assist effective discharge. Wards and directorates will be supported to
deliver local improvement plans which accurately reflect the discharge process and patient
experience.
Further work to improve discharge includes encouraging a greater involvement of patients in
their discharge process with regular information on Hospital Radio, reminding patients to ask
about discharge and medications etc. In addition discharge training for staff will be
prioritised.
The Board of Directors will continue to review key discharge information every month. The
Trust will work with partners across a range of agencies to ensure timely, safe and efficient
processes.
3. Improving Fundamental Care
Aims and rationale
The aim of this priority is to ensure the delivery of the highest standards of fundamental care
to all patients in relation to:
Nutrition and hydration
Pressure ulcers
Communication, privacy, dignity and compassion
Environmental cleanliness
High quality patient experience includes the quality of caring by staff and the environment in
which care is delivered.
The Trust aims to ensure that these standards of care provided by its staff are done well and
in a timely way. This is because we know that these aspects of personal care and
cleanliness are particularly important to patients and their families and are the foundations
for the provision of excellent care. The targets for improvement set at the beginning of
2012/13, the work achieved and results are reported below.
Work done and results
a. Nutrition and Hydration
The Trust’s Nutrition Group leads this work, and initiatives have previously been introduced
to support nutritional care for our inpatient areas. These include the role of nutritional
assistants, mealtime volunteers, protected mealtimes, the use of the red tray system for
patients at nutritional risk, and a regular review of the patient menu.
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Harrogate and District Foundation Trust Quality Account 2012/13
However, The Trust wanted to improve compliance with standards to ensure effective
assessment of nutritional need, and timely actions to support high quality nutritional care.
i. Patients weighed on admission
The Trust has an internal target to weigh at least 70% of patients on admission. The results
of recent audits and monitoring show:
Month of audit /
monitoring
February 2012
February 2013
Number of patients
in sample
58
60
Patients weighed on admission or
reason for not weighing documented*
71% (41/58)
85% (51/60)
*Data source: Monthly Matrons checks
ii. Nutritional screening within 24 hours
The Trust’s internal target is to ensure at least 90% of patients admitted are screened for
nutritional risk within 24 hours, in order to enable staff to address nutritional requirements in
a timely manner. In August 2012, 97% (62/64) patients audited had nutritional screening
undertaken but only 78% were within 24 hours of admission. This is now monitored every
month, and the average result for assessment of nutritional risk on admission for 2012/2013
is 96.6%.
iii. Alignment of nursing and dietetic screening results
An audit in 2011 compared the consistency of nutritional risk screening results by the
nursing staff and dietetic staff, and found that only 23% of the scores were the same. This
implies a risk that the nutrition risk assessment might not be accurate. A further audit in
August 2012 did not demonstrate any improvement. Work has since been undertaken to
improve this including:
Modifications to the screening tool with supporting education for senior nursing staff
in December 2012
Strengthening of the assessment tool guidelines and supporting documents
A screening tool introduced at Ripon Community Hospital
Newly employed registered nurses to have structured time with the dieticians on
induction
Further audits are now planned.
iv. Protected mealtimes
Protected mealtimes are periods on a hospital ward when all non-urgent ward based
activities, both clinical (i.e. drugs rounds) and non-clinical (i.e. cleaning tasks), are limited to
those that are relevant to mealtimes or “essential” to undertake at the time. During these
times patients are able to eat without being interrupted and staff can offer assistance. There
should be a quiet and relaxed atmosphere in which patients are afforded time to enjoy
meals, and unwanted activity through the ward during mealtimes is minimised. We aim to
emphasise to all staff, patients and visitors the importance of mealtimes as part of care and
treatment of patients. Further work has been undertaken during 2012/13 to support
protected mealtimes:
The protected time has been standardised across all adult inpatient areas
Protected mealtimes have been introduced at Trinity Ward, Ripon Community
Hospital
A review of food trolley delivery times to the wards
The Patient Voice Group undertook the first audit of compliance with protected
“evening” mealtimes in November 2012 and concluded that “ …. the understanding
and practice of the protocols for protected mealtimes were noticeably well embedded
14
Harrogate and District Foundation Trust Quality Account 2012/13
within the culture of HDFT”. However some non-urgent clinical activity was observed
on 66% (6/9) wards during the evening meals audited.
Next steps
The planned actions for next year are:
Increasing the number of patients weighed on admission or documenting reasons for
non compliance
Reducing the variances in nutritional screening between nursing and dietetics
A “nutrition focus week” is planned for 2013.
b. Pressure Ulcers
The Pressure Ulcer Steering Group leads this work, monitors results and plans actions that
need to be taken.
Pressure ulcers are a type of injury that break down the skin and underlying tissue, and are
caused when an area of skin is placed under pressure. They are also sometimes known as
'bedsores' or 'pressure sores'. Pressure ulcers tend to affect people with health conditions
that make it difficult to move, especially those confined to lying in a bed or sitting for
prolonged periods of time. Prevention of pressure ulcers in patients at risk, and the treatment
of existing pressure ulcers, requires excellent nursing care. Pressure ulcers are graded from
one (least severe) to four (most severe).
Pressure ulcers of grade three or above are currently reported as a clinical incident, and are
reported via the Quality and Safety Dashboard to the Board of Directors on a monthly basis.
There were six reported in 2011/12 and 12 in 2012/13.
During 2012/13 the Trust has implemented the NHS Safety Thermometer, which is an
improvement tool for measuring, monitoring and analysing patient harms and "harm free"
care at a local level. The tool is used to take the "temperature" of organisations or clinical
settings in relation to four indicators, including pressure ulcers. The NHS Safety
Thermometer classifies pressure ulcers as:
Old: pressure ulcers present on admission or developed within 72 hours of admission
to hospital
New: pressure ulcers developed 72 hours or more after admission to hospital.
On one day each month, all relevant patients cared for on the wards, and treated by the
community teams are surveyed. This “point prevalence” data provides an indication of
relevant harms. The data is not comparable with the incident data above.
% of Patients reported with no Pressure Ulcers
July
% Patients with no reported
Pressure Ulcer
Number of patients with no
reported Pressure Ulcer
% Patients with no reported
NEW Pressure Ulcer
Number of Patients with no
reported NEW Pressure Ulcer
% Patients with no reported
OLD Pressure Ulcer
Number of Patients with no
reported OLD Pressure Ulcer
Aug
2012
Sept
2013
Oct
Nov
Dec
Jan
YTD
Feb
Mar
Totals
Totals %
4835
93.57%
5067
98.06%
4934
95.49%
92.12% 93.63% 92.40% 94.86% 92.80% 95.25% 91.95% 93.10% 95.93%
538
500
486
535
554
542
537
553
590
97.95% 98.31% 98.29% 98.76% 96.65% 98.95% 97.26% 97.98% 98.54%
572
525
517
557
577
563
568
582
606
94.18% 95.32% 94.11% 96.10% 95.98% 96.31% 94.69% 95.12% 97.40%
550
509
495
542
573
15
548
553
565
599
Harrogate and District Foundation Trust Quality Account 2012/13
Next steps
The planned actions for 2013/14 are:
To also report grade 2 pressure ulcers as clinical incidents from April 2013 in order to
monitor the number of less severe pressure ulcers more closely to try and prevent
further pressure damage
To classify pressure ulcers to provide more information about the origin i.e. hospital
acquired, home acquired (patient’s home, residential and nursing home), community
acquired (patient in receipt of HDFT community nursing care)
To hold a Trust wide educational event focusing on the assessment, prevention,
grading and treatment of pressure ulcers during 2013/14
To revise and re-launch the Pressure Ulcer Policy
The appointment of a further Tissue Viability Nurse to commence in May 2013. This
will provide an expert, integrated service across community and acute care settings.
c. Communication, privacy, dignity and compassion
Patient care should be based on a patient’s individual needs and should be delivered with
compassion, dignity and respect. High quality communication between staff, patients and
their relatives is given such a high priority because patients are not merely customers or
clients but human beings with physical problems, fears, anxieties, insecurities, relationship
issues etc, and the Trust wants its staff to recognise this and, as far as possible, to care for
patients with understanding, empathy and wisdom.
Understanding the patient’s pathway from the perspective of the patient will drive
improvements in the quality of patient experience. In order to achieve this, the Trust needs to
encourage patient feedback, and then ensure that it uses the information from our patients
and their relatives and carers to improve the patient experience.
Patients and carers at HDFT are invited to complete a feedback questionnaire on the day of
discharge. This questionnaire currently contains 19 questions covering different aspects of
the care received, and provides an opportunity to make comments and/or suggestions for
improvements. The information generated from this survey is fed back directly to the ward
teams on a monthly basis in order to help them respond to the matters that mean most to the
patients in their care.
The survey has been running for over four years across the adult inpatient wards at
Harrogate District Hospital. At the end of each year the questionnaire is reviewed and
updated to reflect current issues arising from local and national influences.
During 2012/13, the Trust aimed to:
Improve the medical ward patient feedback
Increase the numbers of questionnaires completed by carers
Maintain the existing high level of satisfaction, but improve the results in relation to
areas with lower results in previous years, including staff introducing themselves and
communication around discharge plans
Identify a strategy to increase communications training for staff
Maintain the lower level of complaints relating to staff attitude and communications in
2012/13.
16
Harrogate and District Foundation Trust Quality Account 2012/13
i. Patient satisfaction
The number of patient feedback responses is:
Directorate
Medical wards
Surgical wards
Total
2010-2011
277
1379
1656
2011-2012 2012-2013
289
441
1556
1204
1845
1645
Overall this represents a decrease in the overall number of responses received by 11% from
last year. There has been a decrease in response rate (number of responses out of total
number of discharges) of 23% across the surgical wards but an increase in response rate of
53% across the medical wards. However the current response rate remains higher from the
surgical wards (20%) compared to the medical wards (11%).
More medical wards (including Trinity at Ripon Community Hospital) have participated in the
patient survey this year. The patient satisfaction questionnaire has been adapted to include
the NHS Friends and Family Test (FFT), and will be introduced on Lascelles and Acute
Medical Unit (AMU) Fountains Wards from April 2013. The FFT asks a standardised
question “How likely are you to recommend our ward/A&E department to friends and family if
they needed similar care or treatment?” Combined with follow-up questions, it provides a
standardised mechanism to identify both good and bad performance.
The Trust is still getting low numbers of questionnaires completed by carers, with only 16
completed questionnaires from 2012/13, compared to one completed questionnaire between
September 2011 and March 2012.
The Trust has included all the data relating to communication, privacy, dignity and
compassion from the patient satisfaction survey results in the following table.
Survey Question
Q3.
Did
all
staff
introduce
themselves to you when they
approached you for the first time?
Q4. Were you addressed by your
preferred name?
Q6. Do you feel you privacy and
dignity has been respected as far as
possible?
Q8. Were you involved as much as
you wanted to be in decisions about
your care and treatment?
Q19. Were you kept up to date
about your discharge plans and
informed of any changes?
% of ‘Yes always’
answers
April 12- Nov 12Oct 12
Feb 13
% of ‘Yes, always’ &
‘sometimes’ answers
Apr 12 Nov 12Oct 12
Feb 13
% of patients who
said ‘No’
Apr12- Nov 12Oct 12
Feb 13
78%
75%
95%
96%
<3%
3%
83%
86%
97%
96%
<1%
3%
93%
93%
98%
99%
1%
<1%
83%
79%
97%
94%
2%
4%
59%
62%
73%
77%
11%
9%
Table: Sample of survey questions responses compared to last report October 2012
17
Harrogate and District Foundation Trust Quality Account 2012/13
High levels of satisfaction are maintained in relation to staff referring to patients by their
preferred name, privacy and dignity and being involved in decisions. There has been a slight
improvement in relation to patients being kept up to date about discharge plans.
Next steps
We aim to increase overall patient feedback through a more streamlined version of the
questionnaire which will incorporate the Friends and Family Test. This has already been
extended to include the Emergency Department. People using the maternity services will be
included during 2013. The results will be monitored using a new safety and quality
dashboard which will be reported to each Board of Directors meeting and the results will be
used to make improvements where required, and will be used to benchmark performance.
ii. Communication training
A customer care/patient-staff communication training course called “Every Patient Every
Time” was designed within HDFT during 2010. The course is designed to deliver the public
values enshrined in the NHS Constitution, and the Trust’s objectives, of which delivery of
high quality patient and staff communications is a key feature.
Training continues across the organisation and during 2012/13 626 staff have received
training. This training has now been delivered to 1397 members of staff since January 2011.
Next steps
Further work is still required to identify a strategy to increase communications training for
staff groups currently not accessing the “Every Patient, Every Time” training.
iii. Complaints and concerns
The focus within the Trust on communication and providing high quality care for “every
patient, every time” aims to have a positive effect on the complaints and concerns in relation
to attitude and communication.
2012/13
Q1
Total Concerns and Complaints
2012/13
Q2
2012/13
Q3
2012/13
Q4
Total
113
155
150
161
579
Total Relating to Communication and
Attitude
75
78
80
93
326
Admin Attitude
Medical Attitude
Nursing Attitude
Other Attitude
Allied Health Professional Attitude
Admin Communication
Medical Communication
Nursing Communication
Other Communication
Allied Health Professional Communication
1
16
11
3
1
1
22
15
3
2
6
14
13
1
1
0
28
12
0
3
7
14
12
1
1
4
28
11
2
0
5
12
18
3
2
3
24
14
10
2
19
56
54
8
5
8
102
52
15
7
Table: Complaints and concerns received 2012/13.
During 2011/12, there were a total of 321 complaints and concerns regarding
communications and attitude. The data for 2012/13 shows we have received 326
comparable complaints and concerns, and therefore the number of concerns and complaints
relating to poor attitude and communication has broadly remained the same. This is
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Harrogate and District Foundation Trust Quality Account 2012/13
disappointing given the focus and energy relating to this topic across the organisation during
2012/13.
An important first step in addressing poor attitude and communication is for the staff involved
to reflect and appreciate that their approach could have been better. A greater openness
about poor attitude and communication is being actively promoted, and there has been
careful monitoring of the proportion of cases where the Trust agrees that the case was well
founded. We are encouraged to see a greater openness and responsiveness by staff to
patient feedback and this will continue to be promoted. The ongoing approaches to
improvement for 2013/14 are described in this report, part 2.1.2 item 3.
Next steps
In order to further build confidence in patients and families through excellent communication
practice with ward staff, two projects have been initiated.
1. “Intentional Rounding”
Intentional rounding is a quality improvement process that supports improved
communication between patients and nursing staff. This includes work to assess the
feasibility of undertaking hourly checks on all patients, not only those who require hourly
or more frequent clinical observations. The hourly check will have safeguards to ensure
equity and consistency for all inpatients. The check will have several elements e.g.
personal needs, position, possessions and wellbeing, and “is there anything else I can
do for you?”
The project leader will act as facilitator/coordinator and support the ward sister and
nursing teams to introduce this initiative over a six month period until all inpatient wards
have implemented intentional rounding.
2. “The 15 Steps Challenge” (NHS Institute for Innovation and Improvement)
As part of the productive care work streams this tool kit has been developed to help staff,
patients, service users and others to work together to identify improvements that can
enhance patient and service user experience. The challenge toolkit also helps gain an
understanding of how patients and services users feel about the care provided and what
gives them confidence. It will also help the Trust understand and identify key
components of high quality care that are important to patients and service users from
their first contact with a care setting.
The post holder will make recommendations to the Corporate Nursing Group regarding
the implementation and success of the project and will provide regular updates to the
wider organisation. The project work commenced on 1 May 2013.
In the last quarter, the role of the Quality of Experience Group (QEG) has been reviewed to
emphasise the significance of patient experience to the organisation as a whole. The terms
of reference have been reviewed to increase the numbers of lay representatives to provide
scrutiny.
d. High quality care environments including cleanliness
The Trust acknowledges that creating a positive first impression both by the quality and
cleanliness of the physical environment and the friendliness and approachability of the staff
is important. This builds confidence in the Trust’s services by patients and visitors alike.
During this last year, particular efforts have been put into ensuring that the Trust’s public
spaces are well maintained and as “clutter free” as possible.
19
Harrogate and District Foundation Trust Quality Account 2012/13
The expansion of the Equipment Library has meant that more clinical equipment can be
safely stored away from busy clinical environments and supplied quickly when required for
patient care.
Maintaining high standards of cleaning across the Trust is very important to the Trust. The
Trust’s cleaning staff are important members of the team and feedback from the public is
generally very good. The Trust does however scrutinise standards through a variety of
methods including the regular unannounced inspections throughout the organisation.
The Trust continues to prioritise unannounced Director inspections of all inpatient ward
areas on a regular basis. These focus on infection prevention and control standards within
clinical areas. Twenty four visits and six re-visits have been undertaken between April 2012
and March 2013. This compares to 35 visits and 13 revisits during 2011/12. These are
currently monitored and reported on the Quality and Safety Dashboard. In order to
demonstrate close understanding of front line services and to provide further assurance
regarding the quality of care delivered, since the last quarter of 2012/13 Non-Executive
Directors have joined the unannounced inspection visits. In addition the ward environment
continues to be monitored and reported through the monthly Matron’s checks.
The Patient Led Assessment of the Care Environment (PLACE) has been introduced to
replace Patient Environment Action Team (PEAT). It is anticipated that the requirements of
PLACE will be more challenging than PEAT as it covers additional aspects of the patient
environment and cleanliness. The focus is to put patient’s representatives in the driving seat
of the assessment and therefore the assessments will be patient led. It is intended that the
forthcoming assessments will include representatives from Patient Voice Group,
LINKS/Local Healthwatch and Trust Governors. A mock inspection took place in October
2012 and the overall scores for cleanliness were;
Scoring total cleanliness – Harrogate District Hospital 98.73%
Scoring total cleanliness – Lascelles Ward 95.70%
Scoring total cleanliness - Ripon Community Hospital 98.18%
The actual assessment period will be 2nd April to 21st June 2013 and all organisations should
receive their preliminary results in July 2013, with final national publication scheduled for
September 2013.
The Patient Voice Group as part of their monitoring visits, observe and assess the quality of
the physical and care environment. See section 3.3.5 for details
Next steps
The Trust will aim to undertake two unannounced inspections each month and ensure that
any areas that fall short of the exacting standards applied, would receive a re-visit within a
month.
Summary
HDFT also had a review of dignity, nutrition, safeguarding, staffing, and record keeping
standards through an unannounced inspection by the Care Quality Commission in August
2012. The Trust was identified as being fully compliant.
In addition the Trust achieved NHS Litigation Authority (NHSLA) Risk Management
Standards level three in March 2013, which includes an external assessment of 50
standards. These include patient falls, moving and handling of patients, care of the
deteriorating patient, clinical handover of care and discharge.
20
Harrogate and District Foundation Trust Quality Account 2012/13
2.1.2. Quality Priorities for 2013/14
In seeking to identify its quality priorities for 2013/14, the Trust sought to involve staff,
Governors and other stakeholders. Initial views were received from staff via their Clinical
Directorates. The Trust then invited Governors to review the suggested priorities and also
consulted with:
North Yorkshire Local Involvement Network (LINk), now local Healthwatch
North Yorkshire County Council Scrutiny of Health Committee.
In addition, the Trust consulted a wide range of other stakeholders through its regular
contacts, including the Patient Voice Group and Harrogate and Rural District Clinical
Commissioning Group.
The Trust will have several quality improvements priorities for 2013/14. These have all been
approved by the Board of Directors and will include:
1. High quality and safe discharge
Feedback from patients, relatives and carers through a variety of systems have indicated
continuing issues with the Trust’s discharge process. This issue has a very high profile
status within the organisation and the work to improve is particularly focussed on the patient,
relative and carer experience of discharge.
This priority will focus on continuing the work to deliver efficient discharge from hospital with
appropriate transfer of care and information to ensure patient safety and improved patient
experience. This will include reviewing systems that support effective discharge to ensure
they maximise benefits to both the system and patient experience. Projects will include:
Monitoring key performance indicators in relation to discharge planning across
wards/ Directorates
Supporting wards and directorates to deliver local improvement plans which
accurately reflect the discharge process and patient experience.
2. Use of technology to drive safe and effective care
This priority will focus on increasing the use of technology to improve communication and
accessibility to deliver safe and effective care. This is a quote from the Rev Dr Mervyn
Willshaw, the Deputy Chair of the Council of Governors:
“For me, the most exciting prospect with regard to IT in healthcare is that it offers
patients much greater scope for knowing and understanding the nature of the
diagnosis of their problem and sharing more fully in the therapeutic process.”
The Trust wants to be proactive in exploring all the possible uses of technology to improve
the delivery of care to patients, but the work will include:
Supporting staff by providing access to mobile technology
The development of Assistive Technology programmes (Telehealth, Telemedicine
and Telecare). This includes completing and evaluating a telehealth pilot, which is
due to complete in November 2013, and to make recommendations for next steps
after this. Telehealth has the potential to deliver more localised care for patients and
to provide more timely diagnosis and intervention
21
Harrogate and District Foundation Trust Quality Account 2012/13
Continuing the work to promote safe prescribing and administration of medicines
following the introduction of an electronic prescribing and administration system
(ePMA)
Continuing work to develop technology to support patient handover, including
Hospital@Night.
3. Improving fundamental care
This priority will continue to focus on the delivery of the highest standards of fundamental
care to all patients in relation to nutrition and hydration, pressure ulcers, communication,
privacy, dignity and compassion, and environmental cleanliness. We aim to ensure high
quality fundamental care is provided for every patient, every time, and that all care matches
the recent experience of this patient:
“There were three other ladies on the ward and they needed assistance with
personal care. The night nurse and support worker were prompt to answer bells, they
were kind and courteous and quite frankly wonderful. In my words “nothing was a
bother” and their focus was on the patient. I saw the doctor at night and he was the
same, he told me my diagnosis and what will happen next, he was able to answer my
questions and I was happy.”
Many of the work streams developed previously will be continued, but additional projects will
include:
Working to reduce the prevalence of pressure ulcers reported using the NHS Safety
Thermometer
Responding to the recommendations of the Francis Report II, including:
o Responding to early warning indicators in order to anticipate challenges to
high quality care provision
o Director inspections and safety visits
o Acting on Friends and Family Test results including qualitative analysis and
reports
o Improving care and compassion, through recruitment, training and ensuring
an appropriate culture in clinical areas at all times by all staff
o Changes to complaints management and using patient feedback more
proactively
o Using clinical audit to drive higher levels of care delivery, and documentation
of fundamental care, with particular emphasis on nutrition.
The Quality and Governance Group will monitor progress with this work. Each priority will
have project leads assigned, and specific metrics will be agreed. Baseline reports and
progress reports will be reviewed to ensure progress. In addition, the Quality and
Governance Group will monitor other elements of the quality improvement work plan during
2013/14, which have also been identified by HDFT staff, Governors and external
stakeholders and that are supported by the Board of Directors.
22
Harrogate and District Foundation Trust Quality Account 2012/13
2.2.
STATEMENTS OF ASSURANCE FROM THE BOARD
During 2012/13 HDFT provided and/or sub-contracted 61 relevant health services.
HDFT has reviewed all the data available to them on the quality of care in all of these
relevant health services.
The income generated by the relevant health services reviewed in 2012/13 represents 100
per cent of the total income generated from the provision of relevant health services by
HDFT for 2012/13.
2.2.1. Review of Services/ Quality of NHS Services Provided
Performance summary of 2012/13
All access and waiting times standards were achieved in 2012/13 including cancer
waiting times and 18 weeks referral to treatment times (RTT)
The Trust achieved all three of the newly introduced dementia screening
performance indicators in February 2013 for the third consecutive month, meaning
the Trust has achieved the associated CQUIN target for 2012/13.
The number of operations cancelled at the last minute for non-clinical reasons during
2012/13 was 139. This is higher than the previous year but below the target level. No
patients waited longer than the 28 day standard to be readmitted following a
cancellation at the last minute for non-clinical reasons
The 4 hour Emergency Department standard of 95% was consistently delivered for
the whole year
The five key Emergency Department clinical quality indicators were delivered in all
four quarters of 2012/13
There were no mixed sex accommodation breaches at the Trust during 2012/13
Provisional data indicates that 82% of stroke patients spent 90% or more of time on
the Stroke Unit in 2012/13, above the 80% standard
The Trust achieved the C. difficile trajectory for 2012/13, with a total of 11 cases of
hospital acquired C. difficile infection reported, against a maximum trajectory of 11
There were two cases of hospital acquired MRSA infection in 2012/13. This is above
the Department of Health trajectory of one case, but below the Monitor (healthcare
regulator) “de minimis” target level of six cases
Recruitment of health visitors to support the national “Call to Action” strategy was at
91.6 whole time equivalents (WTEs), which is above the end year trajectory.
External Validation
The Care Quality Commission (CQC) carried out an unannounced visit to review compliance
on 1 August 2012. The inspection team observed how people were being cared for, looked
at records of people who use services, talked to staff and talked to people who use services.
The results in relation to the relevant outcomes were:
CQC Outcome
Outcome 01: Respecting and involving people who use services
Outcome 05: Meeting nutritional needs
Outcome 07: Safeguarding people who use services from abuse
Outcome 13: Staffing
Outcome 21: Records
23
Result
Compliant
Compliant
Compliant
Compliant
Compliant
Harrogate and District Foundation Trust Quality Account 2012/13
The CQC also carried out a visit in February 2013 to monitor Section 120 of the Mental
Health Act 1983 in acute hospitals. The CQC were satisfied that the Trust has the systems
and processes in place to manage the detention of patients with mental disorder, and that
the Trust is continuing to develop its working relationship with the mental health service
provider to enhance the care of mentally disordered patients. We are working with
commissioners and partners to take forward three recommendations.
The Trust was successful in achieving Level 3 of the NHS Litigation Authority (NHSLA) Risk
Management Standards in March 2013 with a score of 49/50 standards. This assessment
included services across the integrated organisation, which is a significant achievement.
Assurance Structure
The Trust’s governance structure and assurance mechanisms enable data to be reviewed
relating to all elements of quality, patient experience, patient safety and effectiveness of
care. Data, performance metrics, audit results, survey results and inspection reports indicate
whether services are being provided to the appropriate standards. If deficiencies are
identified, improvement plans and additional monitoring and data capture is introduced. The
key Trust governance structures and systems are described below.
The organisational structure for delivering integrated governance (incorporating clinical,
research, information, financial, risk management and performance elements) and the
systems that underpin them are explicitly designed to ensure safe, high quality care and to
give appropriate warning of deterioration in standards or performance to enable early
intervention to take place.
The Board of Directors places a strong emphasis on effective communication “Ward
to Board” and this is reflected in the management and governance structures of the
Trust;
At the heart of the structures are the three clinical directorates, which provide the
majority of the Trust’s services. The Clinical Directors attend the Board of Director
meetings each month and provide strong link between the Board and front line multidisciplinary staff;
A Governance Board for each Clinical Directorate is in place and the content of these
meetings reflects both local specialty matters and cross cutting Trust clinical and
non-clinical priorities;
Quality of Care Teams are in place across the organisation and report to the
Directorate Quality and Governance Boards. The focus of these teams is on
continual service improvement;
The Quality and Governance Group has strong representation from both senior staff
within the Directorates and at corporate level and whilst this group does not report
formally to the Board there is a direct line of accountability to the Senior Management
Team of the Trust;
An important element within the governance structure now and previously is the
separation of operational and scrutiny functions. The operational elements are
described above. The scrutiny or assurance elements include the Audit Committee,
which is a formally constituted sub-committee of the Board of Directors. This
committee provides independent assurance on governance and controls including
internal and external audit ;
The Audit Committee is supported by the Standards Group. This group is responsible
for ensuring that recommendations from external reports, audits, visits and regulators
including the CQC are met and that data from the Trust to outside agencies is quality
assured. The Standards Group also provides assurance to the directors and Audit
Committee from clinical audit. It is accountable to the Director Team, but minutes are
received at the Audit Committee;
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Harrogate and District Foundation Trust Quality Account 2012/13
The Corporate Risk Review process is well established within the organisation.
Departmental and Directorate risk registers are reviewed to enable the Board of
Directors to be advised on the principal risks and the plans in place to reduce or
mitigate the risks;
The Assurance Framework is produced annually within the Trust and draws together
progress on the Trust’s strategic objectives, the Care Quality Commission’s outcomes
and the Corporate Risk Register’s principle risks. The framework also includes
references to the Francis II report. An update on progress is produced every six months.
2.2.2. Participation in Clinical Audits and National Confidential Enquiries
Clinical audit is a quality improvement process that seeks to improve patient care and
outcomes through systematic review of care against explicit criteria and the implementation
of change. Put more simply, clinical audit is all about measuring the quality of care and
services against agreed standards and making improvements where necessary (NICE,
2011).
This means that clinical audit identifies the gaps in current practice and identifies areas for
improvement. One of the most important aspects of the audit cycle is to re-audit to ensure
that clinical care has improved following implementation of actions.
National Audits
During 2012/13, 30 national clinical audits and four national confidential enquiries covered
relevant health services that HDFT provides. 14 audits were from the National Clinical Audit
and Patient Outcome Programme and 16 were run by other organisations. During 2012/13
HDFT participated in 93% of the national clinical audits and 100% of national confidential
enquires of the national clinical audits and national confidential enquiries which it was
eligible to participate in. The Trust did not participate in two national clinical audits during
2012/13, however the Trust is planning to participate in one of them in 2013/14. The Trust’s
Standards Group did not agree with the methodology proposed for the other.
The national clinical audits and national confidential enquiries that HDFTwas eligible to
participate in during 2012/13 are shown in the list at Annex 3. The national clinical audits and
national confidential enquiries that HDFT participated in, and for which data collection was
completed during 2012/13 are listed in Annex 3, alongside the number of cases submitted to
each audit or enquiry as a percentage of the number of registered cases required by the
terms of that audit or enquiry.
The reports of five national clinical audits from the 2012/13 programme and nine from the
2011/12 programme were reviewed by HDFT in 2012/13 and HDFT intends to take the
following actions to improve the quality of healthcare provided:
Adult Critical Care
Continued improvement of our processing time resulting in a faster turnaround of
data
Continued monitoring to ensure that our in-hospital cardio-pulmonary resuscitation
rates prior to Intensive Care Unit (ICU) admission remain very low. Our admission
rate is currently lower than would be expected for a unit of our size, and below the
national average. This implies that deteriorating patients are recognised prior to
cardio-pulmonary arrest and admitted to ICU when appropriate.
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Harrogate and District Foundation Trust Quality Account 2012/13
Continuing monitoring to ensure that our unit acquired infection rates (MRSA, C Diff,
blood infections) and admission infection rates (MRSA and C. difficile) remain below
the national average
Continued monitoring to ensure that mortality rates for ventilated admissions and
pneumonia continue to trend down, as they have over the last three years. Current
progress has been achieved as a result of the introduction of a ventilator “care
bundle” and the contribution of on-going audit. The ventilator care bundle is a series
of interventions related to ventilator care that, when implemented together, will
achieve significantly better outcomes than when implemented individually.
Continued monitoring to ensure that our unit mortality ratios continue to trend
downwards and remain below the national average.
Transfusion Sample Labelling
Continued monitoring to ensure that the number of errors in labelling blood samples
taken for transfusion continue to decrease
Continued monitoring to ensure that in two of the high risk areas, Emergency
Department and Labour ward the error rate continues to decrease, thereby improving
patient safety.
Heart Failure
Continued monitoring to ensure that referral rates to cardiac nurses continue to
improve
Continued monitoring to ensure that communication between community heart failure
nurses and secondary care continue to improve discharge planning by holding twice
weekly meetings
Ensure further identification of patients not on cardiology wards is improved by closer
working of Cardiac Nurses and Cardiac Occupational Therapists.
Paediatric Diabetes
Continue the delivery of training to nursing and medical staff on the safe use of
insulin and diabetes in paediatrics
Continue to review, develop and monitor guidelines and protocols in line with NICE.
Lung Cancer
Continue to deliver performance similar to comparator trusts for case mixed adjusted
outcomes
Deliver annual peer review or self-assessment and annual work plan to ensure
performance is maintained and improved
Continue to ensure that radiotherapy rates reviewed at Multi-Disciplinary Meetings
Ensure that the LUCADA (lung cancer data) data base shows steady year on year
improvements.
Local audits
One hundred and fourteen projects (excluding national) audits were registered with the
Clinical Effectiveness Department during 2012/13. This includes 19 projects aimed at
improving quality by using service evaluation and patient experience surveys. As shown in
the figure below, the audits were undertaken by specialities within the following directorates.
The results of local audits are presented at the directorate or specialty audit/governance
meetings. Audits are completed with a summary report identifying recommendations and
actions for improvement. In order to close the “audit loop” and complete the audit cycle reaudits should be completed as evidence that improvements have been made.
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Harrogate and District Foundation Trust Quality Account 2012/13
The reports from 27 of these local clinical audits were reviewed by the provider in 2012/13
and HDFT intends to take the following actions to improve the quality of healthcare provided.
Community Acquired Pneumonia
Community Acquired Pneumonia management including the requirement to
document why a particular antibiotic has been prescribed, will be included in Core
Trainee teaching
If there is variance, from Trust guidelines, reasons for this should be documented in
notes
All prescriptions should have duration and indication and all intravenous (IV)
antibiotics should be reviewed at 48 hours.
Chlamydia screening in under 25's
In order encourage more clients to accept the Chlamydia screening test, a scratch
card has been introduced by Yorscreen that clients can use to assess their risk of
Chlamydia. The Trust supports all people under 25 being given this card on arrival in
the clinic
The Trust will support an improvement in the submission rate of screening samples
by encouraging clients to submit a sample during their clinic visit
Continue to deliver 100% achievement in offering Chlamydia screening test, and
documenting any reasons given for declining the test
Audit of Venous Thromboembolism (VTE)Risk Assessment
VTE risk assessment forms should be completed on relevant inpatients and accurately
identify the clinical indications placing patients at risk of thrombosis and also those at risk of
bleeding if thromboprophylaxis is used. The audit identified that of the patients within the
audit sample (medical and general surgery) 71% had all the relevant risk factors completed
on the risk assessment form.
When the audit is repeated, it will incorporate patients from other areas of the
hospital for example, obstetrics, orthopaedics.
More detailed guidance will also be provided on which comorbidities (additional
diseases) are relevant and put patients at greater risk of VTE and greater detail of
how possible omissions may affect the management of the patients.
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Harrogate and District Foundation Trust Quality Account 2012/13
Management of Suspected Venous Thromboembolism
Ensure increased awareness amongst clinical teams of the importance of specific
tests for patients with suspected pulmonary embolus and DVT, and management of
patients prior to confirmation of diagnosis
In order to facilitate management consider the use of a pre-printed Pulmonary
Embolus pathway document, based on the Outpatient Deep Vein Thrombosis
pathway used by the Emergency Department
Consider the addition of guidance on target times for imaging and clinical
management for suspected VTE
Review HDFT guidelines for management of inpatient and outpatient suspected VTE
in line with National Institute for Health and Care Excellence
Ensure that for all patients in whom a VTE was excluded an alternative diagnosis is
offered and documented
A re-audit is planned for 2013/14.
Management of VTE in emergency surgical patients
The objective of this audit was to ensure that emergency surgical admissions receive
appropriate and timely administration of VTE prophylaxis. The results showed that 71% of
risk assessment forms were completed on admission and 84% were considered to
accurately reflect the clinical conditions which are classed as risk factors.
It has been recommended that the electronic prescribing system (ePMA) is reviewed
to ensure the clinician confirms appropriate risk assessment VTE before prescribing
medications. The system will also be reviewed to prompt the timely administration of
appropriate medication
These recommendations have formed part of the Trust’s action plan on VTE and the
recommendations are being progressed. A re-audit will take place across the Trust.
Audit of Dignity and Nutrition
The Trust has arrangements in place to ensure that people are treated with dignity and
respect; patients reported high levels of satisfaction with the communication and interaction
with staff. The audit included nutritional screening (risk assessment) and appropriate actions
to ensure appropriate nutrition and support while in hospital. The actions to progress are:
To improve the delivery of patient care in respect to dignity and nutrition by ensuring
care is delivered in line with CQC standards
To focus on ensuring patients are routinely weighed on admission and this is an area
that is being focussed on within the ward teams
To act on a review of the training delivered to new nursing staff, and continue the use
of posters for the wards to re-iterate the process of risk assessment and
management
To maintain protected meal times
To reassess the membership of the multi-disciplinary Nutrition Group to develop
greater ownership of nutrition.
Audit of Chronic Obstructive Pulmonary Disease
An audit of practice of the management of in-patients admitted with an exacerbation of
Chronic Obstructive Pulmonary Disease (COPD), compared to guidance produced by the
British Thoracic Society, was carried out in quarter two and quarter four of 2012/13. The
actions to progress are:
To further improve the documentation of clinical findings and management of
inpatients with COPD, including information provision and promotion of health at
discharge.
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Harrogate and District Foundation Trust Quality Account 2012/13
Management of Hyponatraemia
This audit focused on elderly patients to ensure that hyponatreamia (low blood sodium level)
is being appropriately investigated and managed within the Trust. It was found that the
investigation of hyponatraemia was below standard and the following actions have been put
in place:
A protocol for investigations has been developed and agreed within the Trust this
protocol has been placed on the intranet.
Teaching the management and investigation of hyponatraemia has been included in
the teaching programme for the junior doctors, along with teaching hyponatraemia to
different medical and surgical specialties within the Trust.
A re-audit of the management of these patients is currently taking place.
Pre-Operative Investigations Audit
This audit aimed to review practice to ensure patients are prepared safely for surgical
procedures, necessary investigations are being ordered for pre-operative patients and that
pre-operative investigations are not being ordered unnecessarily. 78% of patients had the
appropriate tests preoperatively. The actions identified are:
Clarification of the required tests on guidance charts in the Pre-Assessment Unit
A re-audit will assess whether out of range test results are acted on appropriately.
Moving forward
During 2012/13 a joint audit programme with Clinical Effectiveness and Internal Audit
functions, focussed on the high priority areas for the Trust in order to provide assurance to
the Audit Committee and the Board of Good Clinical Practice, and that the systems and
processes in place lead to improved outcomes for patients. This ensured that there was no
duplication of work and therefore utilised resources more efficiently. Joint working on
identified areas will continue during 2013/14.
2.2.3. Participation in Clinical Research
Research remains a high priority for the trust as there is increasing evidence that active
participation in research improves patient outcomes. The number of patients receiving
relevant health services provided or sub-contracted by HDFT in 2012/13 that were recruited
during that period to participate in research approved by a research ethics committee was
2,024.
This represents an increase of 283 patients on the previous year and has achieved the
regional research network target set for the Trust. The continuing expansion of research into
different clinical areas reflects investment in infrastructure, excellent collaboration between
the Trust and the North East Yorkshire and Northern Lincolnshire Comprehensive Research
Network (NEYNL CLRN) and a clear commitment by the Trust to support and participate in
research.
The number of National Institute for Health Research (NIHR) research studies open for
recruitment of Trust patients is currently 1901 compared to last year’s figure of 1649. A
proportion of these patients (2.2%) participated in high quality, portfolio adopted research
studies sponsored and funded by life science partners achieving the one of the high level
objectives set by the CRN.
Recruitment compares very favourably against the national average for small acute Trusts
and has more than doubled over the past year. In addition recruitment locally has
contributed to NEYNL CLRN achieving a hatched green/green national rating for recruitment
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Harrogate and District Foundation Trust Quality Account 2012/13
to time and target for life sciences research. In addition Harrogate was recognised nationally
as undertaking the highest number of studies within a small NHS Acute Trust in 2011/12
(http://www.guardian.co.uk/healthcare-network-nihr-clinical-research-zone/table/2012-trustresearch-activity)
The number of National Institute for Health Research (NIHR) research studies open as one
of the treatment options for Trust patients is currently 69. Of these, 45% are randomised
controlled trials, 35% are sponsored and/or funded by life science partners. The Trust
Research Department has focused on maintaining activity in research active areas and
working with areas where there is less activity with the goal of ensuring taking part in
research is a choice for as many patients treated within the Trust as possible. With this goal
in mind there is on-going work to track the treatment pathways of patients originating in
HDFT but being treated in other centres to ensure that they also have access to research at
those centres and working to facilitate that access, by becoming a Patient Identification
Centre (PIC) for a research study, for example.
During the period April 2012 and March 2013 the number of dedicated staff participating in
clinical research approved by a research ethics committee at HDFT increased from 35 to 40.
The research conducted at HDFT now embraces 17 different clinical specialties. The Trust,
in collaboration with NEYNL CLRN continues to support training and education of clinical
teams. Maintenance of a responsive workforce, with a mix of specialist and generic research
staff enables the team to manage fluctuating workloads and reduces delays in study start up.
The Trust adopted independent Research Management and Governance systems and
processes from April 1st 2012. These processes were radically re-modelled between
Quarter 2 to Quarter 3 of 2012, and this resulted in the Trust achieving a current working
time ‘from study submission to NHS Permissions to be granted’ that is below the required 30
day target. Results were Quarter 1-53, Quarter 2-71, Quarter 3-15 and Quarter 4-16. This
has enhanced the reputation of the Trust as a site for research, particularly for life science
partners.
Research support services outcome indicators have been implemented to capture quality
and process outcomes as a further means of ensuring good practice and managing
operational risk.
Raising awareness of research activity is vital for increasing participation in research. At
HDFT research staff have worked with patient and public involvement (PPI) representatives
on a number of projects with this goal. This has been achieved through promotional
materials on electronic screens in patient waiting areas, handing out information about
research on International Clinical Trials Day, ensuring that front of house staff know how to
refer on queries about research and displaying details of clinical research teams and ongoing studies in the appropriate clinical area. In addition a number of patient/public groups
have been involved in research, for example a group of patients and their carers with
experience of leg ulcers were recruited. This was in response to a number of requests from
local researchers for such a group to help with their research. In addition an ad hoc group of
patients with a particular condition have been involved in a feasibility exercise for a potential
new study. This will help to ensure we set realistic recruitment targets.
The dermatology research team are leading a national James Lind Alliance priority Setting
Partnership for acne. This process will identify research questions about the treatment of
acne in collaboration with clinicians and patients with the condition. This NIHR funded
process recognizes that priorities for research identified by academic researchers may differ
from those of patients and clinicians.
A number of NIHR studies which recruited patients at HDFT have reported in the last year.
Findings include:
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Harrogate and District Foundation Trust Quality Account 2012/13
EuSOS – a Europe-wide, 7 day cohort study involving 498 hospitals and 46539
patients who had all had inpatient non-cardiac surgery. The researchers found that
the overall mortality rate of 4% was higher than expected and there were wide
variations in patient outcomes between countries. Critical care resources did not
seem to be allocated to patients at the greatest risk of death
PRIME II – this study aims to assess the role of post-operative breast radiotherapy in
women 65 or older with ‘low risk’ breast cancer treated with surgery and hormone
therapy, looking in particular at rates of recurrence in 5 years. In this interim report
the study team concluded that although, so far there is a slightly increased likelihood
of recurrence in the group not treated with radiotherapy (3.3% no radiotherapy; 1.6%
radiotherapy) the recurrence rate is very low and further follow up is needed. Further
funding to facilitate this has been applied for. There is no evidence at present from
this trial to suggest that survival is affected by treatment with radiotherapy.
The Trust staff remain abreast of the latest treatment possibilities and active participation in
research has been shown to improve patient outcomes. Increasingly clinical staff
involvement in research prompts changes to everyday practice. Examples from the last year
include:
Recognition that a referral pathway from a generic to a specialist clinic was flawed,
this has now been highlighted and modified
Use of a questionnaire which monitors the signs of depression in newly diagnosed
patients being extended from being part of a research study to routine clinical care.
These are just two examples but staff and departmental involvement in research prompts
questioning and examining of processes that may be no longer fit for purpose. Participation
in clinical research demonstrates HDFT’s commitment to improving the quality of the care it
offers, testing and offering the latest medical treatments and techniques and to making a
contribution to wider health improvement.
2.2.4. Use of the Commissioning for Quality and Innovation Framework
A proportion of Harrogate and District NHS Foundation Trust income in 2012/13 was
conditional upon achieving quality improvement and innovation goals agreed between HDFT
and any person or body they entered into a contract, agreement or arrangement with for the
provision of relevant health services, through the Commissioning for Quality and Innovation
payment framework. Further details of the agreed goals for 2012/13 and for the following 12
month
period
are
available
online
at:
http://www.monitornhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=3275
The monetary total for the amount of income in 2012/13 conditional upon achieving quality
improvement and innovation goals was £1.9m. HDFT income in 2011/12 was not conditional
on achieving quality improvement and innovation goals through the Commissioning for
Quality and Innovation payment framework, because a regional framework agreement was
in place to ensure delivery of CQUIN goals within existing resource. However, to date, all
CQUIN goals have been achieved.
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Harrogate and District Foundation Trust Quality Account 2012/13
2.2.5. Registration with the Care Quality Commission
Harrogate and District NHS Foundation Trust is required to register with the Care Quality
Commission and its current registration status is unconditional. Harrogate and District NHS
Foundation Trust has no conditions on registration.
HDFT has the following sites registered as of 1 April 2013
Harrogate District Hospital
Lascelles Unit
Ripon Community Hospital
HMP Askham Grange
HMP Northallerton.
The Care Quality Commission has not taken enforcement action against Harrogate and
District NHS Foundation Trust during 2012/13.
Harrogate and District NHS Foundation Trust has not participated in any special reviews or
investigations by the Care Quality Commission during the reporting period.
HDFT has had a routine inspection and a review relating to Section 120 of the Mental Health
Act 1983 in acute hospitals during the year. There were no improvement notices.
2.2.6. Information on the Quality of Data
Harrogate & District NHS Foundation Trust submitted records during 2012/13 to the
Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics, which are
included in the latest published data.
The percentage of records in the published data which included the:
Patient's valid NHS number was:
99.7% for admitted patient care
99.7% for outpatient care
92.4% for accident and emergency care. (This number is lower due to a higher
number of attendances to the department without an NHS number, for example there
are a high number of attendees from outside the area who do not have their NHS
number with them. In other departments a referral detailing the patient’s NHS number
is received in most cases. It is worth noting that performance over 90% for this
indicator is very good).
Patient's valid General Practitioner Registration Code was:
100% for admitted patient care
100% for outpatient care
100% for accident and emergency care.
HDFT’s Information Governance Assessment Report overall score for 2012/13 was 79% and
was graded satisfactory/green. The Trust reported 104 out of 132 standards at level two or
above (there are three levels with level three being the highest), compared to 97 out of 132
last year.
Harrogate & District NHS Foundation Trust was subject to the Payment by Results clinical
coding audit in January 2013 by the Audit Commission. An audit sample of 100 episodes
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Harrogate and District Foundation Trust Quality Account 2012/13
was reviewed, 50 randomly selected elective orthopaedics episodes and 50 randomly
selected obstetric episodes from across the whole range of activity covered by a mandatory
Payment by Results tariff. The specialty areas to be audited were chosen by NHS North
Yorkshire and York.
The results showed an overall error rate (coding errors affecting the Healthcare Resource
Group) of just 4% compared to the latest published national average error rate of around
9%. This result should not be extrapolated further than the actual sample audited. The error
rates reported for diagnoses and treatment coding (clinical coding) in the audit sample were:
Area audited % error rate
Primary procedures
Secondary procedures
Primary diagnoses
Secondary diagnoses
7%
8%
8%
3%
HDFT will be taking the following actions to improve data quality:
The Trust will continue its comprehensive training programme to enable all Clinical
Coding staff, to achieve the national Clinical Coding Accreditation qualification
The Clinical Coding team will continue to meet with individual Consultants to review
and explain the clinical coding process and discuss specific operations
The Trust will continue to routinely review and analyse all Secondary Usage Services
(SUS) processes for the commissioning data set submissions, including reviewing
the quality and completeness of the data items submitted.
2.2.7. Quality Indicators
Set out in the table below are the quality indicators that Trusts are required to report in
their Quality Accounts this year. The data given in this section, unless otherwise stated,
has been taken from the data made available to the Trust by the Health and Social Care
Information Centre.
1. Preventing People from dying prematurely and enhancing quality of life for
people with long-term conditions
Summary Hospital Mortality Index (SHMI)
This measure looks at deaths in hospital or within 30 days of discharge and is standardised
to allow for variations in the patient mix in different hospitals. The Health & Social Care
Information Centre publish a value for each Trust every quarter. The national score is set at
1.0000 – a Trust score significantly above 1.0000 indicates higher than expected death
rates, whereas a score significantly below 1.0000 indicates lower than expected death rates.
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Harrogate and District Foundation Trust Quality Account 2012/13
SHMI (Summary Hospital Level Mortality Indicator)
HDFT value
HDFT banding
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
Jul 11 to Jun 12
Oct 11 to Sep 12
0.9779
1.0186
2 (as expected)
2 (as expected)
1.0000
1
1.2559
1.2107
0.7108
0.6849
HDFT’s latest published score of 1.0186 is within the expected range.
HDFT considers that this data is as described for the following reasons:
Independent clinical coding audits are carried out on an annual basis by accredited
clinical coding auditors to provide assurance of the accuracy of coded data.
The SHMI data is reviewed and signed off on a quarterly basis by the Medical
Director.
HDFT has taken the following actions to improve this rate, and so the quality of its services,
by:
Purchasing an evaluation tool that enables it to clinically review and analyse mortality
data in detail on an on-going basis. The Trust intend to roll this out across the
organisation in 2013/14.
The Trust is working with another NHS trust to evaluate their methods of clinical
reviews against its own with a view to sharing learning in its clinical approach.
Palliative care coding
The data shows the percentage of patient deaths in hospital with palliative care coded at
either diagnosis or specialty level. This denotes that the patient had clinical input from a
specialist palliative care team before their death. In some mortality measures, this is taken
into account in the standardisation, making the assumption that a patient who has had
palliative care input should not be classified as an unexpected death. A proportion of people
who die in hospital will receive palliative care input but the recording of this varies widely
between hospitals.
Palliative care coding - % patient deaths with palliative care coded at either
diagnosis or specialty level
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
Jul 11 to Jun 12
Oct 11 to Sep 12
10.3
11.7
18.4
18.9
46.3
43.3
0.3
0.2
HDFT’s latest published score of 10.3% is below the national average.
HDFT considers that this data is as described for the following reasons:
Independent clinical coding audits are carried out on an annual basis by accredited
clinical coding auditors to provide assurance of the accuracy of coded data.
The Palliative care coding data is reviewed and signed off on a quarterly basis by the
Medical Director.
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Harrogate and District Foundation Trust Quality Account 2012/13
HDFT has taken the following actions to improve this rate, and so the quality of its services,
by:
Purchasing an evaluation tool that enables the Trust to clinically review and analyse
palliative care coded data in detail on an on-going basis. The Trust intends to roll this
out across the organisation in 2013/14.
2. Helping people to recover from episodes of ill health or following injury
PROMs – Patient Reported Outcome Measures
PROMs calculate the health gain after elective surgical treatment using pre- and postoperative patient surveys. Four common elective surgical procedures are included in the
survey: groin hernias, hip replacements, knee replacements and varicose vein operations.
HDFT do not perform significant numbers of varicose vein operations and so this procedure
has been excluded from the results. A high health gain score is good.
PROMs - Patient Reported Outcome Measures
Groin hernia surgery - adjusted average health gains
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
2010/11 (final)
2011/12 (provisional)
0.087
0.085
0.123
0.026
Varicose vein surgery - adjusted average health gains
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
2010/11 (final)
2011/12 (provisional)
Data suppressed due
to small numbers
0.091
0.140
-0.007
Hip replacement surgery - adjusted average health gains
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
2010/11 (final)
2011/12 (provisional)
0.409
0.405
0.471
0.264
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Harrogate and District Foundation Trust Quality Account 2012/13
Knee replacement surgery - adjusted average health gains
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
2010/11 (final)
2011/12 (provisional)
0.296
0.299
0.375
0.199
2011/12 data not yet published by the Information Centre
HDFT’s latest published health gain scores for groin hernias, hip replacements and knee
replacements were similar to national averages.
HDFT considers that this data is as described for the following reasons: We have
participated in the PROMs scheme since inception, routinely analysing and reviewing the
results.
HDFT intends to take the following actions to improve this score, and therefore the quality of
its services, by continuing to actively participate in the scheme, reviewing and analysing the
results to ensure a clear understanding of the data to inform future programmes of work. As
the data for 2011/12 or 2012/13 has not yet been published by the Information Centre the
Trust cannot provide any further comment.
Emergency readmissions to hospital within 28 days
This data looks at the percentage of patients who are readmitted to hospital as an
emergency within 28 days of being discharged. The data is standardised by the Health &
Social Care Information Centre to enable a fair comparison between organisations and is
presented in age groups – ages 0-15 and ages 16 and over. A low percentage score is
good.
Emergency readmissions to hospital within 28 days
Indirectly age, sex, method of admission, diagnosis, procedure standardised percent
Age 0-15
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
2009/10
2010/11
11.21
10.71
10.18
10.15
22.53
14.62
0
0
Age 16+
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
2009/10
2010/11
9.17
9.99
11.16
11.42
13.19
14.09
0
0
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Harrogate and District Foundation Trust Quality Account 2012/13
HDFT’s latest published value for ages 0-15 is just above the national average, whereas the
value for patients aged 16 and over is below the national average.
HDFT considers that this data is as described for the following reasons:
The source data used is taken from the Secondary Uses Service dataset, this is a
national system and data quality indicators linked to this system indicate an excellent
compliance rate.
HDFT has taken the following actions to improve this rate and so the quality of its services,
by:
Purchasing an evaluation tool that enables us to review and analyse a range of
clinical and outcome indicators including emergency readmissions in detail on an ongoing basis. The Trust intends to roll this out across the organisation in 2013/14. This
enables local clinical teams to identify and review ways in which services can be
improved to reduce re-admissions wherever possible.
3. Ensuring that people have a positive experience of care
Inpatient survey – responsiveness to inpatients’ personal needs
This measure is the average weighted score of 5 questions from the national inpatient
survey relating to responsiveness to inpatients' personal needs. The scores are presented
out of 100 with a high score indicating good performance.
Inpatient survey - responsiveness to inpatients' personal needs
Average weighted score of 5 questions relating to
responsiveness to inpatients' personal needs (Score out of
100)
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
2010/11 2011/12
69.2
72.3
67.3
67.4
73.2
72.3
56.7
56.5
HDFT’s latest published score is above the national average and is the highest for any acute
trust in England.
HDFT considers that this data is as described for the following reasons:
Driving improvement for the delivery of high quality fundamental care has been a
major quality improvement priority for the Trust for the last two years. We have had
wide engagement from hospital based nursing staff who have led the implementation
and monitoring of rigorous standards in this area. For example in the areas of
nutrition and communication
These standards are monitored through a governance system which includes
Matrons’ audits, unannounced Director led inspections, Patient Safety visits and local
Quality of Care Teams
A well established system of seeking objective feedback via external bodies and
groups including the Trust’s Patient Voice Group, Governors and Lay
Representatives.
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Harrogate and District Foundation Trust Quality Account 2012/13
HDFT intends to take the following actions to improve this score and so the quality of its
services, by:
The implementation of a detailed action plan relating to the most recent (2012/13)
survey will be monitored through the Trust’s Standards Group with accountability for
the delivery of the plan sitting with the Trust’s Clinical Directorates
The use of patient feedback through the full implementation of the national Friends
and Family Test from April 2013 will enable further improvements to be made
The introduction of two quality initiatives in 2013/14, detailed in section 2.1.1
focussed on high levels of communications between staff and patients and the
environment of care for patients and their relatives/carers.
Staff who would recommend the trust to their family or friends
This data looks at the proportion of staff completing the NHS staff survey who responded
“strongly agree” or “agree” to the question “If a friend or relative needed treatment I would be
happy with the standard of care provided by this organisation”. The scores are presented out
of 100 with a high score indicating good performance.
Staff who would recommend the trust to their family or friends
Proportion of staff who responded "strongly agree" or "agree".
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
2011
2012
76
73
60
63
89
86
33
35
HDFT’s latest published score is above the national average.
HDFT considers that this data is as described for the following reasons:
The Trust receives above average results from national surveys, increasing staff
confidence about the services we deliver
The Trust’s ethos places patients and staff and the delivery of the highest standards
of care at the centre of its work, demonstrated through the Trust’s vision and
objectives, communications strategies, Business Plan and Annual Report and
initiatives such as Patient Safety visits and learning events. There are also
established relationships with Staff Side representatives and the Trust’s Partnership
Forum
The Trust’s two way communication and feedback mechanisms with staff are highly
effective. Much work is undertaken to ensure consistent communications between
the Board of Directors and senior staff with the organisation including monthly Team
Brief sessions across the community and in the hospital.
HDFT has taken the following actions to improve this score, and so the quality of its
services, by:
Further developing its communication and listening strategies to enhance the visibility
of, and access to Directors, including the introduction of listening events, led by
Executive Directors, and an anonymous facility called ‘Ask the Directors’ where staff
can pose questions on the Trust intranet and receive answers within a week,
published for all staff to read
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Harrogate and District Foundation Trust Quality Account 2012/13
Communicating its achievements and areas for development in the most accessible
ways to meet the needs of staff. This has included investment in IT resources.
4. Treating and caring for people in a safe environment and protecting them
from avoidable harm
VTE (venous thromboembolism) risk assessment
The National Institute for Clinical Excellence (NICE) recommends that all patients in hospital
should be assessed for risk of developing VTE (blood clots). This measure shows the
percentage of eligible inpatients who were risk assessed. A high percentage score is good.
VTE (venous thromboembolism) risk assessment - % eligible admitted patients risk
assessed for VTE
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Q1 2012/13
93.9
93.4
99.6
80.8
Data period
Q2 2012/13
94.6
93.8
99.5
80.9
Q3 2012/13
95.0
94.1
99.6
84.6
HDFT’s published scores for the whole year have been above the national average.
HDFT considers that this data is as described for the following reasons:
There is a well-established protocol for VTE Risk Assessment on admission
Data is recorded onto Information and Clinical System (ICS) and collected via reliable
IT systems
Education on VTE Risk Assessment is part of the Trust’s Essential Training so staff
understand the importance of it.
HDFT intends to take the following actions to improve this and so the quality of its services,
by:
Identifying wards with poorer performance and examining whether there are issues
with completion of the risk assessment or inputting of information onto ICS
Closer scrutiny of results at Director level via the Trust’s Performance Group
Linking VTE Risk Assessment to the Trust’s new e-prescribing system so that the
Risk Assessment must be completed in order to proceed with the prescription.
Clostridium difficile (C.diff) rates
The data shows the rate per 100,000 bed days of cases of C.diff infection reported amongst
patients in hospital who are aged 2 years or over. A low rate is good.
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Harrogate and District Foundation Trust Quality Account 2012/13
C.diff - rate per 100,000 bed days of cases of C.diff
infection reported within the trust amongst patients aged
2 or over
HDFT value
National average
Highest value for any acute Trust
Lowest value for any acute Trust
Data period
2010/11 2011/12
13.9
9.3
29.6
21.8
71.8
51.6
7.1
4.1
HDFT’s latest published score is below the national average.
HDFT considers that this data is as described for the following reasons:
The Trust has extremely robust diagnostic testing protocol which uses four laboratory
tests to identify cases
All confirmed cases are closely scrutinised through the Trust’s internal reporting
mechanisms and then reported to Public Health England, Monitor and
Commissioning Organisations
The reduction in cases reflects the Trust’s commitment to preventing C Diff through
the key strategies of high levels of environmental cleanliness, high standards of staff
and patient hand hygiene, an effective antibiotic stewardship programme and
education and awareness for staff and to the public.
HDFT intends to take the following actions to improve this rate, and so the quality of its
services, by:
Future scrutiny of potential cases by the internal C difficile Case Attribution Panel to
ensure that cases reported by the Trust satisfy, in full, the national criteria for the
diagnosis of C difficile infection
Ensure prompt isolation within specific Trust standards of any patient with
unexplained loose stools
Further develop the Trust’s antibiotic stewardship programme through exploitation of
the capabilities within the recently introduced electronic prescribing system.
Patient safety incidents
The data looks at three measures related to patient safety incidents reported to the National
Reporting and Learning System (NRLS)
The rate of incidents reported per 100 admissions. A low rate is good; however
incident reporting rates may vary between trusts and this will impact on the ability to
draw a fair comparison between organisations
The number and percentage of reported incidents that resulted in severe harm to a
patient/s. A low score is good
The number and percentage of reported incidents that resulted in the death of a
patient/s. A low score is good.
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Harrogate and District Foundation Trust Quality Account 2012/13
Patient safety incidents
Data period
Apr 11- Sep 11
HDFT value
National position (all acute trusts)
Highest value for any acute Trust
Lowest value for any acute Trust
Rate of incidents
reported (per 100
admissions)
4.81
6.32
14.37
2.13
Incidents that resulted in
severe harm or death
Rate (per 100
Number
admissions)
0
0.0
3323
0.0
160
0.4
0
0.0
Oct 11 - Mar 12
Rate of incidents
reported (per 100
admissions)
6.33
6.58
17.46
0.94
Incidents that resulted in
severe harm or death
Rate (per 100
Number
admissions)
1
0.00
3440
0.05
144
0.50
0
0.00
HDFT’s latest published scores are below the national average for all three measures.
HDFT considers that this data is as described for the following reasons:
The data is collated by front line staff in relation to patient safety incidents
There is a robust policy and process within the Trust to ensure that all incidents are
identified, managed, reported and investigated in accordance with national guidance
The Trust ensures that there are appropriate measures in place to prevent
recurrence and also promotes organisational learning.
HDFT has taken the following actions to improve this score and so the quality of its services,
by:
Promoting patient safety as a key objective across the organisation and
implementing a number of mechanisms to ensure compliance with, and delivery of
national frameworks for example the Patient Safety First initiative
There is a continual focus on quality at an organisational, Directorate and front line
level through a variety of structures, for example Quality of Care Teams, Quality
Governance Groups at Corporate and Directorate level, Patient Safety Visits,
Quarterly Monitoring Reports, Case Conferences and Learning Events.
In addition the Trust can report an updated position up to September 2012 with data
supplied by the NHS Commissioning Board. HDFT’s reporting rate between 1 April 2012 and
30 September 2012 was 6.4 incidents reported per 100 admissions. Incidents reported by
degree of harm in this period were two graded as severe, and two that resulted in death.
Following the publication of this data a further review of one of the incidents has indicated a
change in grading. The incident has been subjected to robust root cause analysis
investigation and findings have determined that the initial grading was incorrect and should
be upgraded to severe from moderate. Hence there have been three incidents graded as
severe during the period. Of the six incidents (this includes the one incident reported in
October 2011 – March 2012, together with the five incidents described above between April
2012 and September 2012) that resulted in severe harm or death, three were investigated as
serious untoward incidents, and actions to address the findings put in place, and three were
the result of recognised complications and investigation revealed that no further action was
needed. Please note that the time period described here is different to that in part one of this
Quality Report.
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Harrogate and District Foundation Trust Quality Account 2012/13
3.
PART 3: OTHER INFORMATION
3.1.
REVIEW OF QUALITY PERFORMANCE
This section provides an overview of the quality of care offered by HDFT based on
performance in 2012/13 against indicators selected by the board in consultation with
stakeholders, including three priorities for the three elements of quality covering each of:
Patient safety
Clinical effectiveness
Patient experience
The Trust highlighted in its 2011/12 Quality Account that it would report on the following
additional indicators and detailed how they would be monitored throughout the year.
Updates on the majority of the indicators described in part three the 2011/12 Quality Account
are given in this document in part two.
3.1.1. Patient Safety
1. Care of the deteriorating patient
The aim is to ensure that all patients have the severity of their clinical condition identified
early, and that there is a timely and competent clinical response. The response includes
appropriate “escalation” to more senior staff.
In the last Annual Report, we described the problems identified with the processes for
escalation, in particular the inconsistent documentation of responses in the patient record.
Central to making improvements was the planned implementation of the National Early
Warning Score (NEWS), which was to be published by the Royal College of Physicians
during 2012. NEWS incorporates a standardised scoring system to identify the sickest
patients, a new observation chart and a draft clinical response template, which each clinical
area moulds to fit the resources available to them.
In addition, the Trust planned to formally introduce a new paediatric equivalent, the
Paediatric Advanced Warning Score (PAWS) which has been developed by the Leeds
Paediatric services and which will be used throughout the region. The Trust also aimed to reenforce the use of the Modified Early Obstetric Warning Score (MEOWS) for pregnant
women.
During 2012, the Trust undertook all of the development work that was required, and in
January 2013 we implemented these new processes within the Harrogate District Hospital
site. This has involved a significant amount of work including defining the detail of the
observation charts and clinical responses, the development of supporting policies and
procedures and the education and support of large numbers of clinical staff. They are now
being implemented in all appropriate clinical settings within community services, such as
Ripon Community Hospital, Minor Injuries Units and prisons.
Summary
The introduction of NEWS, PAWS and MEOWS is a significant step forward in caring for the
deteriorating patient. The recent implementation means that it is not possible to include any
audit data regarding compliance with the new processes. However we were found to be
compliant with the NHSLA Risk Management Standard for the deteriorating patient in March
42
Harrogate and District Foundation Trust Quality Account 2012/13
2013 when external assessors reviewed a random sample of our inpatient observation
charts. The Trust is planning to undertake audits in August 2013.
2. Safe prescribing and drug administration
The aim is to reduce the number of:
Prescriptions that do not follow Trust guidance and policy for accurate completion
Prescriptions that include a drug to which the patient has a documented allergy
Patients administered a dose of a drug that was not as intended by the prescriber
Patients administered a drug to which they have a documented allergy
During 2012/13 we have continued the implementation of an electronic prescribing and
administration system (ePMA). This has been configured to ensure that all drugs are
prescribed in accordance with Trust standards and policy, and therefore once fully
implemented prescribing standards are fully adhered to. In addition, there is no ambiguity
regarding the prescription which improves safe administration of drugs. Full implementation
on all inpatients wards on the Harrogate District Hospital site was completed three months
ahead of initial project plan, by the end of November 2012.
Pharmacist intervention reports are audits undertaken annually and detail the interventions
that clarify or lead to amendments in prescribing to make them comply with trust policy.
Pharmacist interventions
July 2010
67
October 2011
21
July 2012
9
The 9 interventions documented in July 2012 were all for prescriptions on paper drug charts
on wards that had not yet implemented ePMA.
The introduction of ePMA has released pharmacist time to focus on assessing whether the
drugs prescribed are clinically appropriate and follow best practice, rather than whether they
are clear and legible. The number of documented improvements to prescriptions following
review by pharmacists in a week has increased from 816 (2011) to 1059 (2012), which is a
significant enhancement to quality of care.
When first prescribing medicines for a patient on ePMA, it is compulsory for the prescriber to
confirm the allergy status before proceeding to prescribe. The ePMA system will then raise
an alert should a patient be prescribed, or if a nurse attempts to administer, a drug to which
they have an allergy. Since full implementation of ePMA, monitoring has demonstrated
100% compliance with completion of allergy status, and no prescriptions of medicines to
which the patient has a documented allergy. Regarding administration of a drug to which a
patient had a documented allergy, there were 7 incidents in 2011/12 and only 2 in 2012/13,
both of which involved a paper drug chart prior to implementation of ePMA.
Reported average monthly incidents of administration of incorrect drug, dose or form of drug
has shown a clear reduction from 7.8 (2011/12) to 4.7 (2012/13).
Summary
The impact of ePMA in achieving the aims of this priority is clear and together with a number
of actions put in place following previous audits, has led to the process of prescribing and
administering medicines becoming demonstrably safer.
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Harrogate and District Foundation Trust Quality Account 2012/13
3. Falls prevention
The aim is to reduce the rate of falls occurring in hospital, to improve falls risk assessment
and falls prevention documentation and to improve the numbers of staff receiving falls
prevention training.
Rate of falls
The rate of falls is given as the number of reported falls per 1000 occupied bed days.
Number per 1000 OBD
Rate of Falls & Harm per quarter
10
9
8
7
6
5
4
3
2
1
0
2011/12 Falls
2012/13 Falls
2011/12 Harm
2012/13 Harm
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
The rate of falls occurring in HDFT is currently 9.42. It was 8.9 in the comparable period in
2011/12. There has been a slight increase in the rate of falls which cause harm and our
focus is about promoting the safest clinical environment. In order to do this we will focus
more on risk assessment and care planning. Our plans for this are detailed below:
Risk assessment and care planning
All inpatients should have a falls and bed rails risk assessment (RA) completed within six
hours of admission. If the patient is identified as being at risk of falls, the falls prevention
care guidance must be followed and documented. Targets for improvement were set at the
beginning of 2012/13.
A full audit of falls documentation was undertaken in October 2012 and the results are given
in the table below.
Indicators
Complete risk
assessment
Within 6 hours
Care plan
documentation
2012
(Oct)
93%
2013
(Apr)
95%
Targets
2013
(Oct)
95%
75%
65%
80%
70%
85%
75%
2014
(Apr)
Maintain
90%
80%
Results
Oct 2012
92.1% (falls)
68.1% (rails)
70.9%
62.5%
Although none of the targets for elements of falls risk assessment and documentation
compliance were quite achieved, some fell only slightly short, and it is felt that these targets
are achievable and will remain as the expected standard.
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Harrogate and District Foundation Trust Quality Account 2012/13
As the following chart demonstrates, comparison to previous years audits shows promising
steady progress.
% of complete documentation
Compliance Progress
100
80
Falls RA
Bed Rails RA
Care Plan
60
40
20
0
2009
2010
2011
Oct-12
Dec-12
Falls prevention training
Regular falls prevention training is an essential training requirement for relevant clinical staff.
During 2011/12 this was delivered via face-to-face training sessions but this has been
reviewed and amended in order that training is targeted appropriately. A national e-learning
package is available and is the requirement for hospital based clinical staff with ward based
training to support. Locally provided training specific to each ward will be available from the
link nurse network and the Falls Prevention Coordinator. Community staff now have the
option of completing falls prevention training with clinical handling skills training.
The latest training report from March 2013 shows the current compliance figures for
permanent staff at 64%. The following chart shows progress with training compliance from
2011 to 2012:
With continued supportive training on wards and the changes within community falls training
it is anticipated that the compliance figures will continue to make similar significant progress.
45
Harrogate and District Foundation Trust Quality Account 2012/13
The ward based support training was delivered as a pilot on two ward areas (Jervaulx and
Byland) in 2012 as part of a ‘Falls Awareness Month’. The aim was to rotate to each ward if
the outcome of the pilot was positive.
An audit of compliance with documentation of falls risk assessment and prevention activity
was completed following the two initial ward awareness months to ascertain the impact of
the intensive training and determine if this was the most effective way forward.
The training compliance on the two wards improved from 21% to 71% and 16% to 61%
respectively. However although some elements of falls assessment and care following a fall
were positive and showing improvement there were as many elements that did not show as
much improvement as was hoped. In addition there was no significant reduction in falls. As a
result the Falls Awareness Month rota was suspended whilst the results and future training
methods were discussed at the Falls Strategy Group.
Summary
We have achieved an improvement in the availability, delivery and uptake of falls prevention
training. In addition we can demonstrate a significant improvement in risk assessment and
documentation. A combination of improved training and awareness, and better
documentation should have a positive impact on the numbers of falls as prevention
measures will be better utilised and monitored. However, currently this has not appeared to
be as successful as hoped, but may reflect the increasingly challenging case mix of patients.
The Falls Strategy Group is currently looking at the best options for a falls prevention
programme that would provide continued training and support for clinicians and could be
used as an improvement tool to bring about change from within clinical teams to focus on
reduction of falls in a more sustainable and structured way.
3.1.2. Clinical Effectiveness
1. Stroke care
The care of patients who have had a stroke has been a priority for the Trust for some time
and we reported significant improvement in the Stroke Improvement National Audit
Programme (SINAP) data in the majority of areas in last years report. At the start of 2012/13
the Trust aimed to continue to manage stroke performance against national targets and to
achieve performance above the national average. In addition, the Trust planned to establish
a community stroke team.
The comparative results of the average of the 12 key SINAP indicators (reported in detail in
our last Quality Account) since 2011/12 show that we have continued to improve
significantly, and have exceeded the national average for the last six months.
The Trust is satisfied with this significantly improved performance and the resulting positive
impact that it is having on the care of people who use our services.
HDFT
National
average
Quarter 1
2011/12
41%
61%
Quarter 2
2011/12
55%
66%
Quarter 3
2011/12
70%
68%
Quarter 4
2011/12
67%
69%
46
Quarter 1
2012/13
69%
72%
Quarter 2
2012/13
78%
74%
Quarter 3
2012/13
76%
75%
Harrogate and District Foundation Trust Quality Account 2012/13
The updated SINAP performance figure for Q4 2011/12 is 67%. This was amended from an
earlier figure of 69% following an identification of an error in our local performance
calculations.
SINAP data will not continue to be reported in the future, and further information will be
recorded in the Sentinel Stroke National Audit Programme (SSNAP). The Clinical
Information Management System for Stroke Services (CIMSS) is being implemented to
ensure the datasets for SSNAP are completed, and the Trust can continue to monitor
performance relating to stroke care.
The Community Stroke Team was recruited during 2012. Work was prioritised to ensure
good inductions and to design robust competency frameworks for the reablement assistants
employed. Documentation and patient information was carefully designed and disseminated
and the team started seeing patients in September 2012. The first six month review will be
undertaken in April 2013. This will include activity indicators, a review of team membership
and skill mix, and the Trust will also develop a tool to assess patient progress and
satisfaction.
Summary
The stroke data has again shown a huge improvement and the Trust aims to remain at or
above the national average for the relevant indicators. The six month review of the
Community Stroke Team will enable progress to be evaluated and further improvements to
be prioritised. Mobile working solutions, for example the use of hand held devices are
already being planned, which will enable more efficient working to be implemented.
2. Clinical handover of care
The Hospital at Night Project (H@N) is a national programme initiated and supported by the
NHS Modernisation Agency. The aim of H@N is to enhance the provision of safe and timely
care to adult in-patients at night. It aims to achieve this by pooling resources across
specialties during the out-of-hours period. It requires resident-on-call medical staff and allied
health professionals to work flexibly as part of a larger multispecialty team to deliver care to
adult in-patients across several specialties. H@N also advocates supervised multi-specialty
handover in the evenings. The aim for this work for 2012/13 was:
1. Effective implementation of the H@N protocol
2. Assessment of the impact on H@N on waiting times to assessment for emergency
admissions
3. Development and refinement of the H@N protocol in consultation with the H@N
team.
An audit was undertaken prior to the introduction of H@N for patients admitted as
emergencies arriving on the ward 11pm and 7am and is summarised below:
Time from arrival on ward to assessment by
doctor
For patients presenting to the Emergency
Department, time between arrival in the
Emergency Department and assessment on
ward
Mean
(minutes)
129
Median
(minutes)
116
Range
(minutes)
30 – 305
352
345
165 - 612
This baseline data will allow comparison to be made between waiting times experienced
before and after the introduction of H@N.
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Harrogate and District Foundation Trust Quality Account 2012/13
In order to introduce a H@N system to HDFT it was necessary to secure support from
several medical specialties and to develop a protocol for the H@N team that was acceptable
to the contributing specialties. An agreed protocol for H@N was produced and the H@N was
introduced between 23.00 and 07.00 at the Trust on 12/11/2012, with attendance recorded
at the handover meetings.
There has been an important cultural shift in the delivery of out of hours care, with improved
communication between specialties at night. However some challenges remain:
The system is not universally popular and almost all doctors involved express
dissatisfaction with the start time for H@N at 23.00 and the requirement for multiple
handovers
Electronic handover is not being widely used and morning handovers do not take
place regularly
Cross-cover between specialties is not required/ asked for on many nights
Cross-cover is not possible on some nights because all teams are very busy
An audit of attendance at 27 consecutive H@N evening handover meetings showed
that up to nine staff could, or should attend, but there was a range of attendance of 1
to 8 staff and a mean attendance of 5.4 staff.
Summary
The implementation of H@N has been difficult and further work is required to facilitate a
unified handover. It has been agreed that further audit of waiting times should be deferred
until the work outlined above has been completed and any changes implemented.
3. Screening
We undertook some new audits of screening procedures during 2012, and have chosen to
include the results of these audits as an additional quality indicator. Screening is the testing
of “well” people, without symptoms and is undertaken when there is evidence that the
advantages of identifying an abnormality, outweigh the disadvantages.
MRSA Screening
Many people carry meticillin-resistant staphlococcus aureus (MRSA) on their skin or in their
nose. If it can be identified by taking a swab from the skin, a simple treatment can be used to
get rid of as much of the bacteria as possible. This means there is a smaller chance of the
person getting an MRSA infection or passing MRSA on to another patient.
We audited 30 patients (elective and non-elective) with a positive MRSA screening result
during 2012 to ensure appropriate communication of the result and appropriate
decolonisation therapy (treatment to reduce and possibly remove MRSA bacteria from the
body).
Elective patients
100% of patients were informed of the result within 14 days, which is our local standard.
70% were informed by telephone and 30% by letter. 70% of clinicians were informed of the
result within 14 days, and in one instance the clinician was not informed. This is
disappointing and new processes and training have since been implemented. 100% of
patients received decolonisation therapy in accordance with local policy.
Non-elective patients
75% of patients were informed of the result within 24 hours. This result reflects the patients
who were still in hospital on receipt of a positive result. However there was less consistent
compliance with informing patients who had already been discharged from hospital, with one
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Harrogate and District Foundation Trust Quality Account 2012/13
informed within 14 days and a lack of documentation regarding whether the remaining four
patients had been informed. Further training to clarify roles and responsibilities is needed.
60% of clinicians were informed within 24 hours, and 100% within 14 days. 100% of patients
received decolonisation therapy in accordance with the policy, but there was a delay of 4872 hours for 15%. This has resulted in a change in process to add an alert to the eprescribing system for inpatients with a positive MRSA screening result, requesting
immediate prescription and commencement of decolonisation.
Next steps
All Infection Prevention and Control nursing staff are to undertake local training to clarify
standard operating procedures for managing patients with a positive MRSA screening result,
and the audit is to be repeated during 2013.
Bowel Cancer Screening
The NHS Bowel Cancer Screening Programme offers a colonoscopy (an examination of the
lower bowel using a thin flexible tube with a tiny camera) to patients who have been found to
have faecal occult blood (blood in the bowel motions) on initial screening. We have audited a
sample of patients screened during 2012, to review compliance with the processes for giving
patients and their GP the results of the colonoscopy.
Patients telephoned next day
Patients sent letter to confirm results or
given appointment to discuss results
within required time
Patients with cancer discussed at next
MDT
Letter to GP within required time
Standard
Recall
Polyps
Cancer
100%
100%
92%
92%
92%
100%
75%
100%
100%
100%
Not applicable
100%
100%
100%
100%
HDFT use the Bowel cancer Screening System (BCSS), which is a national IT system that
supports the screening programme and offers a range of functions that enable the
management of the local screening programme. The BCSS provides the means of managing
the patient pathway, and generates failsafe and operational reports that provide assurance.
This local audit has demonstrated good compliance with the process and timescales for
informing patients and clinicians of the outcome of screening. The cases where timescales
were not met were generally due to weekend delays and patient holidays, so 97% (35/36) of
patients were telephoned within three days, with the remaining 3% (1/36) contacted after
one week because of the patient’s holiday.
Next steps
The local audit will be repeated annually.
3.1.3. Patient Experience
1. Outpatient waiting times
The aim is to continue to improve waiting times for patients arriving in a clinic to being seen
by the healthcare professional. This work arose from feedback from service users, which
highlighted that some clinics had significant delays for patients waiting to be seen. In
addition, feedback from the CQC and Picker National Outpatient Surveys revealed that
outpatient waiting times were above average and patients reported not being informed of
delays.
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Harrogate and District Foundation Trust Quality Account 2012/13
The results for the number of patients seen by the first healthcare professional within the
specified time:
Ophthalmology (within 15 minutes)
Gastroenterology (within 15 minutes)
Orthopaedics (within 30 minutes)
Cardiology (within 30 minutes)
October
2011
72%
72%
February
2012
96%
96%
June
2012
96%
100%
70%
100%
October
2012
82%
77%
These audits are difficult to undertake due to the volume of patients attending, and the
utilisation of nursing staff to facilitate the audit. However it has been valuable and work has
been undertaken to change pathways to improve outpatient waiting times. In addition,
standards for informing patients of the clinic progress have been established with methods
for monitoring this by patient satisfaction surveys, suggestion boxes and staff feedback. The
results for ophthalmology clinics in October showed a deterioration, which was felt to be due
to a large number of new staff recruited prior to that, and a delay in relevant training.
Summary
Good progress has been made with this work to improve outpatient waiting times, and
patient information. Regular audits will continue within some of the specialties.
2. Community equipment provision
The aim of this priority is to ensure equipment required by patients in the community is
delivered and collected within identified parameters and is appropriate for the patients
needs. The service specification states that the service should aim to provide core
equipment within seven working days of the assessment of need. HDFT has four community
equipment stores.
20 requests for equipment from each of the equipment stores were randomly selected and
audited in Quarter 1 and Quarter 3 2012/13, and the results are given in the table below.
Indicator
percentage
deliveries
within seven
days
Community Equipment Stores audit results Quarter 1 and Quarter 3 2012/13
Harrogate
Colburn
York
Scarborough
Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter
1
3
1
3
1
3
1
3
83%
85%
100%
100%
95%
65%
80%
60%
The reasons for the delays in Q3 were recorded and included:
A three day bank holiday following clinician assessment during the audit period
Items being out of stock
Delays in the referral being delivered to the store
Unable to contact the patient to deliver the equipment
Staff are often asked to prioritise some deliveries e.g. to support early discharge,
within 24 hours, and these requests are often accommodated, but this impacts on the
delivery of routine or non-urgent equipment
An increased number of two man jobs, reducing the number of deliveries that can be
made from each store
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Harrogate and District Foundation Trust Quality Account 2012/13
The audit has identified work that needs to be undertaken to improve the delivery and
collection of equipment to patients. Online ordering is to be introduced during 2013 which will
improve some of the identified delays. A catalogue of standard stock and single use items
has been developed for use across all stores for both health and social care equipment.
The referral form has been reviewed and the referrer will be required to agree to re-assess
the patient after six weeks to ensure the equipment is still appropriate to their needs.
Equipment no longer required will be collected by the stores for refurbishment. An audit tool
for reassessment of pressure relieving equipment is currently being piloted in York and
Harrogate.
Further work is needed to assess the requests for deliveries within 24 and 48 hours, by
working with the community district nursing team, to ensure that these can be prioritised
without delaying delivery of other equipment beyond seven days.
Summary
This work has demonstrated some good practice, whilst identifying areas for further work
and improvement. Future audits will be planned following these changes.
3. Dementia care
The aim of this priority is to improve the care of patients with dementia, by implementing the
2012/13 National Commissioning for Quality and Innovation (CQUIN) indicator for dementia.
HDFT is a core member of the Harrogate Dementia Collaborative and is working in
partnership with Tees, Esk and Wear Valley NHS Foundation Trust (TEWV), North Yorkshire
County Council, and the Harrogate and Rural District Clinical Commissioning Group to
implement joint projects which will improve care for patients with dementia. The
Collaborative is using “lean methodology” to support implementation of work programmes,
and has run a number of rapid improvement events over the last year. These have included:
An RPIW to improve the first seven days of admission to Byland Ward for patients
aged over 65 with dementia
Developing an improved pathway for patients with dementia attending the
Emergency Department
Implementing a single point of contact for access to older people’s mental health
services
The development of a shared assessment protocol for patients with dementia across
health, mental health and social care.
Other projects are being identified by the multi-agency project board and these will be
delivered using the same RPIW format over the next six months.
National CQUIN for dementia
This indicator involves screening all patients aged 75 and above, admitted as an emergency,
for dementia, risk assessing those who have scored positively on the screening question,
and referring those with a possible diagnosis of dementia.
The data collection was commenced in July 2012, following the development of processes to
enable staff to record and monitor the results of the three elements of dementia care. By
December 2012, the Trust had achieved the required 90% target for all elements of the
indicator.
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Harrogate and District Foundation Trust Quality Account 2012/13
Improved care for patients with a diagnosis of dementia
The physical care environment in acute hospitals is often bewildering for elderly patients with
dementia and can pose risks. When such patients need to be in hospital, the Trust should
aim to provide coordinated care and return the patient to their familiar surroundings as soon
as possible.
The RPIW to improve the care of patients with dementia on Byland Ward has now been
completed and the learning from this event is now being disseminated to other wards across
HDFT. This work included:
Focusing on reducing the length of stay for patients aged over 65 years with a
diagnosis of dementia on our medical wards. The work has achieved a 9% reduction
in length of stay from 19 days to 17.3 days. Continuous improvement is planned to
reach our internal target of 10 days average length of stay. This will involve using
daily multi-disciplinary decision making and the use of electronic visual control
boards to support the planning of patient care;
Aiming for an improvement in workplace safety and environment, which has been
achieved with staff reporting significant benefits and increase in available time to care
for patients;
Improving the environment for patients by colour coding nursing bays and toilets,
using contrasting toilet seats and handrails, separate and dedicated social areas,
improved signposting and reducing posters to create a calmer environment. These
improvements have been used as a template for other wards;
Focusing on training in dementia. 48% of staff on Byland Ward have received training
in dementia care, and the use of the Butterfly Scheme to identify patients with
dementia, has been re-launched together with the use of “All About Me” forms that
support personalised care.
The Trust has also begun a pilot of an ‘opt in’ to the Butterfly Scheme at the point of
diagnosis. This is the first of its kind in the country and involves dementia voluntary agencies
informing patients about the Butterfly Scheme during a support programme following
diagnosis and asking if they would like to opt in at that point. This is then communicated to
colleagues at HDFT who will instigate the Butterfly Scheme if appropriate, when the person
is admitted to hospital. This helps the person with dementia to make their own choice.
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Harrogate and District Foundation Trust Quality Account 2012/13
There is a network of dementia champions throughout the Trust whose aim is to share good
practice and provide good dementia care in their own area.
Staff are able to improve their knowledge and understanding of dementia care by accessing
the open dementia learning programme via their e-learning accounts, and training days are
available via the Trust’s Workforce Development programme.
Managers are also involved in various dementia networks across the region.
Summary
The work relating to dementia care has resulted in achievement of the national CQUIN
indicator targets, and improvements to the care of patients with dementia on Byland Ward.
Learning is being disseminated to other wards, and a Dementia Steering Group has been
set up to help guide progress in dementia care.
3.2.
PERFORMANCE AGAINST KEY NATIONAL PRIORITIES INCLUDING
INDICATORS AND PERFORMANCE THRESHOLDS IN THE FRAMEWORK
The following table demonstrates Harrogate & District NHS Foundation Trust’s performance
against the indicators in Monitor’s Compliance Framework for each quarter in 2012/13.
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Harrogate and District Foundation Trust Quality Account 2012/13
3.3.
ADDITIONAL CONTENT FOR QUALITY
HDFT has identified additional elements of service quality to additionally highlight in this
Quality Account.
3.3.1. CQUIN indicators 2012/13
Indicator 1 – VTE risk assessment. The trust achieved the required performance level of
90% in each month of 2012/13, as per the data submissions to the Department of Health via
Unify.
Indicator 2 – Composite indicator on responsiveness to personal needs (national inpatient
survey). The Trust scored 72.3 as the composite score in 2011 and 71.8 in 2012, which is
99.3% of the score achieved in 2011, meaning that the Trust has achieved the required level
of above or equal to 98% of the 2011 score.
Indicator 3 – Improve collection of data in relation to pressure ulcers, falls, urinary tract
infection in those with a catheter, and VTE. The Trust has submitted Safety Thermometer
submissions to the Health and Social Care Information Centre for each month since the data
collection commenced in July 2012.
Indicator 4 – Dementia. As per data submissions to the Department of Health via Unify, the
Trust has achieved 90% in all three dementia screening indicators in each month since
December 2012, hence achieving the indicator for at least 3 consecutive months during
2012/13.
Indicator 5 – Integrated care. The Trust has provided an update on the Trust’s
implementation of the first module of the Productive Community Services at Ripon
Community Hospital.
Indicator 6 – Patient experience. The Trust implemented a post discharge online inpatient
survey during 2012/13 utilising Survey Monkey technology. Only 10 responses were
received during the Quarter 4 period. As this would not constitute a large enough sample to
be representative, we submitted a summary of the Trust’s local inpatient survey which was
completed by 369 inpatients during Q4 and which includes two questions relating to the
discharge process.
Indicator 7 – Effective discharge communication. The Trust’s Quarter 4 performance was
that 48.9% of admissions had an e-discharge letter created on the ICE software. This
compares to a baseline position of 20.0% in March 2012. Therefore the Trust has achieved
the target of a 20% improvement on the baseline position.
Indicator 8 – COPD discharge care bundle. Of the ten indicators, two only included five
relevant patients in the Quarter 4 audit and so have been excluded based on the small
numbers criteria previously agreed. For the eight remaining indicators, the average score is
72.6%, thus achieving the required level of 70%.
3.3.2. Key staff survey results 2012 and comparison with 2011
Every year the Trust takes part in an NHS wide staff survey. The results are published
nationally and can be obtained from the national NHS staff survey web site. In 2011 HDFT
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Harrogate and District Foundation Trust Quality Account 2012/13
was in the best 20% of Trusts in the country for 14 key findings, which represented 36.8% of
the total key findings. In 2012 HDFT was in the best 20% of Trusts for 11 key findings,
which represented 39.3% of the total key findings and signifies an improved position in our
highest scoring areas. The number of questions in the Survey was reduced for 2012.
In 2012 no key findings were in the bottom 20% of Trusts in the country.
The following key findings have placed the Trust in the ‘best 20%’ for 2 out of the last 3
years:
Staff experiencing violence from staff in the last 12 months (low score)
Staff job satisfaction
Staff recommendation of the Trust as a place to work or receive treatment
Staff motivation at work
The Trust provides equal opportunities for career progression
Staff experiencing discrimination in the last 12 months (low score).
For comparative purposes with the 2011/12 Quality Account the table below demonstrates
the Trust performance in relation to staff recommending the Trust as a place to work or
receive treatment.
3.3.3. Responsiveness to patient needs
The Care Quality Commission (CQC) published the 2012 National Adult Inpatient Survey on
16 April 2013.
Overall HDFT performed well, scoring “significantly better than average” for 2 out of 64
questions. It remains a significant achievement that HDFT had no questions rated
“significantly worse than average”. 473 patients treated at HDFT responded in the survey
this year (a local response rate of 57%), similar to last year.
The information below provides a sample of survey questions comparing this year’s scores
with last year. Note – there are minor differences in the question sets between the two years.
The following question is ranked “significantly better" in both 2012 and 2011:
Q3 - While you were in the A&E Department, how much information about your
condition or treatment was given to you?
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Harrogate and District Foundation Trust Quality Account 2012/13
The following question is ranked “significantly better" in 2012 and “about the same" in 2011:
Q47 - Before the operation or procedure, did the anaesthetist or another member of
staff explain how he or she would put you to sleep or control your pain in a way you
could understand?
The following four questions were ranked “about the same" in 2012 and “significantly better"
in 2011:
Q21 - How would you rate the hospital food?
Q29 - Did nurses talk in front of you as if you weren't there?
Q48 - After the operation or procedure, did a member of staff explain how the
operation or procedure had gone in a way you could understand?
Q59 - Did a member of staff tell you about any danger signals you should watch for
after you went home?
The detailed results are being reviewed and the resultant action plan to ensure the Trust’s
learn all possible lessons from the survey will be monitored closely by Directorates and at
corporate level.
3.3.4. Complaints
Results - Formal Complaints and Informal “Patient Advice and Liaison Service” Type
Contacts
Formal Complaints Received by Financial Year 2007-2013
250
215
214
200
218
179
150
107
106
100
50
0
2007/2008 2008/2009 2009/210 2010/2011 2011/2012 2012/2013
Data source is local patient feedback data
The data from April 2007 to March 2011 refers only to acute hospital services and from April
2011, the data represents both acute and community services following the integration of
community services into the Trust. The Trust increased in size associated with the delivery
of a significant number of new services.
The Trust introduced a detailed grading matrix for negative feedback during 2011, which is
based on severity of concerns and timescales for response. This includes four levels of
formal complaint (green, yellow, amber and red). The breakdown of complaints received in
2012/13 is presented below by grade and quarter in which it was received.
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Harrogate and District Foundation Trust Quality Account 2012/13
Complaints Total
Complaint Green
Complaint Yellow
Complaint Amber
Complaint Red
2012/13
Quarter
1
42
14
28
0
0
Quarter
2
57
39
14
4
0
Quarter
3
48
26
19
3
0
Quarter
4
71
48
22
1
0
Total
218
127
83
8
0
Data source is local patient feedback data
Quarter four saw the greatest number of complaints received, with the greater proportion
being graded as low level (green complaints). This coincided with the publication of the
Final Report of the Public Inquiry into the Mid Staffordshire NHS Foundation Trust (Francis II
Report) conducted by Sir Robert Francis and in some cases, complainants did make
reference to Mid Staffordshire in their complaint.
In addition, the Trust handles informal “PALS” (Patient Advice and Liaison Service) type
contacts, which includes concerns, information requests and comments. In total in 2012/13,
762 were received compared to 653 in last year’s report for 2011/12. However of these 762,
361 were concerns, 100 were requests for information and 301 were comments.
The top five themes for complaints and concerns can be seen in the graph below. The main
themes have consistently included issues around communication and aspects of care either
medical care, including diagnosis or nursing care.
It should be noted that not all complaints/ concerns received are upheld. Action plans are
developed to improve patient care as a result of feedback and these are monitored regularly.
In response to the communication concerns, the Trust provides a communications and
customer care training programme, “Every Patient, Every Time” described elsewhere in this
report.
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Harrogate and District Foundation Trust Quality Account 2012/13
Seven cases were referred to the Health Service Ombudsman during 2012/13 (compared to
10 in 2011/12). Out of the seven cases, six were closed with no further investigation or
action and one case was referred back to the Trust to provide a further response to resolve
the issue.
Results-Compliments
Compliments Received by the Patient 2009/10
Experience team
Compliments excluding to the media
233
2010/11
2011/12
2012/13
354
354
291*
Data source is local patient feedback data. This data excludes all records of thanks received
directly at ward and team level.
* During 2012/13, 331 records of thanks were reported via the local media compared to 367
in 2011/12.
3.3.5. Eliminating Mixed Sex Accommodation
The Trust recognises the importance to patients and relatives of ensuring high standards of
privacy and dignity. As part of this, monitoring against national standards relating to
Eliminating Mixed Sex Accommodation (EMSA) is undertaken on a weekly basis. Since the
beginning of 2011, National EMSA standards have been extended to include outpatient and
day facilities within hospitals. Standards relating to men and women not sharing sleeping
accommodation within hospitals (apart from within highly specialised environments such as
intensive care or coronary care) have been in place for a number of years.
Reporting by NHS Foundation Trusts against the new standards formally commenced in
April 2011. The results of this for HDFT in 2012/13 are:
Quarter 1
Quarter 2
Quarter 3
Quarter 4
0 breaches
0 breaches
0 breaches
0 breaches
The Trust has strict standards relating to single sex use of sleeping accommodation and
toilet facilities within its inpatients wards.
3.3.6. Care Quality Commission (CQC) Quality and Risk Profile
The CQC publish a “Quality and Risk Profile” (QRP) for each trust in 9 out of 12 months of
the year. The QRP uses information from a wide variety of data sources to assess and risk
rate each trust against a range of around 600 measures. The QRP is reviewed routinely
within the Trust with particular attention paid to any measures rated “worse than expected”
or “much worse than expected”. Actions plans are put in place to address any issues and the
Trust board is updated on a monthly basis on any changes.
For the latest published QRP, 619 measures out of a total of 636 (97%), were rated “better
than expected” or “similar to expected” for Harrogate and District NHS Foundation Trust. 10
measures were rated “tending towards worse than expected” and four measures were rated
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Harrogate and District Foundation Trust Quality Account 2012/13
“worse than expected” or “much worse than expected”. Of these four measures, two now
have completed action plans and the Trust is confident that the performance on these
measures will improve in the coming months. For the other two of the measures, a review is
in progress and actions are being identified to ensure that the Trust will be compliant going
forward.
When compared to the same time last year, this shows an improved position - 95% of the
measures were rated “better than expected” or “similar to expected” in March 2012.
3.3.7. The Patient Voice Group (PVG)
The PVG is the Trust’s Patient and Public Involvement group. The group comprises 15
voluntary lay members, including one Governor. It monitors the quality of the patient
experience for inpatients, day care patients and patients in the community. Members visit
wards, services and community services in the Trust, talk to both patients and staff, and
through their written reports to senior management in the Directorates indicate the
effectiveness of the Trust’s commitment to providing high quality fundamental care. The
reports highlight what patient care works well and make recommendations for improvement
where required. It is important to state that the PVG makes suggestions on issues, where
they occasionally arise, rather than individual complaints. The areas in relation to patient
care which are monitored in the PVG reports include:
Care of the elderly and patients with dementia
Privacy and dignity of patients
Cleanliness and safety of patients
Feedback mechanisms and listening to patient concerns and complaints
Clear communication between nursing staff and patients/relatives
Meeting nutritional needs
Effective discharge and provision of after-care plans
The Trust responds in detail to the PVG recommendations and there is now a link on the
Trust’s home page to all the PVG reports and Trust responses.
(i) What the PVG have done: In the past year, the PVG has visited and reflected the views of
patients on their care in the following wards and services, for example
:
Phlebotomy
Maternity
Children’s ward (Woodlands ward)
Jervaulx ward
Byland ward
Nidderdale ward
In the reports, there was clear patient validation of the care and sensitivity of the staff, the
routine cleanliness of wards and evident patient satisfaction with their care whilst in the
hospital. However, the reports did note some areas in need of improvement, for example,
where space was restricted to the detriment of patient comfort, as in Phlebotomy, or where
there was a lack of information for patients and relatives about discharge, protected
mealtimes, and procedures for complaint. It was rare to receive negative comments on
staffing attitude or communication with patients in the reports.
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Harrogate and District Foundation Trust Quality Account 2012/13
(ii) Requests from the Trust: The PVG is being increasingly requested by the departments to
visit them and give written feedback on the patient satisfaction with the service they receive.
One such interesting example was the Chapel of Rest. Here PVG members made strong
recommendations for an upgrade in the furnishings and décor of the rooms. The Trust is
currently looking at these.
PVG Members were also asked to audit the effectiveness of the Protected Evening
Mealtimes protocols where the focus of all staff is on serving and assisting patients with their
meals and entry onto the ward of any other person is restricted. The PVG visited nine wards
and found that there was an embedded culture on all wards of staff helping patients with
their meals and of stopping any other entry on to the ward during the evening meals.
Members did highlight however an absence of leaflets for relatives about Protected
Mealtimes, tables not cleared prior to the meal, and emphasised the usefulness of more
volunteers to assist on the wards at the evening mealtimes.
Several PVG members have been trained in the questions and approach of the new PatientLed Assessment of the Care Environment (PLACE) inspection which will now take place
annually across the country and looks at all areas of safety and hygiene, privacy and
dignity,.
PVG Members have also been asked to provide (a) patient feedback from patients attending
the Chronic Pain Clinic and (b) patients’ experience of the effectiveness of the Patient
Experience Team (PET) which looks at patients’ concerns and complaints as well as receive
compliments and comments.
(iii) Current developments: A new departure for the PVG this past year has been to look at
one of the Trust’s community services: Community Nursing care. This was an extensive
piece of work which involved shadowing community nurses on their home visits in Harrogate
and Knaresborough and visiting patients, with their permission, at home to record their views
of their care. There was high patient satisfaction with the care received and little negative
comment. Amongst other matters, the report particularly focused on the need for more IT
support for staff and systems that talked to each other; the avoidance of duplicated notes
and the need for more integration between social and health care services, GPs and
community nurses. It was pointed out that there was a need to establish a single point of
referral to ensure patients were referred to the correct team and avoided unnecessary visits
and this has now been implemented.
(iv) The future work programme: This includes the completion of the schedule to monitor rest
of the Trust wards by July 2013 in the light of the Trust reconfiguration of some of the ward
functions that has taken place, and the aftermath of the Mid-Staffordshire Francis report. A
particular emphasis in the questions the PVG ask of both patients and relatives will be
placed on care and safety of the elderly, the discharge process and the importance of
compassionate care, a focus that will reflect that of the Trust. The PVG will also look at
work currently being undertaken by the Dementia Collaborative to improve care of patients
with dementia. There will be further monitoring of patient care work in the community
services. In addition, with the increase in care in the community and also more elderly,
unwell and confused patients staying in hospital, it is the intention of the PVG to look at
additional ways of collecting patient feedback on their care and treatment apart from
monitoring the wards.
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Harrogate and District Foundation Trust Quality Account 2012/13
4.
ANNEX ONE: STATEMENTS FROM STAKEHOLDERS
In accordance with the NHS Quality Accounts Regulations, Harrogate and District NHS
Foundation Trust sent a copy of the draft quality report to its lead Clinical Commissioning
Group, Harrogate and Rural District, Healthwatch North Yorkshire, North Yorkshire County
Council Scrutiny of Health Committee and the Council of Governors for comment prior to
publication and received the following statements:
4.1.
NHS HARROGATE AND RURAL DISTRICT CLINICAL COMMISSIONING
GROUP QUALITY ACCOUNT STATEMENT 2013
NHS Harrogate and Rural District Clinical Commissioning Group welcome the transparency
in this year’s Quality Account from Harrogate District NHS Foundation Trust (HDFT). Of
particular value from the perspective of the Clinical Commissioning Group is the emphasis
on improving patient safety, and the progressive development of a safety culture. The
process of engagement has been a positive one, and HDFT has responded constructively to
commissioner feedback.
As the Trust has outlined, there has been much good work on the quality agenda over the
last 12 months, and the Clinical Commissioning Group welcomes the openness of the
challenges detailed by HDFT for the forthcoming year.
21 May 2013
4.2.
HEALTHWATCH NORTH YORKSHIRE QUALITY ACCOUNT STATEMENT
2013
The document contains evidence of:
An overall statement of accountability for Harrogate District NHS Foundation Trust
(HDNHSFT) from the Chief Executive
The identification of 3 improvement priorities and implementation, monitoring and
reporting arrangements to monitor progress
Confirmation that HDNHSFT participates in clinical research. Harrogate District
Hospital income is not dependent on achieving CQUIN goals but all have been
achieved
Confirmation of CQC registration
Confirmation of compliance of Monitor Compliance Framework
Data quality
Review of quality esp. the indicators
The document is not so good at:
Demonstrating clearly that there has been an improvement on all last year’s
priorities. “Progress” is not improvement. For example:
o Improving Discharge – the next steps state “The Discharge Steering Group
will continue to monitor progress and promote activity and opportunities to
support efficient discharge planning.” No evidence of outcome or, in plain
English, how has this improved the care/experience for the patient
o Unpicking the acronyms
17 May 2013
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Harrogate and District Foundation Trust Quality Account 2012/13
4.3.
NORTH YORKSHIRE COUNTY COUNCIL SCRUTINY OF HEALTH
COMMITTEE QUALITY ACCOUNT STATEMENT 2013
Thank you for attending the North Yorkshire Scrutiny of Health Committee on 8 February
2013 and giving Elected Members an opportunity to contribute to Harrogate and District NHS
Foundation Trust’s Quality Account for 2012/13.
Please accept this letter as the comments from the Committee.
As we know Quality Accounts (QAs) are now in their 4th year. The way in which the
Harrogate and District NHS Foundation Trust has engaged with the Scrutiny of Health
Committee over this period has been commendable. It demonstrates that the Trust has
entered into the spirit of QAs as a way of continually improving quality of services in terms of
patient safety, clinical effectiveness and patient experience.
Fundamental care (including nutrition, personal support, dignity, basic care) and End of Life
Care were highlighted as priority areas at our Committee meeting on 8 February 2013. It is
reassuring, therefore, to see that these issues feature strongly in the QA and there are plans
to improve the service in these areas.
Since taking over community health services in 2011 the Trust is taking forward a number of
initiatives to improve non-acute care and to integrate services with social care. I particularly
have in mind the Healthy Ripon initiative which includes the future role of Ripon Community
Hospital. Consequently I fully support measures that will improve the discharge experience
for patients and carers and measures to make greater use of technology to drive safe and
effective care as set out in the QA. The way in which the Trust is working in partnership with
the Tees, Esk and Wear Valleys NHS Foundation Trust, for instance, to develop the
Harrogate Dementia Collaborative is an excellent example of partnership working to improve
care for people with dementia. I look forward to future versions of your QA highlighting how
you are improving community health services, working in partnership with other acute
providers and giving integration with social care even more impetus.
It is reassuring that in his Statement at the beginning of the QA the Chief Executive refers to
a major review of complaints process has already taken place and how action will be
implemented to improve the process early in 2013/14. The QA also highlights that the Trust
has introduced a detailed grading matrix which includes 4 categories of complaint based on
severity of concern and timescale for response. The Francis report was a “wake up” call for
all involved in healthcare, including scrutiny committees, for complaints to be taken
seriously. Against this background and in order for the Committee to contribute to how the
process is improved, I would like to take this opportunity to invite the Trust to attend a
meeting of the Scrutiny of Health Committee to provide more information on how the
categorisation of complaints works in practice, including what measures are in place to
ensure all complaints are categorised appropriately.
Finally, the process which the Trust has followed in producing its QA demonstrates a
commitment towards involving patients and the public in service development and a
willingness to engage in an open way with the Scrutiny of Health Committee.
Yours sincerely
County Councillor Jim Clark
Chairman – North Yorkshire County Council Scrutiny of Health Committee
15 May 2013
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Harrogate and District Foundation Trust Quality Account 2012/13
4.4.
COUNCIL OF GOVERNORS QUALITY ACCOUNT STATEMENT 2013
The Council of Governors members are exposed to a wide variety of quality issues on a
regular basis across the Trust. This is through membership of the Patient and Public
Involvement fora, NICE and Medicines Management Group, PLACE inspections and the
"buddying" of Public Governors to wards’ and departments’ Quality of Care Teams. The
Council of Governors also reviews the Annual Report, Annual Plan and Quality Account as
they are drafted and are consulted at key stages. The Council of Governors supports and
endorses the findings of the report and the areas in which to concentrate future effort.
16 May 2013
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Harrogate and District Foundation Trust Quality Account 2012/13
5.
ANNEX TWO: STATEMENT OF DIRECTORS’
RESPONSIBILITIES
The directors are required under the Health Act 2009 and the National Health Service
(Quality Accounts) Regulations 2010 as amended to prepare Quality Accounts for each
financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of
annual quality reports (which incorporate the above legal requirements) and on the
arrangements that foundation trust boards should put in place to support the data quality for
the preparation of the quality report.
In preparing the Quality Report, Directors are required to take steps to satisfy themselves
that:
the content of the Quality Report meets the requirements set out in the NHS
Foundation Trust Annual Reporting Manual 2012-13;
the content of the Quality Report is not inconsistent with internal and external
sources of information including:
o
o
o
o
o
o
o
o
o
o
o
Board minutes and papers for the period April 2012 to June 2013
Papers relating to Quality reported to the Board over the period April 2012 to
June 2013
Feedback from the commissioners dated 21/05/2013
Feedback from governors dated 16/05/13
Feedback from local Healthwatch organisations dated 17/05/2013
Feedback from North Yorkshire County Council Scrutiny of Health Committee
dated 15/05/2013
The trust’s draft complaints report published under regulation 18 of the Local
Authority Social Services and NHS Complaints Regulations 2009, dated
22/05/2013
The 2012 national patient survey 16/04/2013
The 2012 national staff survey 28/02/2013
The Head of Internal Audit’s annual opinion over the trust’s control
environment dated April 2013
CQC quality and risk profiles dated April 2013
the Quality Report presents a balanced picture of the NHS foundation trust’s
performance over the period covered;
the performance information reported in the Quality Report is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review
to confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Report is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review; and the Quality Report has
been prepared in accordance with Monitor’s annual reporting guidance (which
incorporates the Quality Accounts regulations) (published at www.monitornhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality
for the preparation of the Quality Report (available at www.monitornhsft.gov.uk/annualreportingmanual)).
The Directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Report.
64
Harrogate and District Foundation Trust Quality Account 2012/13
By order of the Board
..............................Date.............................................................Chairman
..............................Date............................................................Chief Executive
65
Harrogate and District Foundation Trust Quality Account 2012/13
6.
ANNEX THREE: NATIONAL CLINICAL AUDITS
Name of audit
Number of patients
Data submitted for
2012-13
Data submitted as a
percentage of the
number of
registered cases
required for that
audit
Report status
Neonatal
Neonatal intensive and special
care (NNAP)
117
100%
Action plan in
progress
Children
Diabetes (RCPH National
Paediatric Diabetes Audit)
64
100%
Not yet published
for 2012
submissions
Fever in children (College of
Emergency Medicine)
50
100%
Action plan in
development
100%
Report not yet
published
Not applicable
Report not yet
published
100%
Report not yet
published
100%
Action plan in
progress
100%
Report not yet
published for
2012/13 data
56%
Action plan in
development
Acute care
Emergency use of oxygen
(British Thoracic Society)
Adult community acquired
pneumonia (British Thoracic
Society)
Non-invasive ventilation -adults
(British Thoracic Society)
Adult critical care
Potential donor audit (NHS
Blood & Transplant)
Renal Colic (College of
Emergency Medicine)
1
Audit remains open and
data collection current.
Local audit undertaken
8
456
100
28
Long term conditions
66
Harrogate and District Foundation Trust Quality Account 2012/13
Name of audit
Diabetes (National Adult
Diabetes Audit)
Number of patients
Data submitted for
2012-13
Data submitted as a
percentage of the
number of
registered cases
required for that
audit
Report status
28
100%
Report published
March 2013
100%
Action plan in
development
100%
Report not yet
published
8% (to date)
Report due in
2014
Heavy menstrual bleeding
(RCOG National Audit of HMB)
Did not participate
Local audit
Dementia Audit (Royal College
of physicians)
40
Parkinson's disease (National
Parkinson's Audit) Patient
Management, Physiotherapy,
Occupational Therapy and
Speech and Language
Therapy
20 Patient
Management
30 Therapy services
Total=50
Inflammatory bowel disease
(Data collection Commenced
January 2013)
4
Adult Asthma
14
100%
Report not yet
published
Stroke National Audit
Programme (SSNAP)
226
100%
Report not yet
published
90%
Report not yet
published
100%
Action plan in
development
Pain database
Did not participate
Elective procedures
Hip, knee and ankle
replacements (National Joint
Registry)*
837
Cardiovascular disease
Acute Myocardial Infarction &
other Acute Coronary
Syndrome (MINAP)
311
67
Harrogate and District Foundation Trust Quality Account 2012/13
Name of audit
Heart failure (Heart Failure
Audit)*
Number of patients
Data submitted for
2012-13
Data submitted as a
percentage of the
number of
registered cases
required for that
audit
69
100%
Action plan in
progress
Report status
Cancer
Lung cancer (National Lung
Cancer Audit)*
120
100%
Report due
December 2013
Bowel cancer (National Bowel
Cancer Audit Programme)*
107
100%
Report due July
2013
50
100%
Report due June
2013
282
100%
Report awaited.
On-going action
plan from
continual audit
process
147
106% (based on HES
data and expected
submissions)
Quarterly reports
reviewed
Oesophago-gastric cancer
Trauma
Hip fracture (National Hip
Fracture Database)*
Severe trauma (Trauma Audit
& Research Network)
Neck of femur (College of
Emergency Medicine)
50
100%
Action plan in
development
143
100%
Report published
2
100%
Report to be
published later
2013
Subarachnoid haemorrhage
1
Study remains open
Alcohol related liver disease
3
Transfusion
Blood sample labelling
Massive transfusion
National Confidential Enquiries
Report due
autumn 2013
Report due June
68
Harrogate and District Foundation Trust Quality Account 2012/13
Name of audit
Number of patients
Data submitted for
2012-13
Data submitted as a
percentage of the
number of
registered cases
required for that
audit
Report status
2013
Bariatric surgery
Cardiac arrest procedures
Asthma Deaths Review
Child Health Reviews
Organisational
questionnaire only
Report “Too lean
a Service”
published,
reviewed and
action plan
reported
4
Report “Time to
intervene”
published,
reviewed and
action plan
reported
1
100%
1 case reviewed
by Royal College
of physicians
1
100%
1 case reviewed
by Royal College
of Paediatrics and
Child Health
481
97% pre-op
58
35% post op
Elective Surgery (Patient
Reported Outcome
Measures)
Hip replacement, knee
replacement, varicose veins
(6 months data only available)
69
Harrogate and District Foundation Trust Quality Account 2012/13
Glossary
AMU
BCSS
C.difficile
CLRN
COPD
CPR
CQC
CQUIN
CRN
CSU
DH
DNACPR
DVT
EMSA
FFT
H@N
HDFT
ICE
ICU
LCP
LINks
MEOWS
MRSA
NEWS
NHSLA
NICE
NIHR
NRLS
PALS
PAWS
PCT
PEAT
PET
PPI
PROMs
PVG
QA
QEG
RA
RTT
SSNAP
STEIS
TEWV
VTE
WTE
Acute Medical Unit
Bowel Cancer Screening System
Clostridium difficile
Comprehensive Local Research Network
Chronic Obstructive Pulmonary Disease
Cardiopulmonary Resuscitation
Care Quality Commission
Commissioning for Quality and Innovation
Clinical Research Network
Commissioning Support Unit
Department of Health
Do Not Attempt Cardiopulmonary Resuscitation
Deep Vein Thrombosis
Eliminating Mixed Sex Accommodation
Friends and Family Test
Hospital at Night
Harrogate and District NHS Foundation Trust
Integrated Clinical Environment (Electronic Reporting and Requesting System)
Intensive Care Unit
Liverpool Care Pathway
Local Involvement Networks
Modified Early Obstetric Warning System
Methicillin-Resistant Staphylococcus Aureus
NHS Early Warning Score
National Health Service Litigation Authority
National Institute for Health and Clinical Excellence
National Institute for Health Research
National Reporting and Learning System
Patient Advice and Liaison Service
Paediatric Advanced Warning Score
Primary Care Trust
Patient Environment Action Team
Patient Experience Team
Patient and Public Involvement
Patient Reported Outcome Measures
Patient Voice Group
Quality Accounts
Quality of Experience Group
Risk Assessments
Referral to Treatment
Sentinel Stroke National Audit Programme
Strategic Executive Information System
Tees, Esk and Wear Valleys
Venous Thromboembolism
Whole-time equivalent
70