Quality Accounts
2014-15
2
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Statement on Quality –
A Letter from Our Chief Executive
Dear Patients, Relatives, Carers and Colleagues of Wye Valley NHS Trust
Welcome to the Quality Accounts 2014/15 for Wye Valley NHS Trust. Each NHS organisation publishes Quality Accounts
every year. The document sets out areas where we have made improvements over the past 12 months and our
priorities for the forthcoming year.
This document is set out into 3 areas;
1. Priorities for Improvement
Our three key areas for improvement over the coming financial year
2. Review of Quality Performance 2014/15
Our performance over the past financial year, including an update on last year’s priorities.
3. Mandatory Statements Relating to Quality of Services
The Department of Health mandates statements we must produce in relation to the quality of our services.
During 2014/15, the Trust was subject to a Care Quality Commission (CQC) Inspection which saw each of our services
reviewed and assessed accordingly. As a result of this inspection the Trust was moved into special measures. A number
of key areas for improvement were highlighted, many of which the Trust was already aware of and working hard to
improve.
Following this inspection, the Trust developed a Patient Care Improvement Plan (PCIP) which is our key focus for
unlocking our potential. This is not simply a reaction to an inspection report but contains every action needed to
produce a more resilient organisation which meets our service quality expectations as well as constitutional and
regulatory targets. With key areas including; urgent care, organisational development, reducing harm, patient
experience and stroke care taking a focal point in our PCIP we are confident that progress has already been made and
we will achieve a level of care we would expect for our friends and family.
Wye Valley NHS Trust strives to work with our partners within the Herefordshire health economy and to this end both
Healthwatch and the Herefordshire Clinical Commissioning Group were consulted on the Quality Accounts prior to
publication. We received constructive feedback from Healthwatch which has been considered and where appropriate
incorporated into the Quality Accounts.
We welcome feedback on our Quality Accounts as well as any feedback on our services (positive or negative). If you do
have any feedback please do not hesitate to contact the Quality & Safety Department on 01432 355444 x5803 or via
email at safety@wvt.nhs.uk
To the best of my knowledge the information in this report is a true and accurate reflection of the current position of
Wye Valley NHS Trust.
Yours sincerely
Richard Beeken
Chief Executive
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
3
Section 1: Priorities for Improvement in 2015/16
Introduction
This section of the Quality Accounts sets out Wye Valley NHS Trust’s priorities for improvement in 2015/16. The Trust has
a Quality and Safety Improvement Strategy in place with focused priorities which is driving key areas for improvement
from 2014 to 2017. The priorities set out within the Quality Accounts also reflect those within our Quality and Safety
Improvement Strategy and ensures the appropriate focus has remained on key areas.
In addition, the priorities set out are separated within the three key themes for quality and safety;
• Patient experience
• Patient safety
• Clinical effectiveness
The Trust’s priorities for the forthcoming year are;
Priority
Theme
Responsible Officer
Deadline
Friends and Family - To
achieve an improvement
into the top quartile for
Friends and Family across
all areas.
Patient experience
Michelle Clarke,
Director of Nursing &
Quality
31st March 2016
Safety Thermometer - To
aim for 100% harm free
care with a minimum
acceptable level of 95%
harm free care
Patient safety
Michelle Clarke,
Director of Nursing &
Quality
31st March 2016
Mortality - To achieve and
maintain an annualised
Hospital Standardised
Mortality Rate and
Summary-level Hospital
Mortality Index within
expected levels.
Clinical effectiveness
Susan Gilby, Medical
Director
31st March 2016
In developing the priorities for the Quality and Safety Improvement Strategy, which are echoed as part of the Quality
Accounts, a significant amount of consultation was undertaken with the organisation’s stakeholders i.e. patients, staff
members and external agencies. The Trust has utilised feedback from surveys, focus groups and national reports to
determine its priorities for quality and safety as set out in the Quality and Safety Improvement Strategy. Appendix 1 details
the comments made by external agencies.
4
W ye Va l l ey N H S Trust Q uali ty Ac c ounts 2014/15
Patient Experience
Priority 1
To achieve an improvement into the top quartile for Friends and Family across all areas.
Rationale
The Friends and Family Test is a national measure used to gather patient feedback on the services they receive. All
patients are asked;
“How likely are you to recommend this ward / service to your Friends and Family should they require similar care or
treatment?”
Using this measure will allow the Trust to benchmark its patient experience feedback against other NHS Trusts and
ensure the Emergency Department, community services, inpatient services and outpatient services are routinely
collecting patient experience data as well as acting upon the findings.
Baseline
Please refer to section 2.1.6.
Our Goal
The Trust is aiming to be within the top quartile when compared to other NHS Trusts for both response rates and
scores within each of the different service areas;
• Emergency Department
• Community services
• Inpatient services
• Outpatient services
How the goal will be achieved
To achieve an increased response rate and maintain this throughout the year the Trust will ensure that the being asked
the Friends and Family Test question is embedded across the Trust. This will include;
• Raising awareness of the Friends and Family Test, why it is important and our results so far with staff through Trust
Talk and Team Brief each month.
• Ensuring patients are given the opportunity to respond through inclusion of the Friends and Family Test question in
information leaflets and handbooks and discharge processes.
• Sharing lessons from areas with a high response rate with those that require improvement.
• Regular real time monitoring to ensure wards and departments are aware of their response rates and scores at all times.
Monitoring and Reporting
This priority will be monitored through a number of routes;
• Weekly reporting to ward and department leads to ensure direct and immediate action can take place.
• Monthly reporting to Service Unit Governance Meetings and Service Unit Performance meetings to ensure trends
and themes within Service Units can be identified and acted upon.
• Monthly reporting to the Quality Committee and Trust Board to ensure Trust wide trends and themes can be
identified and acted upon.
• In addition, quarterly reporting will occur within the Patient Experience Report to the Quality Committee this will
ensure trends and themes over time are captured and acted upon.
Responsible Officer
Director of Nursing and Quality
Wy e Va l le y NHS Trus t Qua lity A cc ounts 2014/15
5
Patient Safety
Priority 2
To aim for 100% harm free care with a minimum acceptable level of 95% harm free care using the national Safety
Thermometer tool.
Rationale
The Safety Thermometer is a national tool used to measure harm free care. The four key harms measured are;
• Pressure ulcers
• Falls
• Catheter/UTIs
• VTE (venous thromboembolism)
Using this national tool will enable the Trust to benchmark not only against its previous performance but also against
other Trusts.
Baseline
Our Goal
The Trust aims to increase harm free care to 100% with a minimum acceptable level of 95%.
This is in line with the national aim of 95% for the Safety Thermometer programme.
How the goal will be achieved
A number of improvements have been made which will have a positive impact on the harm free care delivered by the
Trust. This includes;
• Development of an action plan to continue the focus on reducing avoidable category 3 and 4 pressure ulcers. The
actions have been identified following a review of key themes identified throughout 2014/15. Please see section
2.2.6 for more info.
• Introduction of falls sensors (an early alert system when a patient mobilises) within the County Hospital and
Community Hospital settings.
• Continued monitoring of the completion of VTE risk assessments on a daily basis with escalation occurring where
appropriate.
6
W ye Va l l ey N H S Trust Q uali ty Ac c ounts 2014/15
Monitoring and Reporting
This priority will be monitored through a number of routes;
• Monthly reporting to Service Unit Governance Meetings and Service Unit Performance meetings to ensure trends
and themes within Service Units can be identified and acted upon.
• Monthly reporting of results in Team Brief and Trust Talk to ensure staff members are kept informed of current
progress with the Safety Thermometer.
• Monthly reporting to the Quality Committee and Trust Board to ensure Trust wide trends and themes can be
identified and acted upon.
Responsible Officer
Director of Nursing and Quality
Clinical Effectiveness
Priority 3
To achieve and maintain an annualised HSMR and SHMI within expected levels.
Rationale
This priority links to the harm free care aspects of the Safety Thermometer however using mortality rates as an
indicator for areas where quality of care needs to be improved has been an ongoing priority for the Trust and this has
been reflected in previous Quality Accounts.
Baseline
The most recently available data for HSMR and SHMI is;
• SHMI – October 2013 to September 2014 - 113.01
• HSMR – February 2014 to January 2015 – 115.5
Our Goal
To achieve and maintain an annualised HSMR and SHMI within expected levels.
How the goal will be achieved
A number of key areas have been identified to improve clinical effectiveness and patient safety which in turn will be
reflected in the Trusts HSMR and SHMI rates;
• Establishment of a new governance structure for mortality.
• Delivery of a trust wide educational programme.
• Implementation of a sepsis screening tool.
• A review of coding in relation to capturing co-morbidities.
• Introduction of a revised vital signs chart with links to sepsis and Acute Kidney Injury (AKI) care bundles (a set of
interventions when performed collectively and reliably, have been proven to improve patient outcomes).
• A review of end of life care.
Monitoring and Reporting
This priority will be monitored through a number of routes;
• Monthly reporting to the Quality Committee and Trust Board to ensure Trust wide trends and themes can be
identified and acted upon.
Responsible Officer
Medical Director
Wy e Va l le y NHS Trus t Qua lity A cc ounts 2014/15
7
Section 2: Review of Quality Performance 2014/15
This section sets out our quality performance from 1st April 2014 to 31st March 2015 under the following four areas as
well as progress against the priorities that were set in the last year’s Quality Accounts:
• Patient Experience
• Safety
• Effectiveness
• Staff Engagement
Each section includes a brief introduction, the performance data, where we have performed well and where further work
is required.
Progress against Priorities set for 2014/15
Priority
Update
To achieve an improvement into the top quartile for
acute Trusts for the CQC National Inpatient Survey.
Not achieved. The recently published National Inpatient
Survey has shown that the Trust has not achieved this
objective. Key actions have been highlighted within
section 2.1.5 that will ensure improvements are
implemented and outcomes monitored. This continues
to be a priority for the Trust in its Quality Improvement
Strategy.
To aim for 100% harm free care with a minimum
acceptable level of 94% harm free care
To achieve an annualised HSMR and SHMI of 100 or
below (by March 2015)
Achieved. The Trust has achieved this priority with an
average rate of harm free care of 96.5% and continues
to aim for improvements with an increased minimal
acceptable level of harm free care being set at 95% in
this year’s Quality Accounts.
To achieve a SHMI less than 100 (by March 2015)
Not achieved. The Trust has not yet achieved this priority.
However, significant actions have been taken this year
and are planned for the forthcoming year. Please refer
priority 3.
Section 2.1: Patient Experience
The Trust welcomes feedback from our patients, their carer’s and families at all times through various routes including;
• Patient Experience Team based at the main reception of the County Hospital
• Comments and suggestions boxes stationed in all areas
• Leaflets and posters on how patients can raise complaints are available in all areas
• Feedback is actively sought through local and national patient experience surveys
• Quarterly patient forums are held with the Director of Nursing and Quality
• Patient stories are also heard at Trust Board
• Access to the formal complaints process through written letters to the Chief Executive or via email at
makingexperiencecount@wvt.nnhs.uk
8
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.1.1 PLACE Assessments
Introduction
Patient Led Assessments of the Care Environment (PLACE) are patient-led annual audits and are a snapshot of the hospital
environment as perceived by those using it.
The patient assessor’s role is:• Assessing what matters to the patients /the public
• Reporting what matters to the patients/the public
• Ensuring the patient/public voice plays a significant role in determining the outcome of the audit.
At least 50% of the people taking part in the PLACE assessment must meet the definition of patient, in other words a user
of the service rather than the provider of the services.
This is the third year that the PLACE audits have been rolled out and this year as well as assessing cleanliness, food, privacy
and dignity, condition appearance and maintenance the Trust will be scored on how ‘Dementia Friendly’ they are.
The Trust welcomes the introduction of the assessment of ‘Dementia Friendly’ environments as part of the PLACE
assessments in 2015. The Trust is already proactive in ensuring dementia friendly environments with dementia training
offered to all of our staff and ‘Dementia Champions’ are now in place across the Trust.
Performance Data
The PLACE scores for Wye Valley NHS Trust in 2014 were;
Better than national average
Key
Above national average (within 2%)
Below national average
Site
Wye Valley
NHS Trust
Overall Score
Cleanliness
Score
Food and
Hydration
Privacy, Dignity
and Wellbeing
Condition
Appearance and
Maintenance
95.29%
78.42%
87.03%
91.30%
Key Achievements
Following previous experiences the Trust was able to quickly identify areas for development and an action plan to address
areas for improvement was developed. This action plan was then shared with the relevant staff to ensure improvements
were made swiftly. Examples of actions taken are included within the next section.
Although there are areas of improvement that were identified and actions to address these highlighted below the Trust
was also pleased to have scored above the national average within 7 areas across its sites and three of the four categories
were above national average overall.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
9
Lessons Learned/Areas identified for further improvement
Following the results of the PLACE assessment the Trust put in place a robust action plan to improve the cleanliness, food,
privacy and dignity, condition appearance and maintenance across all of its sites.
An example of some of the actions taken and improvements made as a result include:
• The assessors at Bromyard Physio Department identified areas for improvement. As a result a painting programme was
put in place with work being completed in October 2014.
• Oxford Suite at the County Hospital was identified as being cluttered with the reception in need of special attention.
Also concerns were raised about the security of patient notes left in the corridors outside clinic rooms. Taking on board
these comments, work was undertaken in an existing scheme already in place to redesign the department. New secure
notes trolleys have been purchased, better signage is now in place, and the reception area redesigned providing a better
friendlier waiting area. This work was completed by December 2014.
• In addition, the Trust has adopted the Credit 4 Cleaning audit tool which has now been cascaded out and used across
the Trust. This provides greater assurance that routine service environment checks are more consistent, provide more
reliable data and establish where there is need for improvement.
In response to the scores identified in ‘Food and Hydration’ across Wye Valley NHS Trust the Trust has;
• Created a comprehensive action plan to address the major issues identified during the audit.
• Set up a Nutrition Steering Group, a Nutritional Support Team chaired by the Director of Nursing & Quality and
Nutritional Care Group (including patient representation) to oversee all aspects of nutrition & hydration.
• Developed nutrition policies including the Food Service and Nutritional Care Policy
• Review of menus at the County Hospital and improvement of the provision of meals for Therapeutic Diets
• Reviewed the menus at Hillside to better provide for stroke patients.
• Prepared a business case for the provision of snacks at the County Hospital. Community Hospitals already include this
option.
Section 2.1.2 Patient Experience Walkrounds
Introduction
Patient Experience Walkrounds have been carried out each month in outpatient, inpatient and community areas. The walk
round team is made up of an Executive Lead, a Non-Executive Lead, a Quality & Safety representative, an Infection Control
representative and member of Health Watch. The team speaks with both staff and patients and gathers views about how
services can be further improved.
Performance Data
18 Patient Experience Walkrounds have been undertaken in 2014/15.
10
W ye Va l l ey N H S Trust Q uali ty Ac c ounts 2014/15
Key Achievements
In the final report, areas for improvement and areas of good practice are highlighted to ensure that staff can share good
practice and take action to address areas requiring improvement.
Examples of good practice identified include;
• A visit to Teme Ward in July 2014 showed that patient’s feedback was uniformly positive with patients describing staff
and the care they received as caring, professional, timely and that they had 100% trust in the doctors treating them.
• During a visit to the Day Case Unit in October 2014, staff were observed to be friendly and positive in an uncluttered
and clean environment.
• February 2015’s visit to Leadon Ward found that staff felt they worked in an open environment where they could raise
concerns if they had any.
Lessons Learned/Areas identified for further improvement
As described earlier, every visit identifies areas of good practice and areas for further development. Examples of areas
for improvement identified during Patient Experience Walkrounds include;
• During a visit to Children’s Ward in January 2015, it was observed that there was potentially some confusion in
identifying staff roles by their uniforms. The Children’s Ward were carrying out a change of uniforms at this time
and promotional literature about the new uniforms was later displayed to help with identifying staff uniforms.
• It was identified in a number of visits that some staff were not aware of the Service Unit structures in place within
the organisation. Information explaining this structure is now available to all staff on the intranet and was promoted
through Trust Talk and Team Brief.
Section 2.1.3 Mixed Sex Accommodation Breaches
Introduction
The NHS Operating Framework requires all providers of NHS funded care to comply with the national definition ‘to
eliminate mixed sex accommodation except where it is in the overall best interests of the patient, or reflects patient
choice’.
The Trust monitors compliance with this national indicator daily and reports on its performance monthly to Service Units,
the Quality Committee and Trust Board.
Compliance is monitored via the Clinical Site Management Team, Ward and Department Teams and regular patient
surveys. If a breach or potential breach is identified, it is escalated immediately to senior managers, the Chief Operating
Officer and Director of Nursing & Quality, action is then taken to avoid or address the breach.
Wy e Va l le y NHS Trus t Qua lity A cc ounts 2014/15
11
Performance Data
The chart below displays the Mixed Sex Accommodation breaches reported by Wye Valley NHS Trust in 2014/15.
During 2014/15 the Trust experienced mixed sex breaches in CCU and ITU. Occurrences of mixed sex breaches within these
areas are where the patients condition has improved and they are deemed ward-able but are awaiting a general bed.
Key Achievements
A visit by the Trust Development Authority (TDA) and Clinical Commissioning Group (CCG) in January 2015 clarified the
criteria for reporting a mixed sex breach and following this the Trust has been able to set out a Standard Operating
Procedure to reduce mixed sex breaches and manage them appropriately if they do occur.
Lessons Learned/Areas identified for further improvement
The Trust will now need to implement this Standard Operating Procedure and monitor its effectiveness when used in day
to day working practice. The appropriate management of mixed sex accommodation breaches is a priority for the Trust
and will continue to work to reduce mixed sex accommodation breaches.
12
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.1.4 NHS Choices, Patient Opinion, I Want Great Care
Introduction
The NHS Choices feedback page is linked to the Patient Experience Team (PET) which acknowledges, receives and actions
any feedback logged on NHS Choices.
Patients using the site are encouraged to contact the team with any feedback, positive or negative. Comments received by
the PET are shared with the responsible managers. When postings are made anonymously we reply thanking them for
their comments and ask if they would like to contact the PET to discuss their comments, this allows us to address
concerns.
The majority of comments received are positive and complimentary - it is as important to use information about where we
are doing well, as well as where we need to improve.
In addition to comments relating to the Trust, we regularly receive comments relating to services provided by other
organisations such as West Midlands Ambulance Service, General Practice and our Private Finance Initiative partners who
are responsible for some of the environmental issues, such as car parking and catering. These concerns are forwarded to
the correct organisations who send a reply back to PET and/or contact the person directly.
Performance Data
The table below demonstrates a decrease in the use of NHS Choices over the past 12 months to log concerns.
2015
2014
2013
2012
2011
NHS Choices
18
65
44
-
-
Patient Opinion
0
5
7
5
5
Key Achievements
The Trust receives, on average, more compliments through these sites than concerns. An example of a comment posted
on NHS Choices can be seen below:
‘My father was admitted to your hospital on the 3rd May by ambulance. He was admitted to Frome Ward then transferred
to Arrow Ward. He was with you for 10 days. Our family would like to express our thanks and gratitude for the care that
he received as well as the support my mother my sister and me received. My mother was provided with relative room and
this enabled her to stay close to my father during his stay. All staff, consultants, doctors, palliative care, porters and
cleaners could not have done more to help us cope with what is a very upsetting time. Thanks again your care is first
class.’ Posted April 2014
‘I had a routine appointment in the X-ray department at Leominster. Previously I had attended Hereford hospital for this
purpose. Leominster was very user friendly, staff were polite and kind, the car parking was close by and free, my wait was
very short. The service given was thorough, as it had been at Hereford.’ Posted December 2014
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
13
Section 2.1.5 National CQC Inpatient Survey
Introduction
Each year the CQC undertake an Inpatient Survey across all NHS Trusts in England. This data is then used to establish a
benchmark and comparisons between other Trusts.
A full copy of the benchmarking report can be found on the CQC website.
Performance Data
The National Inpatient Survey took place between September 2014 and January 2015 questioning a total of 850 patients
who had an overnight inpatient stay during August 2014. The results were released by the CQC in May 2015.
A total 470 surveys were returned completed, representing a response rate of 57%, which was above the national
average.
The satisfaction levels are lower than the previous year, however, only one question highlighted a ‘statistically significant’
deterioration namely:
Q15 Were you ever bothered by noise at night from patients?
Wye Valley NHS Trust will focus on the reasons why satisfaction levels fell in this particular area by speaking with our
patients and using the information gained to review how noise from other patients can be reduced. The Trust is
considering the use of ear plugs and eye shields that have been successful in other NHS organisations.
Key Achievements
The main increase in patient satisfaction levels was with respect to being nursed in single sex accommodation.
Lessons Learned/Areas identified for further improvement
The Trust is disappointed to have been placed within the ‘worst’ performing Trusts (bottom 20%) in the following
questions:
Q28 Did you have confidence and trust in the nurses treating you?
Q32 Were you involved as much as you wanted in the decisions about your care and treatment?
Q34 How much information about your treatment or condition was given to you?
Q46 Were you told how you could expect to feel after you had your operation?
In order to establish what would improve the patient experience in these areas, the questions will be included in the
patient surveys currently being carried out by volunteers and tangible actions identified.
The volunteer surveys have been carried out for some time and feedback from patients has on the whole been very
positive, as has feedback from Friends and Family. Clearly real time feedback can be at variance with some of the scores
received in the national survey and the Trust will be reviewing other methods to capture patient experience to ensure a
balanced view is obtained.
14
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.1.6 National Friends & Family Test
Introduction
The Friends and Family Test is a national requirement whereby patients are asked;
“How likely are you to recommend this ward / service to your Friends and Family should they require similar care or
treatment?”
This simple question allows patients to give quick and easy feedback into the services they have received by Wye Valley
NHS Trust.
All feedback is fed through as part of a national submission which allows the Trust to benchmark itself against other NHS
Trusts.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
15
Key Achievements
The Friends and Family Test has been a key focus for Wye Valley NHS Trust this year and a number of achievements and
developments have been made. During 2014/15 the Trust has:
• Extended the Friends and Family Test to patients in community settings, Day Case Unit and outpatients.
• The Trust was an early adopter site and amongst the first within the NHS to introduce the Friends and Family Test within
outpatient settings.
• Held a monthly Friends and Family Test competition within each Service Unit to reward wards with the highest scores,
highest response rates and most improved scores.
• Maintained an Inpatient Friends and Family Test response rate above the target of 40% which has shown that for March
2015 data Wye Valley NHS Trust is in the top quartile when compared to other NHS Trusts.
An example of the Trust response to specific feedback received from the Friends and Family Test includes provision of WiFi
in the Paediatric areas, prominent display of waiting times in A&E and the introduction of the Noise at Night Charter.
16
W ye Va l l ey N H S Trust Q uali ty Ac c ounts 2014/15
Lessons Learned/Areas identified for further improvement
It has been noted that in times of increased pressure in the Emergency Department the response rate for Friends and
Family Test can decrease and this is believed to be due to the pressures that staff members are under. However, this is also
a very important time for the Trust to gauge patient experience and therefore the Trust will look to develop and implement
a process that is consistent during times of pressure in the Emergency Department.
The Trust already asks additional questions to try to help establish the cause of any negative feedback. This data will be
utilised more fully and in a timely manner to ensure any areas in need of improvement are addressed swiftly. These areas
are;
• Communication with staff
• Being treated with dignity and respect
• Cleanliness
• Food
• Ward environment
• Being kept informed about your treatment
Section 2.1.7 Expert Patients Programme (EPP)
Introduction
EPP is a generic self- management course for patients living with one or more long term or chronic health condition(s). It
consists of six weekly sessions lasting two and a half hours per week. Course sessions cover key topics such as managing
symptoms, relaxation techniques, dealing with stress, depression and low self-image, healthy eating, safe exercise,
communication skills, goal setting and problem solving. Participants are encouraged to share experiences, learn from each
other and develop ways of overcoming specific difficulties. The course works on the principles that the patient knows best
how their condition affects them and with proper support, can take the lead in managing their condition.
It is facilitated by volunteer tutors who live with long-term condition(s) and have attended the course prior to becoming a
tutor. They understand the challenges that participants face on a day to day basis. The tutors are fully trained and
accredited and are assessed annually to ensure compliance to the EPP quality framework.
The course is for:
• Any adult over 18 living with one or more long term or chronic health condition which can only be controlled and not,
at present, cured
• Conditions such as arthritis, diabetes, asthma, thyroid conditions, depression, multiple sclerosis, Parkinsons, ME, back
pain, Fibromyalgia.
Performance Data
• In 2014/2015 16 courses were held in different locations around Herefordshire.
• A total of 195 participants completed the course.
Wy e Va l le y NHS Trus t Qua lity A cc ounts 2014/15
17
Key Achievements
•
•
•
•
•
•
•
•
•
Compared to 2013/14 participant numbers have increased from 177 to 195.
Numerous positive articles and photographs in local papers promoting both the courses and becoming a volunteer tutor
Four new tutors have been recruited and attended training. These tutors are currently delivering courses.
The Trusts EPP organised own Tutor Training for the first time in Hereford for newly recruited tutors. Plans are in place to
hold further Tutor Training in 2015.
The EPP Co-ordinator is currently training to become an Assessor to enable in-house assessments on Tutors, and also
enable the exchange of services with other providers of EPP.
Continued successful working with local GP surgeries to promote the programme by carrying out mailshots to patients
with long term conditions, and also raising awareness of the benefits of the course with both GPs and other Health
Care Professionals within the NHS
Courses continue to be held with local work-match organisations JHP/Learn Direct, Pertemps and Job Centre Plus to
assist those off work with long term sickness get back into employment.
A Reunion/Information Day was held for participants of previous courses and to encourage new tutors. Over 50
participants attended with interest from a number of potential tutors. There were also talks and stands from local
service providers e.g. Healthy Lifestyle Trainers, Healthwatch.and WVT’s Patient Experience Team.
Two new tutors have been interviewed and are awaiting training.
Examples of positive comments from users of EPP:
“The course has certainly fulfilled the aim of helping me to self-manage my diabetes…I have learnt a lot about coping
with all kinds of problems I have encountered and it has made me look at the best way to balance my life”
“I found the course very informative and helpful. It teaches you effective ways of coping better in times of pain, tiredness,
depression. The Tutors were very helpful and have a personal understanding of living with long term conditions”
Lessons Learned/Areas identified for further improvement
Due to the base of volunteer tutors being low this year the same number of courses were held as the previous year. The
number of Tutors needs to continue to be increased in order to allow capacity for the number of courses to increase.
Following the quality framework requirements of the Programme, Tutors must have a long term condition and have
attended at least 4 sessions the course before applying to become a volunteer. Volunteer tutors also have to attend an
interview to assess suitability, attend a 4 day training course and undergo DBS check
Tutors will continue to be recruited by:
• Using current tutors, Co-ordinator and Assessors to identify potential tutors
• Working with the Communication Team and local media to promote the benefits of becoming a Tutor
• Working with local Volunteer centres
• Holding information and recruitment days for potential tutors
• Promotional stands at community events to promote both courses and Tutoring
18
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.1.8 Dementia Carers Survey
Introduction
As part of the national CQUIN targets for 2014/15, we have continued to survey carers of patients with a confirmed
diagnosis of dementia by telephone and paper (postal) surveys.
This survey seeks to test the support services we provide to carers. The results from the surveys are collated and sent for
information to the Dementia Leads and Lead Nurses.
Performance Data
233 carers have been contacted by telephone or post to complete the short surveys out of 234 eligible patients with
dementia, the total number of completed surveys is 122. Out of the 37 longer surveys handed out, 17 have been
returned which equates to 46%.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
19
Key Achievements
The Friends and Family Test question is a national requirement for all patients. To ensure cohesion across our surveys Wye
Valley NHS Trust introduced the Friends and Family Test question to the survey to see if carers would recommend the ward
to Friends and Family if they needed similar care or treatment.
After review it was concluded that the most effective way to complete surveys was to contact carers once the patient had
been discharged from Hospital. Also following feedback direct from the carers they felt that a paper survey was a more
efficient way to answer the survey. This has also improved the number of responses we have received.
The data and feedback is being sent to the Dementia Leads and Heads of Nursing to ensure staff are able to act on the
information received and ensure necessary service improvements are implemented.
This year an increased number of carers have requested the more in depth survey than in previous years. This allows the
Trust to gain a greater insight into the views of carers and gather more valuable data to ensure any service improvements
required are acted upon.
Lessons Learned/Areas identified for further improvement
The following actions have been taken as a result of the feedback from carers:
• Mandatory Dementia Awareness Training for all staff
• Regular feedback to the Dementia Lead and Heads of Nursing to share with staff
For 2015/16 a further revision of the questions is to be taken forward for both the short and long surveys to ensure more
valuable information can be obtained. In addition, feedback from carers will be directed to the relevant ward areas to take
action on the feedback received.
Section 2.1.9 Compliments
Introduction
The Trust receives many compliments each month, mostly about staff and care received.
Each ward and department provides the number of compliments received each month to the Patient Experience Team
(PET), together with some examples of the type of compliments received. This information is included in the Service Unit
performance data.
Compliments are often sent directly to the PET or through the website ‘feedback’ page.
Compliments received through the Chief Executive’s office are also forwarded to the PET. Compliments data is displayed in
each ward as part of their ‘Huddle Board’. Positive feedback from Friends and Family is also now recorded as a
compliment.
20
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Performance Data
From 1 April 2014 to 31 March 2015, the Trust has received 12362 compliments. This represents an increase of 7,336
from the previous year, mainly due to the inclusion of positive Friends and Family scores in our compliments data.
The vast majority of compliments relate to quality of care and helpfulness of staff.
The Wards and Departments receiving the most compliments during the year were:
• Childrens Ward (318)
• Teme Ward (273)
• Redbrook Ward (248)
Key Achievements
• The number of compliments collected has increased by168% when compared with the previous financial year.
• The Trust now includes positive feedback received through the Friends and Family Test within its compliments data.
Lessons Learned/Areas identified for further improvement
Although the Trust records the number of compliments received by area, there is little analysis of the data. It is important
that wards and departments learn from positive feedback as well as negative and further work will be taken to share and
learn from the data more widely across the Trust.
An increased focus on collating this form of feedback from our community teams is planned.
Section 2.1.10 Concerns
Introduction
Patients and service users often wish to give feedback in an informal way or require advice or assistance to help them. The
PET provides on the spot assistance and advice. The team are based at the main reception at the County Hospital,
Hereford making the service very visible and accessible.
Patients and the public can access PET through a variety of methods, including face-to-face, telephone, letter and through
the website address ‘Making Experiences Count’. The service covers the whole of the Trust, including community hospitals
and community services.
Often patients contact PET with concerns but do not wish to make a formal complaint. They wish to feedback their
experiences to those involved and ultimately improve services for other patients or may require ‘real time’ assistance to
improve the situation they are in.
The service is patient centred and the PET will work with the individual to agree an outcome and timescale for resolution.
Wy e Va l le y NHS Trus t Qua lity A cc ounts 2014/15
21
Performance Data
Between 1st April 2014 and 31st March 2015, the PET has dealt with 1056 concerns and 229 comments about services,
an increase of 170 contacts from the previous year.
The top three topics of concern are:Information and Communication
Quality and Safety of Care
Access to Services
Key Achievements
• The introduction of a Patient Experience Team, including PALS and complaints, to ensure a seamless service and greater
flexibility
• During the year 59 concerns could not be resolved through the PET service and went on to become formal complaints,
this represents just 5.5% of all contacts.
• Appointed Polish interpreters to provide an improved service with greater continuity
• Continued to develop good working relationships with staff.
• Patient Forums led by the Director of Nursing & Quality have been held regularly through the year to listen to the patient
voice
Lessons Learned/Areas identified for further improvement
The Trusts learns from all comments received. Here are a few examples of actions taken by the Trust following feedback
from our patients:
Concern
Action
Lack of communication in Emergency Department
Information leaflet has been developed to assist and
improve communications
Patients unhappy about the small windowless room they
are expected to wait in on the Surgical Admissions Unit.
Facilities have been improved and staff have been
reminded to keep patients informed whilst waiting for
theatre.
22
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.1.11 Complaints
Introduction
A complaint is defined as an expression of dissatisfaction that takes longer than 48 hours to resolve or where the
individual clearly states that they are making a complaint. A formal complaint is an expression of dissatisfaction usually in
writing to the Chief Executive and the complainant wishes to receive a written response through the NHS complaints
procedure.
Performance Data
The Trust has received a total of 242 formal complaints from 1st April 2014 to 31st March 2015, exactly the same number
of complaints as the previous twelve month period.
The two tables below shows the top five themes for complaints and complaints by professional group as detailed in the
annual national return to the department of health.
A total of seven complaints have been referred to the Parliamentary Health Service Ombudsman (PHSO) of which one
complaint has been upheld, four have not been upheld and two are ongoing.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
23
Key Achievements
• As a consequence of feedback from a Patient Forum it was highlighted that general nurses did not necessarily
understand the mental health aspects of care, as a consequence 2Gether Mental Health Trust delivered training to the
nurses in relation to this and a further event is planned for physical health care to be delivered to 2Gether Mental Health
Trust.
• The Trust has appointed Governance Support Workers within the Service Units to provide a link to the Patient Experience
Team. They are specifically focusing on complaints.
• The process for managing complaints is much more ‘open’ with Service Units now offering meetings at a much earlier
stage to involve the patient.
• Training sessions regarding the production of draft response letters has been provided to all staff who may potentially be
involved in providing complaint responses and meetings.
Lessons Learned/Areas identified for further improvement
Positive, open and honest steps have already been introduced to initiate the changes required to provide a robust
complaints process. This emphasises the requirement to learn and respond. Prior to the implementation of the revised
process all complaints were formulated from telephone conversations, emails and letters sent to the Complaints Manager
from a number of sources which was often disjointed and defensive in nature.
The Trust must continue to encourage Service Units to take ownership of complaints to include personal contact with
complainants to discuss their concerns in a more patient centred way. Assurance must be given to complainants that their
complaint has made a difference in preventing reoccurrence. The complaint process must strive to be as independent as
possible.
24
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.1.12 Claims
Introduction
Claims fall into four categories, which are as follows:
• Clinical Negligence (patient claims)
• Employers’ Liability (staff claims)
• Public Liability (visitors, contractors etc.)
• Property Expenses (anything related to Trust property)
Performance Data
This year the Trust received 29 clinical negligence claims compared to 36 in 2013/14.
Service Unit
Total
Elective Care
15
Integrated Family Health Services
6
Urgent Care/ Care Closer to Home
8
Total for Wye Valley NHS Trust
29
Key Achievements
The Trust has seen a reduction in the number of claims made in 2014/15 and is progressing in sharing the lessons learnt
from clinical negligence claims to prevent reoccurrences.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
25
Section 2.2: Safety
Section 2.2.1 WHO Checklist
Introduction
The aim of the Surgical Safety Checklist is to ensure safe surgery for all patients and aid communication between all
members of the clinical team. It was launched by The World Health Organisation (WHO) in response to an identified
global risk to patient safety. The checklist includes a number of safety checks which have to be undertaken at the
following stages:
• Before anaesthetic
• Before the surgical operation begins
• Before the patient leaves the operating room
The checklist requires all members of the team to be involved at each stage.
Performance Data
Wye Valley Trust monitors completion of the checklist on all surgical operations in each of our operating theatres on a
continuous basis. Results have shown high levels of completion at 99.8 -100% throughout 2014/15. Results for each
month are shown below:
Compliance
Patient Opinion
Apr 14
May 14
Jun 14
Jul 14
Aug 14
Sept 14
100%
99.9%
99.9%
100%
100%
100%
Oct 14
Nov 14
Dec 14
Jan 15
Feb 15
Mar 15
99.9%
99.9%
99.8%
100%
100%
100%
Results are reported on a monthly basis to heads of relevant departments, clinical directors, the Quality Committee, Trust
Board and to Herefordshire Clinical Commissioning Group.
Key Achievements
• Very high levels of compliance with all safety checks have been maintained throughout the year, with an improvement
on 2013/14 figures.
• A “WHO Shield”, showing the number of days with fully completed checklists, is displayed within Theatres and is
updated on a daily basis.
• If the WHO checks are not fully performed, the incident is escalated to the appropriate senior manager through the
Trust’s incident reporting system and a full investigation of the case is undertaken. Wherever investigations show that
actions are required to prevent this happening again, the appropriate actions are taken.
• Training on Human Factors has been provided to staff. This is designed to help staff to challenge other members of the
team who may not be supporting the WHO process.
• Midwives and Obstetric Support Workers are trained in theatre etiquette and WHO checklist. This has led to greater
understanding of the WHO checklist as a safety tool.
26
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Lessons Learned/Areas identified for further improvement
The Trust has achieved very high levels of compliance with the WHO Safer Surgery Checklist in 2014/15. The Trust’s
incident reporting and investigation process will continue to be followed whenever any safety checks are not fully
performed. Continuous monitoring and reporting will also continue.
Section 2.2.2 VTE Risk Assessments
Introduction
Venous thromboembolism (VTE) is a term that covers both deep vein thrombosis and its possible consequence: pulmonary
embolism (PE). A deep vein thrombosis (DVT) is a blood clot that develops in the deep veins of the leg. If the blood clot
becomes mobile in the blood stream it can travel to the lungs and cause a blockage (PE) that could lead to death.
Since the 1st June 2010, all NHS hospitals have been monitored nationally to ensure 95% of patients have a VTE risk
assessments undertake on admissions. The completion of risk assessments also formulates part of NHS national CQUIN
targets.
Apr 14
May 14
Jun 14
Jul 14
Aug 14
Sept 14
95.3%
95.2%
95.1%
95.2%
95.45%
95.1%
Oct 14
Nov 14
Dec 14
Jan 15
Feb 15
Mar 15
95.1%
95.0%
88.2%
95.2%
95.4%
95.3%
Key Achievements
A number of measures are in place to ensure any non-compliance with completing the VTE risk assessments is quickly
identified and acted upon:
• Service Unit Managers and Service Unit Directors continue to be notified on a weekly basis of any areas that have been
identified as non-compliant.
• The completion of VTE risk assessments continues to be incorporated into Service Unit Key Performance Indicator
dashboards and scrutinised as part of the Service Unit Governance and Performance meetings.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
27
Lessons Learned/Areas identified for further improvement
To further improve the compliance against VTE and ensure an effective process in capturing this data the Trust plans to;
• Review and improve the data capture and reporting systems to ensure it as ‘real time’ as possible.
• Undertake awareness sessions with medical colleagues to ensure the importance of completing VTE assessments for all
relevant patients is understood.
Section 2.2.3 Serious Incidents Requiring Investigation (SIRI)
Introduction
SIRIs are incidents that occur that have, or potentially may have, caused serious harm to patients or the Trust. Although
measures are in place to prevent these incidents, when things do go wrong we ensure staff are open and honest about
what has happened and encourage speedy reporting of such incidents. This allows for a culture of learning, which in turn
will benefit patients by strengthening what we already do to ensure harm doesn’t come to patients whilst in our care.
SIRIs have to be reported immediately through the Quality and Safety Team, who then notify the relevant external
organisations; a Root Cause Analysis (RCA) investigation is then commenced. These investigations are led by a clinician or
nurse and follow the incident trail to determine why the incident occurred and how it can be prevented in the future. Staff
members are given training on how to complete these investigations
Before investigations are signed off as complete they are subject to rigorous review by Executive Directors to ensure
necessary steps have been taken to identify the root cause and put in place mitigating actions to prevent incidents from
reoccurring.
Performance Data
Any types of incident could potentially be reported as a SIRI depending on the consequence; however there is national
guidance available to ensure that the Trust reports accurately. The graph below shows all the types of incidents reported as
SIRIs in 2014/15.
28
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Top 3 Themes
The top 3 incidents reported as SIRIs are;
• Category 3 pressure ulcer
• Patient fall resulting in a fracture or serious injury
• Suboptimal care of the deteriorating patient
Pressure ulcers are the most reported SIRIs and as such are a priority for the Trust. A significant amount of work has been
undertaken by the Tissue Viability Team and nursing staff to reduce pressure ulcers as detailed in section 2.2.6.
Out of the 71 pressure ulcers that were reported, 37 were reported by the Neighbourhood Teams and 34 were reported
by the acute and community hospitals.
Patient falls resulting in a fracture or serious injury is the next highest reported, with 16 reported by the acute and
community hospitals. The actions taken to reduce the number of falls are detailed in section 2.2.10.
We have reported 13 serious incidents of suboptimal care of the deteriorating patient in 2014/15. These were identified
when staff reported delays in care or treatment and were subjected to full reviews using Root Cause Analysis techniques.
Key Achievements
• Development of a culture that is honest and transparent, and to actively encourage staff to raise the alarm when they
see poor practice and to protect them when they do so.
• Update of the incident policy to involve the Executive Directors at an early stage when a serious incident occurs and to
chair the initial roundtable discussion when necessary.
• Development of a Quality and Safety page on the intranet to share lessons learnt.
Lessons Learned/Areas identified for further improvement
• Timely medical intervention and treatment.
• Appropriate escalation of the deteriorating patient in a timely manner.
• The importance of following up examinations and test results to ensure the correct and most appropriate treatment is
given.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
29
Section 2.2.4 Central Alerting System Alerts
Introduction
CAS is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety
critical information and guidance to the NHS and others, including independent providers of health and social care.
CAS was established in 2008, replacing the previous Public Health Link (PHL) and Safety Alert Broadcast System (SABS).
Issued alerts are available on the CAS website and include safety alerts, messages, drug alerts, Dear Doctor letters and
Medical Device Alerts issued on behalf of the Medicines and Healthcare products Regulatory Agency, the National Patient
Safety Agency, and the Department of Health.
All alerts received by the Trust are assessed and sent out to relevant Service Units and managers for action. All alerts, field
safety notices etc., are time bound and the Trust need to action/close the alert within specific time frame.
Performance Data
During 2014/15 there were a total of 160 alerts issued to WVNHST.
All alerts were received, escalated and actioned as appropriate:
• 86 alerts required no action by the Trust
• 36 alerts were applicable to the Trust and actioned within timeframe.
• 7 alerts are currently being assessed for relevance to the Trust and remain within timescale.
• 31 alerts where response was not required by MHRA
Key Achievements
The Trust is pleased to have managed and responded appropriately to all CAS alerts within the appropriate timeframes in
2014/15.
In addition, 2014/15 has seen the introduction of shared learning across all NHS Trusts with good practice locally being
shared with other NHS Trusts though Patient Safety First. Examples of good practice identified and shared includes:
• Sharing of the Trusts ‘How to use Potassium Permanganate Solution Soaks’
• Registered a new Medical Device Officer and Medication Safety Officer to facilitate alerts that are received by Trust.
30
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.2.5 RIDDOR: Reportable Incidents 2014/15
Introduction
RIDDOR is the law that requires employers, and other people in control of work premises, to report and keep records of:
• work-related accidents which cause death
• work-related accidents which cause certain serious injuries (reportable injuries)
• Diagnosed cases of certain industrial diseases
• Certain ‘dangerous occurrences’ (incidents with the potential to cause harm)
Reporting certain incidents is a legal requirement. The report informs the enforcing authorities (HSE), local authorities
about deaths, injuries, occupational diseases and dangerous occurrences, so they can identify where and how risks arise,
and whether they need to be investigated. RIDDOR also allows the enforcing authorities to target their work and provide
advice about how to avoid work-related deaths, injuries, ill health and accidental loss.
The Trust has a legal duty to report all RIDDOR reportable incidents in a timely manner. Work related accidents which lead
to member of staff unable to work for more than 7 days needs to be reported within 15 days of incident. More serious
incidents, deaths, fractures, breaks need to be reported within 48hrs.
Performance Data
During 2014/15: there were a total of 14 RIDDOR reportable incidents reported to the HSE. These included;
• 7: Reports were related to; sprain, strain where individual was off work for more than 7 days.
• 4: Reports related to fractures, Nasal bones, arm, wrist and elbows.
• 2: Reports related to dangerous occurrence; (dirty needle stick incidents/injuries)
• 1: Report relating to release of biological agent/Pathology. Hazardous specimen manipulated on open work bench.
Key Achievements
The Trust was inspected by the Health & Safety Executive (HSE) following a RIDDOR report, potential release of hazardous
specimen within our Pathology Department. Following the inspection the HSE inspector fed back that they were satisfied
with the setup of the laboratories and the process/procedures involved. No notices were issued by the HSE to the Trust.
During 2013/14 reporting period the Trust reported 10 RIDDOR reportable incidents in comparison to 14 incidents during
this financial year. This increase in reporting is believed to be due to an improved reporting procedure and raised
awareness amongst staff in relation to incident reporting and RIDDOR reportable incidents.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
31
Lessons Learned/Areas identified for further improvement
7 of the RIDDOR reports for this period are related to muskoskeletal/sprains and strains injuries. In response to this, Wye
Valley NHS Trust has highlighted to all managers and staff the importance of attending mandatory and refresher training
which includes manual handling training. In addition, Education and Development trainers now highlight in each training
session manual handling risks, correct procedures to use and the importance of risk assessment. With these actions in
place, the Trust is hoping to see a reduction in RIDDOR reports for 2015/16 in regard to manual handling incidents.
More training and information has been aimed at staff in regard to clinical waste/needle stick safety. A new presentation
is being delivered on mandatory induction and refresher training to all levels. The new sessions looks at needle safety,
procedures, incident reporting and the use of Trusts safety needle devices. Training also looks at post incident procedures
to follow, which includes prophylaxis treatments, blood screening etc.
An incident occurred outside a toilet where water/fluids were spilt. Following this incident Sodexo is now checking toilet
areas on a regular basis and has introduced signature sheets for the toilets stating when areas were last cleaned. In
addition, contact numbers/departments will be on information sheets in the case of reporting any problems, spillages etc.
Section 2.2.6 Pressure Ulcers
Introduction
Around 412,000 people in the UK are likely to develop a pressure ulcer (Bennett et al 2004) including 4-10% of patients
admitted to hospital (Royal College of Nursing 2005). Due to this, and the associated costs, pressure ulcers are a core
quality indicator for patient safety.
We have a zero tolerance approach to pressure ulcers and aim to eliminate all avoidable category two, three and four
pressure ulcers. The Harm Free Care initiative and the CQUIN for 2014/15 relating to the use of the National Safety
Thermometer all aim to reduce pressure ulcers.
What is a pressure ulcer?
A pressure ulcer is a type of injury that affects the skin and underlying tissue and is caused when an area of skin is placed
under pressure. Pressure ulcers can occur after pressure has been exerted for a short period of time or when less pressure
is applied but over a longer period of time. The wounds can vary from discolouration of the skin to an open wound that
may expose bone or muscle.
Why do we report them?
All acquired category three and four pressure ulcers have to be reported as a Serious Incident Requiring Investigation (SIRI)
as they are a key quality indicator for the organisation. The Trust is focussed on improving patient care and all actions that
are identified as a result of the Root Cause Analysis undertaken for each category three and four pressure ulcers are
shared with the wards and with the Service Units.
32
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Performance Data
Number of Pressure Ulcers Reported by Location
County Hospital
33
Neighbourhood Teams
37
Community Hospitals
1
Total
71
• The Trust had reported 71 category 3 and 4 pressure ulcers in 2014/15. This shows an 11% reduction when compared
to the previous year.
• Following the RCA process it has been found that, 39% of the category 3 and 4 pressure ulcers reported in 2014/15
were unavoidable.
Key Achievements
• Each team has ensured they have a Link Nurse for Tissue Viability
• There has been an 11.5 % decrease in the number of acquired category 3 and 4 pressure ulcers reported compared to
the previous year.
• Cameras are available to both the community and acute sectors to document the condition of wounds.
• Tissue Viability training now included on the mandatory clinical refresher training.
Lessons Learned/Areas identified for further improvement
The Trust is committed to a further reduction in hospital acquired pressure ulcers and we will continue to strive to make
effective changes that will reduce the risk to our patients and eliminate avoidable category 3 and category 4 pressure
ulcers across the community and acute sectors.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
33
Section 2.2.7 Incident Reporting
Introduction
The Trust works in an integrated way, bringing together both acute and community services. Incidents that are reported
cover a wide range of issues from lack of equipment being delivered to a patient’s home to a patient fall in hospital. We
are committed to improving quality and safety in all of our work and by incident reporting we can both learn and improve
the quality of service that we deliver.
Generally the higher the rate of reporting the stronger the safety culture is in the organisation provided the actual
consequence of the incident does not increase.
The Trust uses a web based incident form to report incidents, this is a secure system where any member of staff can access
an incident form online (the Trust’s intranet site) and enter the details of the incident electronically. Once the incident form
has been completed correctly it is then submitted to the line manager to review, investigate and action appropriately. The
system will allow individuals to be notified of an incident which may be in their remit to investigate.
The electronic reporting system provides a much more timely way of reporting and can provide instant information on the
number of incidents reported by one particular area or department. Reporting, analysing and monitoring incidents enables
us to take appropriate actions and change services if necessary to improve both the quality and safety of care we deliver.
Ensuring a culture of open and honest reporting and learning from incidents remains a key focus for the Trust with active
promotion of incident reporting and duty of candour taking place in 2014/15. A number of initiatives have taken place to
ensure this including, SEE IT, SORT IT, REPORT IT which has proved successful and is reflected in the number of incidents
being reported increasing month on month but maintaining a low level of harm.
Performance Data
Numbers of incidents reported April 2014 to March 2015
34
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
All Incidents reported by the Trust in both Acute and Community areas which are reported to the National Reporting and
Learning System (NRLS)
Please note the remaining incidents for February and March 2015 are still in review and therefore will not be uploaded to
the NRLS until they are finally approved.
The National Reporting and Learning System now shows the rate of incidents reported per 1000 bed days for the period
April 2014 – September 2014. The latest available data comparing the Trust with other Trusts places us in the middle of
reporters with a median of 34.1 per 1000 bed days, the Trusts rate was 36.4.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
35
Incidents by degree of harm
The degree of harm from incidents is measured by the Trust, to improve the knowledge about how these incidents occur
and affect patients. This will help to concentrate efforts on those incidents that cause a higher degree of harm but also
understand multiple incidents of the same nature which result in minor harm.
Key Achievements
• The Trust was in the top performing 20% of NHS Trusts in the National Staff Survey 2014 for the percentage of staff
reporting errors, near misses and incidents witnessed.
• Embedding of lessons learnt from incidents shared Trust wide within Team Brief and Trust Talk.
• Introduction of a form in the community to document when a patient declines pressure relieving equipment or advice.
• Feedback from incidents is shared in medical forums.
Lessons Learned/Areas identified for further improvement
• Developing Medical staffs’ involvement in the investigation of incidents and completion of Root Cause Analysis reports.
• We have identified that we need to improve the quality of documentation and filing of medical records as there has
been an increasing number of incidents reported concerning these issues.
36
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.2.8 Infection Prevention & Control
Introduction
The Trust has continued its focus on the prevention of healthcare associated infections. Infection prevention is a key
priority for the Trust and as such a zero tolerance approach is enforced across the Trust to all avoidable healthcare
associated infections. These include Methicillin-Resistant Staphylococcus Aureus (MRSA), Clostridium difficile (C.diff) and
any bloodstream infections which occur more than 48hrs after admission to hospital.
Organism
Externally Set Maximum Level
Actual (2014/15)
MRSA bacteraemia
0
0
C. diff
12
18
Of the 18 cases of C.diff, 5 were identified to be due to lapses in care. Specifically, 4 were in relation to a lack of
compliance with hospital antibiotic guidelines and 1 in relation to evidence of transmission on a ward. The total of 18
cases is comparable to the Trust total of 17 in 2013/14.
In the other 13 cases, there were no identified lapses of care which may have contributed to the C. diff. Not all cases of C.
diff are avoidable as they usually follow a course of antibiotics which was necessary for another infection e.g. pneumonia.
Key Achievements
The Trust has maintained its excellent record on prevention of MRSA bacteraemia. It has gone the longest without an
MRSA bacteraemia of any acute hospital in the West Midlands.
The Trust has been MRSA bacteraemia free for 786 days.
There is now a more robust assessment of each case of C diff which includes the Consultant, Ward Sister and the Infection
Prevention Team and this is overseen by the Herefordshire Clinical Commissioning Group (CCG).
In addition, the Trust has developed an Ebola Response Plan which ensures that a suspected case can be managed safely
in isolation with minimal impact on the rest of the hospital.
To ensure ease of access to the relevant guidelines required by clinical staff, the Trust has launched an “app” to improve
accessibility of antibiotic guidelines.
Lessons Learned/Areas identified for further improvement
Although overall compliance with antibiotic guidelines is good, there is still room for improvement, especially with regard
to documentation. This is likely to be an area of national focus – both for prevention of C diff and, pressingly, for
minimisation of antibiotic resistance.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
37
Section 2.2.9 Never Events
Introduction
Never Events are a sub-set of Serious Incidents and are defined as ‘serious, largely preventable patient safety incidents that
should not occur if the available preventative measures have been implemented by healthcare providers’.
Some types of Never Events hold high potential for significant harm, and are designated Never Events regardless of the
actual degree of harm that occurred. Some types of incidents are designated Never Events only if death or severe harm
results.
Performance Data
We have had two Never Events reported in the period 1st April 2014 – 31st March 2015,
• Retention of a guide wire following completion of a procedure
• Wrong implant/prosthesis during surgery
Numbers of Never Events reported in the period 1st April 2014 – 28th February 2015 from NHS England
Total number of organisations reporting Never Events
136
Total Number of Never Events
271
Total Number of organisations reporting more than 2 Never Events
68
Wye Valley Trust
2
Lessons Learned/Areas identified for further improvement
A number of lessons have been taken from the Never Event that occurred in Wye Valley NHS Trust this year. These
include:
• A revised guideline has been produced in relation to the insertion and removal of a guide wire.
• An associated training programme has been implemented to ensure all staff are familiar with the new procedures
introduced.
The second Never Event is currently under investigation and therefore the actions will be considered when the RCA is
completed.
38
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
2.2.10 Patient Falls
Introduction
Patient falls are one of the highest numbers of incidents reported in the Trust and occur, largely, in the inpatient areas approximately half on the acute wards and half in the community hospitals.
It is important to record patient falls as it could indicate an underlying health issue or simple issue with mobility that
requires a review. Falls increase the risk of injury –related morbidity or loss of independence and can increase the length of
stay of a patient. Reporting patient falls also enables the Trust to analyse areas that may be experiencing an increase in the
numbers and therefore target actions to reduce the risk. Any fall that results in a fracture or serious harm is reported as a
Serious Incident Requiring Investigation (SIRI) and is subject to a root cause analysis investigation.
Performance Data
Number of falls and harm per 1000 bed days
The highest recorded areas where patients fall were reported are:
•
•
•
•
•
•
•
Lugg Ward
Ross Community Hospital
Frome Ward Acute Assessment Unit /Short Stay Unit/Frailty Assessment Unit
Hillside
Leominster Community Hospital
Wye
Arrow
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
39
For 2014/15 Wye Valley NHS Trust has been set a CQUIN to achieve a reduction in the number of patient falls across
Community Hospitals and Hillside. The target for this CQUIN has been agreed at <285 patient falls in Community Hospital
settings and Hillside.
The chart below shows performance against this target.
Key Achievements
• There has seen a decrease in the number of patient falls within the Trust compared to the previous year.
• The purchase and use of sensor matts (an early alert if a patient mobilises) for patients who have fallen and are at high
risk of falling.
• The falls policy has been updated to reflect the guidance by the Royal College of Physicians.
• 1:1 staffing with patients as necessary.
• The promotion of the correct footwear being worn by patients.
Lessons Learned/Areas identified for further improvement
• Completion of the falls screening tool and subsequently the falls risk assessment if indicated.
• There is a falls working group reviewing patient falls and identifying any further actions which can be undertaken to
reduce the numbers.
40
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.3: Effectiveness
Section 2.3.1 Clinical Audit
Introduction
Clinical audit is a process designed to measure and improve quality in healthcare. It is therefore important to staff,
patients and the wider public. Clinical audit includes:
• Measuring processes and outcomes of patient care against agreed and proven standards for high quality
• Where results show that practice is not in line with the standards, changes are implemented by clinicians, teams or
services to improve the quality of care and health outcomes
• A further check is then performed to make sure that the changes have led to the standards being met. This further
check is referred to as re-audit.
Performance Data
The Trust has an annual programme of clinical audit projects, both national and local projects, covering all clinical areas.
The projects are prioritised, with priority one being the highest priority. The table below shows the status of all projects at
the end of 2014/15, indicating that no projects were failing to progress.
No.of projects
Priority
RAG
rating
On
Approval
2014/15
Programme
Started
2014/15 but
not on
Programme
Started
before
2014/15
Totals
(% of
priority
group)
0
0
0
0
29
16
6
51 (11%)
105
38
31
174 (37%)
134
54
37
225
0
0
0
0
53
15
2
70 (15%)
39
28
1
68 (14.6%)
92
43
3
138
Not started less
than one month
from intended
start date
0
0
0
0
Project on hold
17
14
3
34 (7%)
5
7
56
68 (14.6%)
22
21
59
102
0
0
0
0
99
45
11
155 (33.3%)
149
73
88
310 (66.7%)
248
118
99
465
Status
Abandoned
One
Total priority one
projects
Two
Total priority two
projects
Three
Total priority three
projects
All priorities
Total projects
Started but not
progressing
Not started one
month after
intended start
date
To be established
Not yet due to
start
Started and
progressing
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
41
Key Achievements in 2014/15
• The Trust has implemented a new process for acting on the results of national clinical audits. This process is based on
good practice identified by the Healthcare Quality Improvement Partnership – the national organisation which coordinates clinical audit. Templates have been developed and implemented for reporting the Trust’s key results and any
actions required. These have proved very useful to Trust clinicians and by the Trust Committees and groups receiving the
reports.
• An audit showcase was held in February 2015, where Foundation Year One doctors (doctors in training) presented the
findings of audit projects in which they had been involved to a large multidisciplinary audience.
• Patient and Public Involvement in clinical audit is being taken forward in the Trust through the setting up of a Patient
Panel for Clinical Audit.
Lessons Learned/Areas identified for further improvement
Within Wye Valley NHS Trust it has been identified that the results from clinical audit should be more closely linked with
quality improvement. This reflects the position found nationally. During the coming year there will be a focus on linking
audit data with quality improvement.
Section 2.3.2 Patient Reported Outcome Measures (PROMS)
Introduction
Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to patients from the patient perspective.
The national PROMs programme measures health gain in NHS patients having hip or knee replacements, varicose vein
surgery, or groin hernia surgery. Patients having these operations are invited to complete a questionnaire before their
operation (pre-operative) and then either at 3 months (groin hernia and varicose veins) or 6 months (hip and knee
replacements) after their operation (post-operative). The pre-operative questionnaire is given to the patient by the
hospital; the post-operative questionnaire is posted to the patient by the national centre. The questionnaires include
questions about general quality of life and some which are specific to the type of operation, from which scores can be
calculated. Comparison is made of the scores after surgery with those from before surgery, to gauge the level of health
improvement following the operation.
The PROMs help the NHS and individual hospitals to measure and improve the quality of its care.
Performance Data
Participation rates for 2013/14 and April to September 2014 were published in February 2015 and are shown in the
following table below. These are based on provisional data only but indicate that Wye Valley Trust continues to have high
completion rates of questionnaires given out before operation. However, response rates for questionnaires sent out after
operations are lower for the Trust than the national average. As the post-operative questionnaires are sent out by the
national centre the reason for low responses is not clear.
42
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Timing of operation
April 2013 - March 2014
Wye Valley
England
Participation rate (completion of pre-operative questionnaires)
109.7%
77.3%
Response rate for post-operative questionnaires
61.5%
67.8%
Participation rate (completion of pre-operative questionnaires)
113.8%
76.7%
Response rate for post-operative questionnaires
15.7%
25.7%
April 2014 - September 2014
Results of outcomes, in terms of improvement or worsening in scores after operation, were also published in February
2015. These are again based on provisional data so are liable to change before final publication. The following table
shows results for patients with an operation date between April 2013 and March 2014. The results indicate that for all
measures except one the Trust had greater numbers of improved scores compared with the national average. The only
score where improvement levels were not greater than the national average was for the EQ VAS in hip replacements. This
is a measure of general health rather than specifically related to outcome following surgery. The results of this particular
measure also showed that the Trust had lower numbers of patients with worsening scores compared with the national
average.
Scores improved
Score
EQ-5D Index
score (a
combination of
five key criteria
concerning
general health)
Procedure
Scores worsened
Wye Valley
Trust
England
Wye Valley
Trust
England
Groin hernia
59.5%
50.6%
8.3%
17.8%
Hip replacements
90.1%
89.3%
3.5%
5.3%
Knee replacements
81.4%
81.4%
8.3%
9.1%
Varicose vein
66.7%
51.8%
10%
16.5%
40.5%
37.3%
41.21%
44.2%
64.9%
65.1%
23.7%
24.2%
66.2%
55.1%
22.3%
31.9%
46.7%
40.1%
30%
41.6%
Groin hernia
EQ VAS (current
state of the
Hip replacements
patients general
health marked on
Knee replacements
a visual analogue
scale)
Varicose vein
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
43
Scores worsened
Scores improved
Score
Procedure
Groin hernia
Condition
Specific Measures Hip replacements
Oxford Hip/Knee
Score; Aberdeen Knee replacements
V. Vein Score
Varicose vein
Wye Valley
Trust
England
Wye Valley
Trust
England
No score applicable
97.3%
97.2%
1.4%
2.3%
94.7%
93.8%
4.1%
5.0%
93.3%
83.6%
6.7%
16.3%
Key Achievements
The Trust has higher than national average rates of completion of questionnaires given to patients asking about their
health before their operations.
Outcome results show that for all measures except a general health measure in hip replacement the Trust achieved higher
than national average levels of improvement in scores following operation.
Lessons Learned/Areas identified for further improvement
Rates of completion of questionnaires and outcome scores will be kept under regular review.
If completion rates of post-operative questionnaires continue to be lower than the national average, further investigation
will be undertaken with the national centre to try and establish reasons for this.
44
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 2.3.3 Commissioning for Quality and Innovation (CQUIN)
Introduction
This year, the Trust was set 17 CQUIN targets. Every NHS Trust is set CQUINs, some of which are set nationally, others
locally, depending upon the priorities across the health economy.
CQUINs drive improvements within the organisation and the targets and milestones set within each CQUIN have a
financial incentive attached to them.
CQUIN
Achievement
Implementation of staff Friends and
Family Test in acute settings
Report to commissioners confirming implementation
Achieved
Implementation of staff Friends and
Family Test in community settings
Report to commissioners confirming implementation
Achieved
Early implementation of patient
Friends and Family Test in acute
settings;
• Outpatients
• Day case
Report to commissioners confirming implementation
Achieved
Early implementation of patient
Friends and Family Test in
community settings;
• Community services
Report to commissioners confirming implementation
Achieved
Full implementation of patient
Friends and Family Test across all
areas in community settings.
Report to commissioners confirming implementation
Achieved
Achievement of response rate in
Emergency Department and
Inpatient for patients Friends and
Family Test.
Quarter 1;
• A&E – >15% response rate
• Inpatient – >25% response rate
Quarter 4;
• A&E – >20% response rate
• Inpatient – >30% response rate
Achieved
Status at Year End
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
45
CQUIN
Achievement
Achieved of increased response in
inpatient for patients Friends and
Family Test in March 2015
>40% response rate
Achieved
Reduction in pressure ulcers.
Monitored using the NHS Safety
Thermometer tool
<1.9%
Achieved
Dementia - Find,
Dementia Assess
Dementia Refer
>90% (3 consecutive months)
Achieved
• Submission of training plan
• Achievement of training plan
Achieved
Named lead clinician for dementia
and appropriate training for staff, to
ensure sufficient clinical leadership
of dementia within Wye Valley NHS
Trust and appropriate training of
staff
Status at Year End
Ensuring carers of people with
dementia feel adequately supported
by undertaking a monthly survey of
carers of people with a confirmed
diagnosis of dementia.
Bi annual report demonstrating monthly survey results of
carers of people with dementia to test whether they feel
supported and action plan addressing any findings from
surveys.
Achieved
Development of personalised selfmanagement plan to support
transition of young people with long
term conditions to the adult
pathway.
Quarter 1;
• Development of template for personalised selfmanagement plans
Quarter 2;
• Baseline audit
Quarter 3;
• Increase in percentage achievement from baseline audit
Quarter 4;
• >90% achievement
• Survey of young people to understand if the selfmanagement plans were useful to young people with a
long term condition.
Achieved
Embedding care bundles across the
acute hospital to ensure that
patients consistently receive effective
clinical care
Quarter 1;
• Baseline audit
Quarter 2;
• Increase in percentage achievement from baseline audit
Quarter 3;
• Increase in percentage achievement from quarter 2 audit
Quarter 4;
• Increase in percentage achievement from quarter 3 audit
Partially Achieved
46
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
CQUIN
Achievement
Demonstrate improvement in quality
of services as a result of acting upon
the ‘Child’s Voice’
• Development of action plan
• Delivery against action plan
Achieved
Reduction in all falls across
Community Hospitals and Hillside
(All falls - Regardless of whether
injury sustained) compared with
previous year
<285
Achieved
Improve the experience of safety
maternity service users by promoting
the increase in supernumerary time
of midwives on the delivery suite
Quarter 1;
• Baseline audit
Quarter 2;
• >80%
Quarter 3;
• >85%
Quarter 4;
• >90%
Achieved
Improvement in the quality and
timeliness of issue of outpatient
letters to General Practices
Quarter 1
• Development of project plan and agreed templates
Quarter 2
• Baseline audit
Quarter 3
• 50%
Quarter 4
• 70%
Status at Year End
Partially Achieved
Key Achievements
• Successful implementation of the Friends and Family Test within outpatient and community services.
• Response rate for the Emergency Department increased from 15.1% in April 2014 to 23.3% in March 2015.
• Decrease in pressure ulcers reported as part of the NHS Safety Thermometer from 3.05% in April 2014 to 1.01% in
March 2015.
• Implementation of dementia training plan across the County Hospital.
• Introduction of an ‘Ambassadors’ Group in children services to ensure greater engagement from children and young
people as part of the promotion of the Childs Voice.
• 16% reduction in patient falls in Community Hospitals and Hillside.
Lessons Learned/Areas identified for further improvement
• The system and processes in place for collecting Friends and Family data in the Emergency Department needs to be
improved to ensure more patients and their relatives have the opportunity to provide feedback on the services they
receive whilst being treated in Emergency Department. A number of actions are to be put in place going forward such
as increased visibility and promotion of the Friends and Family Test through posters and staff members. The potential for
increased involvement of volunteers is also being explored.
• The Care Bundles have recently been rolled out again with greater awareness being raised and colour coding systems in
place to ensure ease of use amongst staff.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
47
Section 2.4: Staff Engagement
Section 2.4.1 National NHS Staff Survey
Survey 2014
Introduction
The annual staff survey was undertaken in October – November 2014. A proportion of all staff were asked to complete a
questionnaire based upon their experiences whilst working at Wye Valley NHS Trust.
The response rate to the survey was 43% which is average compared to other acute trusts. However, there is no
comparison data at present for integrated community and acute Trusts.
Performance Data
RAG
2013
2014
Top 20% of Trusts
None
8
Remaining 60% of Trusts
27
32
Bottom 20% of Trusts
21
8
35 Additional questions not asked in 2013
Top 20% of Trusts
10
Remaining 60% of Trusts
21
Bottom 20% of Trusts
8
Key Achievements
The Trust has improved in a number of areas in the latest staff survey when compared with the previous year with an
evident increase in scores within the top 20% and decrease in those in the bottom 20%.
Improvements have been noted as follows;
• Received Health and Safety training in the last 12 months – up by 11%
• Agreed that preventative action is taken when errors are reported – up by 11%
• Staff given feedback about changes made in response to reported errors or incidents – up by 10%
• Agreed that staff are informed about errors, near misses and incidents that happen in the organisation – up by 10%
• Agreed that they have adequate materials, supplies and equipment to do their work – up by 8%
Lessons Learned/Areas identified for further improvement
There are however areas where the Trust needs to undertake further improvements. Areas highlighted as declining are;
• Number of staff receiving appraisal in last 12 months – reduced by 5%
• Agreed that their role makes a difference to patients/service users – reduced by 2%
A robust action plan will be agreed with staff side and will be developed, implemented and monitored through Finance
and Performance Meetings and Staff Side Forum.
48
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Section 3: Mandatory Statements Relating to Quality of NHS Services Provided
Introduction
This section includes all the mandatory section that are required as part of the Department of Health Quality Accounts
Toolkit. It provides details of key quality aspects relevant to the Trust.
3.1 Review of Services
During 2014/15 we provided and/or sub-contracted 54 NHS services. Wye Valley NHS Trust has reviewed all the data
available to them on the quality of care in 54 of these NHS services.
The income generated by the NHS services reviewed in 2014/15 represents 100 per cent of the total income generated
from the provision of NHS services by Wye Valley NHS Trust for 2014/15.
3.2 Participation in Clinical Audit
During 2014/15, 38 national clinical audits and two confidential enquiries (National Clinical Outcome Review Programmes)
covered NHS services that Wye Valley NHS Trust provides.
During that period Wye Valley NHS Trust participated in 97% of the national clinical audits and 100% of the national
confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate
in. The only remaining national audit in which the Trust has not participated in fully during 2014/15 is the National
Cardiac Arrest Audit. However, during 2014/15 this audit was reviewed by the Trust’s Resuscitation Committee and the
Trust is now to participate, registration is underway.
The table below lists the national clinical audits and national confidential enquiries that Wye Valley NHS Trust was eligible
to participate in during 2014/15 and indicates whether or not participation took place. The table also shows the number
of cases submitted to each audit or enquiry as a percentage of registered cases required by the terms of that audit or
enquiry for those where data collection was completed during the period April 2014-March 2015.
WVT participated
Percentage of required
cases submitted
(position at 23/4/15)
Comments
Acute coronary syndrome or Acute
myocardial infarction
3
100%
Continuous data
collection. All eligible
cases submitted.
Adherence to Standards for Ulnar
Neuropathy at Elbow Testing
3
-
Percentage of cases not
applicable as
organisational audit.
Adult Community Acquired
Pneumonia (British Thoracic Society)
3
-
2014/15 data
submission ongoing
Eligible National Audits
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
49
Eligible National Audits
Adult critical care (Case Mix
Programme)
WVT participated
Percentage of required
cases submitted
(position at 23/4/15)
3
100%
Comments
National Comparative Audit of Blood Transfusion Programme includes:
• Audit of Anti-D Immunoglobulin
prophylaxis
3
100%
• Audit of Patient Information and
Consent
3
100%
• Audit of transfusion in children
and adults with Sickle Cell Disease
3
No eligible cases
National Bowel Cancer Audit
3
100%
National Cardiac Arrest Audit
7
Cardiac Rhythm Management
National Audit
3
Data not submitted for
14/15 but Trust now
registered to participate
100%
Continuous data
collection
Chronic Obstructive Pulmonary Disease (COPD) National Audit Programme, includes:
• COPD Organisational Audit –
Resources and organisation of
care in acute NHS units in England
and Wales
3
-
• Clinical audit of COPD
exacerbations admitted to acute
NHS units in England and Wales
2014
3
95%
50
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Not applicable,
Organisational audit
Chronic Obstructive Pulmonary Disease (COPD) National Audit Programme, includes:
Eligible National Audits
WVT participated
Percentage of required
cases submitted
(position at 23/4/15)
3
100%
• Adult Diabetes Core Audit
Comments
• Pregnancy in Diabetes Audit
3
100%
Relates to eligible
women who consented
to take part in the audit.
Data submitted for all
consenting patients.
• Diabetes Foot-care Audit
3
-
Data submission for
2014/15 ongoing
National Paediatric Diabetes Audit
3
100%
Relates to patients seen
in 2013/14
Elective surgery (National Patient
Reported Outcomes Measures
Programme)
3
113%
Based on completion of
questionnaires before
operation. Rates
reported for AprilSeptember 2014 by
national centre.
National Emergency Laparotomy
Audit Organisational Audit
3
-
Not applicable,
Organisational audit
WVT participated
Percentage of required
cases submitted
(position at 23/4/15)
Comments
3
100%
50 cases requested and
submitted
College of Emergency Medicine Audits, includes:
Eligible National Audits
• Older People (care in Emergency
Departments)
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
51
WVT participated
Percentage of required
cases submitted
(position at 23/4/15)
Comments
• Mental Health (care in Emergency
Departments)
3
100%
50 cases requested and
submitted
• Fitting Child (care in Emergency
Departments)
3
100%
50 cases requested and
submitted
Epilepsy 12 National Audit Round
Two, 2014 (Childhood Epilepsy)
3
88%
Taken from national
report published
November 2014
WVT participated
Percentage of required
cases submitted
(position at 23/4/15)
Comments
3
100%
Continuous data
submission. All cases
submitted.
100%
Continuous data
submission. The only
patients eligible for
submission by Wye
Valley Trust are those
diagnosed at the Trust.
Ongoing care is
provided by other
centres.
Eligible National Audits
Falls and Fragility Fractures Audit Programme includes:
Eligible National Audits
• National Hip Fracture Database
National Hip Fracture Database
National Head and Neck Cancer
Audit
52
3
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Inflammatory Bowel Disease Programme includes:
WVT participated
Eligible National Audits
• Inflammatory Bowel Disease
National Audit (Round 4)Ulcerative colitis
3
3
• Biologics Therapy
Percentage of required
cases submitted
(position at 23/4/15)
Comments
100%
50 cases requested from
each Trust but only 13
cases were eligible at
Wye Valley. All eligible
cases submitted.
31.81%
All cases submitted but
due to technical
problems with the
website only 7 of 22
cases were included.
Neonatal Intensive and Special Care
National Audit
3
100%
Figure taken from
national report
published 2014 based
on 2013 patients.
National Audit of Intermediate Care
3
-
Not applicable,
Organisational audit
100%
Figure taken from
national report
published 2014 based
on 2013 patients.
-
Figure taken from
national report
published 2014 based
on 2013 patients.
Figure taken from
national report
published 2014 based
on 2013 patients.
3
National Joint Registry
National Lung Cancer Audit
3
National Oesophago-Gastric Cancer
Audit
3
>90%
Pleural Procedures National Audit
(British Thoracic Society)
3
100%
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
53
Eligible National Audits
WVT participated
Percentage of required
cases submitted
(position at 23/4/15)
Comments
National Prostate Cancer Audit
3
-
Latest report published
November 2014 relates
to organisational data
and retrospective
analysis of existing
datasets
Rheumatoid and Early Inflammatory
Arthritis National Audit
3
-
Data submission for
2014/15 ongoing
Sentinel Stroke National Audit
Programme
3
90+% (highest level)
Average case
ascertainment levels for
April – September 2014.
36.1%
Figure based on
snapshot in time.
Retrospective
submission of data
2014/15 ongoing.
Severe Trauma (Trauma Audit &
Research Network)
3
Maternal, Infant and Newborn Clinical Outcome Review Programme (MBRRACE):
Eligible National Audits
• Maternal mortality surveillance
• Perinatal mortality surveillance
WVT participated
3
3
Percentage of required
cases submitted
(position at 23/4/15)
Comments
100%
Details of any deaths
fitting the criteria for
inclusion would be
submitted
100%
National centre compare
submitted data with
national register to
ensure all cases
captured.
Medical and Surgical Clinical Outcome Review Programme: National Confidential
Enquiry into Patient Outcome and Death (NCEPOD).
Studies active in 2014/15:
54
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Eligible National Audits
• Gastrointestinal Bleeding Study
• Lower Limb Amputation Study
WVT participated
3
3
Percentage of required
cases submitted
(position at 23/4/15)
Comments
50% of clinical
questionnaires
Organisational
questionnaire
completed.
4 clinical questionnaires
received, 2 completed
100%
Organisational
questionnaire and all
relevant clinical
questionnaires
completed
• Tracheostomy Study
3
100%
Organisational
questionnaire and all
relevant clinical
questionnaires
completed
• Sepsis Study
3
-
Study still open
• Acute Pancreatitis Study
3
-
Study still open
Within Wye Valley NHS Trust the results from national and local clinical audits are reviewed by the clinical teams involved in
the audit. If the review indicates that improvements are required action plans are devised and implemented. Results of
national audits and planned actions are presented to the Clinical Effectiveness and Audit Committee and then to the
Trust’s Quality Committee (sub-committee of the Trust Board). Reports and action plans from national and local audits are
reviewed by the Trust’s Service Unit Governance Groups.
The reports of 14 national clinical audits were reviewed by the provider in 2014/15 and Wye Valley NHS Trust intends to
take the following actions to improve the quality of healthcare provided on those projects where results indicated that
improvements were required:
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
55
Review of National Clinical Audit Reports
Audit
National Comparative Audit of Blood Transfusion - Audit of Patient
Information and Consent
This national audit co-ordinated by NHS Blood and Transplant assessed whether
patient’s consent to transfusion was recorded in the medical notes and the
provision of information to patients about the transfusion. It also surveyed
patient awareness/recall of the information supplied to them.
Action
Results showed that the Trust compared well on meeting the national standards.
The only area where action was required was in the provision of a patient leaflet
to patients who had a previously unplanned transfusion during an operation. A
leaflet is now given to relevant patients on their discharge from hospital. A
mandatory field has also been added to the electronic summary which is
completed on discharge, to ensure the leaflet is provided.
Audit
National Comparative Audit of Blood Transfusion - Audit of Anti-D
Immunoglobulin Prophylaxis
This national study measured compliance with UK guidance on anti-D prophylaxis
in pregnancy.
Action
The Trust’s results compared well with standards and with other Trusts. The only
area where improvements were required was in the recording that an
information leaflet on anti-D prophylaxis had been given to Rhesus negative
women. The electronic patient records system used in the Maternity Unit has
now been adapted to record when the leaflet has been given.
Audit
UK Inflammatory Bowel Disease (IBD) National Audit – National clinical
audit of inpatient care for adults with ulcerative colitis.
This national audit seeks to improve the quality and safety of care for all IBD
patients throughout the UK by auditing individual patient care and the provision
and organisation of IBD service resources, and by assessing inpatient experience
and patient‐reported outcome measures.
Action
Following a review of the results the following areas for improvement actions
were identified:
• The proportion of patients seen by a member of IBD Team during their
admission to be increased. It is felt by the Team that appropriate action has
already been taken to improve this. The IBD Multidisciplinary Team was formed
in June 2013, halfway through the year covered by the national audit. The
Team has continued to develop over time to enable more robust joint
management of surgical and medical patients. It is anticipated that this new
initiative will impact on patients being seen by a member of the team during
admission.
• Prescribing of bone protection to patients discharged home on steroids.
Actions to improve the prescription of bone protection are to be developed by
the IBD Multidisciplinary Team at its next meeting.
56
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Audit
UK Inflammatory Bowel Disease - National clinical audit of biological
therapies in adults.
The purpose of this audit is to measure the efficacy, safety and appropriate use of
biological therapies, in patients with inflammatory bowel disease (IBD) in the UK
and to capture the views of patients on their quality of life at intervals during their
treatment.
Action
Unfortunately, due to a problem with the national website, not all data submitted
from Wye Valley Trust were analysed and reported. It has therefore not been
possible to identify whether improvements are required. Problems with the
website for data submission have been reported to the national audit centre.
Audit
National Hip Fracture Database (NHFD).
The NHFD is part of the national Falls and Fragility Fracture Audit Programme
which aims to improve the delivery of care for patients having falls or sustaining
fractures through effective measurement against standards and feedback to
providers of care.
Review of the 2014 Annual Report indicated areas of good performance as well
as areas for improvement. The main areas for improvement were identified as:
Action
• Surgery within 36 hours of admission to Emergency Department
Monthly multidisciplinary meetings have been set up to review performance on
all aspects of care, including time to surgery.
Poster presentations and hand-outs on best practice in hip fracture have been
given to all new doctors on the Foundation Programme (doctors in training).
Performance data are now analysed within the Trust and disseminated to
relevant staff on a weekly basis.
• Orthogeriatric review within 72 hours of admission to Emergency
Department
The Trust is advertising for additional Consultant Orthogeriatricians. In the
interim a rota has been drawn up by the existing Geriatric Medicine
Consultants ensure that relevant patients are reviewed within 72 hours.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
57
Audit
National Neonatal Audit Programme.
The key aims of the audit are:
• To assess whether babies admitted to Neonatal Units in England and Wales
receive consistent care in relation to the audit questions; and
• To identify areas for quality improvement in Neonatal Units in relation to
delivery and outcomes of care.
Action
The annual report published in October, relating to babies on the Neonatal Unit in
2013, showed that local performance had improved compared to the previous
year in 5 of the 6 national standards measures. The main areas identified for
action were:
• Full recording of data on the electronic records system (Badgernet) used in the
Neonatal Unit. The national reports are based on data entered on to this
system and the need to ensure complete data are entered has been reinforced
to all relevant staff in the Unit.
• Follow-up at two years. The existing two year follow-up pathway is being
reviewed to assess whether changes are required
Audit
Severe Sepsis and Septic Shock Clinical Audit Report 2013-14
This national audit by the College of Emergency Medicine assessed the treatment
of severe sepsis and septic shock in Emergency Departments against national
clinical standards.
Action
Review of the national report issued in 2014/15 identified areas for improvement
for which actions have been developed as follows:
• To improve the timely administration of fluids, all care bundles have been
allocated to Emergency Department teams to raise awareness. These bundles
are being made more accessible from all areas with visible prompts placed in
patient areas.
• To improve the timely administration of antibiotics, sepsis trolleys are being
introduced.
• To ensure urine output is measured, awareness of the sepsis care bundle has
been raised through teaching sessions
• Teaching has been undertaken on ensuring blood glucose measurements are
taken within 15 minutes of arrival. Options available to record this within the
electronic Ascribe system are being explored.
58
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Audit
National Parkinson Audit 12/13 - This national audit includes the early
treatment, maintenance, complex care and palliative care phases of the pathway
of care for people with Parkinson’s disease, but excludes people newly referred to
the service for purposes of diagnosis. Report of the 2012/13 round of the audit
was published February 2014. It was included in the reports to the relevant Trust
Committees in 2014/15 and has therefore been included in the 2014/15 Quality
Account.
Action
The results of the audit showed that the Trust had scored highly on all domains
audited and when compared with other centres, the Trust’s assessment and care
planning process scores were above the national median.
Following the results the assessment of patients has been refined, specifically
around the presence of daytime sleepiness and driving and monitoring of
compulsive behaviours in patients taking dopamine agonists.
Audit
Intensive Care National Audit (ICNARC)
This national audit has been running since 1994 and now collects data from 90%
of adult critical care units in England, Wales and Northern Ireland. Data on patient
activity and outcomes of all patients admitted to critical care are submitted to
ICNARC for analysis and reporting.
Action
Overall the Critical Care Team is pleased with the most recent results. To ensure
that good quality care is provided the following are in place within the Trust:
• Multi-disciplinary meetings established on a monthly basis to review all ICNARC
results
• Every death that appears on the ICNARC registry is reviewed at the monthly
multi-disciplinary meeting. All deaths in 2013-14 have been reviewed and no
specific concerns were identified.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
59
Audit
Stroke Sentinel National Audit Programme (SSNAP)
The SSNAP clinical audit programme collects a minimum dataset for every stroke
patient, including acute care, rehabilitation, 6-month follow-up, and outcome
measures in England, Wales and Northern Ireland. The aims of the audit are:
• To benchmark services regionally and nationally
• To monitor progress against a background of organisational change to stroke
services and more generally in the NHS
• To support clinicians in identifying where improvements are needed, planning
for and lobbying for change, and celebrating success
Action
The SSNAP national centre issue reports on a quarterly basis and these are
reviewed by the Trust’s Multidisciplinary Stroke Team to identify any areas
needing improvements. The following actions have been taken:
• Stroke performance escalated to the Trust’s Chief Executive and to the Clinical
Commissioning Group (CCG).
• Project manager appointed to look at the options to improve local stroke care
in line with national standards.
• Trust manager tasked with implementing the changes agreed with the CCG,
who are providing additional finance, to re-design the stroke service.
Data submission for this national project continues
Audit
National Lung Cancer Audit (NLCA)
This national audit captures data on all patients diagnosed with lung cancer.
Action
The 2013 report of the national data indicate that the Lung Multidisciplinary
Team (MDT) at Wye Valley is delivering a good service with no concerns when
compared to national standards as set out by the National Lung Cancer Audit.
However, it was noted that the recorded data on patients being seen by the
Respiratory Clinical Nurse Specialist was below the national average. A review of
the cases and the service revealed a data recording and validation problem. A
meeting was arranged with the Cancer data management team and a number
of action points issued to ensure complete data are captured.
• The MDT coordinator collects the data prospectively in the MDT meeting
• Telephone consultations with the nurse specialist is recorded on the Infoflex
electronic system
• Clinic letters are copied to the MDT co-ordinator to update nurse specialist
contact with patients.
The 2014 report has now been issued and is under review.
The reports of 41 local clinical audits were reviewed by the provider in 2014/15. Some of these audits indicated that all
standards were met and no actions were required. For audits which identified improvements were required Wye Valley
NHS Trust intends to take the following actions to improve the quality of healthcare provided:
60
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Audit
Audit of Shoulder Dystocia (Shoulder dystocia is a rare emergency that can
happen during the end of the second stage of labour when the baby’s head has
been born but one of the baby’s shoulders becomes stuck).
This audit assessed local practice on the management of shoulder dystocia
including appropriate reporting on the incident system and use of the dystocia
proforma. Staff attendance in annual obstetrics skill drill was also audited.
Action
Results showed that local practice on shoulder dystocia was good and all staff
had been appropriately trained in the skill drill. The only area where
improvement action was identified was in the completion of the proforma for
dystocia. The existing proforma is to be updated and then fully implemented.
Audit
Out of Hours Transfusions Audit
This audit assessed local compliance with the British Committee Standards in
Haematology (BCSH) guidelines on blood transfusions.
Action
Results showed that there were no delays between the blood being collected and
the transfusion started but further refinements are being made to the process
as follows:
• To avoid unnecessary out of hours transfusions laboratory staff will ask for
further information if the request for out of hours blood does not contain valid
justification
• Laboratory staff will inform the ward when blood is ready for transfusion by
telephoning the ward and logging on apex (computer system)
• A presentation on how to prevent delays in reviewing results, prescribing and
starting transfusion has been given to staff in the Department of General
Medicine and is included in induction training for new doctors
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
61
Audit
Audit of the Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR)
documentation in Community Hospitals
Following recommendations from the national Francis Report and the Keogh
Review, 6-monthly audits of DNACPR documentation take place in Wye Valley
Trust Community Hospitals.
Action
Audit in 2014 showed significant improvements achieved compared with the
previous rounds. However, areas where further improvement could be
achieved were identified and the following actions are being taken:
• Individual feedback has been provided to ward managers, outlining any areas
of concern identified by the audit
• To ensure that DNACPR forms can easily be located in a patient’s records, staff
have been made aware of the correct position for filing the form in the notes.
• To make sure that all forms are fully completed the importance of ensuring
accurate and complete documentation, to comply with Trust policy, has been
raised with relevant staff. Any forms not initiated by a Consultant or General
Practitioner will be countersigned as soon as possible by a Consultant or
General Practitioner.
• To improve the documentation of resuscitation decisions in the medical record,
a review of DNACPR decisions will take place at the patient’s discharge or
when the patient’s condition changes
Audit
Imaging of Suspected Pulmonary Embolism (PE)
This audit involved an assessment of all the CTPA and Isotope lung scans
performed over a 2 month period.
Action
Following the results of this audit the following changes have been made:
• All requests for CT pulmonary angiogram (CTPA) or radionuclide lung scan to
include the Wells score, D-dimer result and glomerular filtration rate, ideally by
using the standard stamp
• Pregnant patients have a relatively low risk of pulmonary embolism and should
have a radionuclide lung scan as the first line examination if the chest x-ray is
normal
• Consideration should be given to performing radionuclide lung scan in all
patients aged under 50 with a normal chest x-ray.
62
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Audit
Maternal Obstetric Early Warning Score (MEOWS)
In the UK, the National Confidential Enquiry into Maternal Deaths recommended
that an early warning score should be used for all obstetric admissions to improve
early recognition of sick women. The Maternal Obstetric Early Warning Score
(MEOWS) is in place at Wye Valley Trust. The audit was carried out to assess its
use within maternity services at the County Hospital.
Action
Results of the audit showed that all records assessed had been correctly scored
and there was clear documented evidence of when a patient needed to be
referred to an obstetrician for review. However, it was identified that
improvements were required in the completion of all vital signs. The following
actions are being taken:
• Present the findings at Governance and Audit meetings and include in Safety
Newsletter
• Review the MEOWS scoring triggers on the new electronic patient record
system
• Amend the guideline for the management of the severely ill pregnant woman
to include the MEOWS chart and escalation chart on the new electronic
maternity records system
• Re-audit after full implementation of the new electronic records system to
ensure that improvements have been achieved
Audit
Audit of Intravitreal Lucentis (Ranibizumab) Treatment in Diabetic
Macular oedema
This audit assessed initial results with Ranibizumab in diabetic macular oedema,
using National Institute Clinical Excellence (NICE) guidance.
Action
Results showed that early visual acuity gains were comparable with national
studies. However, it was felt by the team that to be able to sustain good
responses to treatment over time would require additional resource being applied
to the intravitreal retinal treatment service as a whole. A Business Case for
additional resources has been developed.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
63
Audit
Qualitative Audit of Booking Information for women known to have
complex social factors in pregnancy
The main aim of this audit was to establish the overall quality of child protection
medical reports which are then shared with other relevant Safeguarding
Agencies.
Action
Audit findings were that the information collated reflected current known
complex social factors that affect women and their families in pregnancy. The
audit identified that detailed booking information should always be obtained and
a management plan put in place to help identify and support women who are
vulnerable in pregnancy. The results have led to the following actions
• The findings have been fedback to staff through governance structures and
team meetings
• The requirement for full booking history to include all family members, with
regard to the effects of substance misuse on the family as a whole, is included
in Continued Professional Development and Safeguarding Supervision
• To ensure multi-agency collaboration is encouraged and met, other
professionals involved with women will be documented on the new electronic
maternity records system at the commencement of booking. This will also be
covered in Continued Professional Development/Safeguarding Supervision/Wye
Valley Trust Safeguarding Forum
• Guidance for Complex Needs standards is being re-launched
• Levels of knowledge amongst relevant staff will be measured through
Safeguarding Supervision and benchmarked against standard
Audit
Community Resuscitation Trolley Checks
Following recommendations from the Francis Report, Resuscitation Services
perform spot-checks on resuscitation trolleys in Community areas, to assess
whether the contents of the trolleys have been checked by Community staff.
Action
Results showed that all trolleys achieved the minimum standard of 90% for
checks and all trolleys were checked at the required frequency. Individual
feedback is given to staff at the time of the audit, highlighting any areas for
improvement. The main areas identified for improvement in the 2014/15 have
been in checking stock levels and expiry dates and the availability of audit forms
which are to be completed following any resuscitation attempt. All staff have
been reminded of the need to check the trolleys at the required frequency.
Improvements in the overall results on trolley checks have been made during the
year.
64
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Audit
Resuscitation Trolley Audit at the County Hospital
The resuscitation trolleys are audited by the Resuscitation Services Team on a
regular basis to ensure that the equipment is intact and also to identify any failure
in the regular checks that are required.
Conclusions reached in the regular audits were that the trolleys were being
maintained to a high standard and equipment was correct and in date. There
was a reduction in the number of checks being made at the appropriate
frequency. However this was following an increase being made to the number of
checks required.
Action
Individual feedback of the findings was given to relevant staff at the time of the
audit by the Resuscitation Services Team, to enable any problems identified to be
rectified immediately. All areas were reminded of the required frequency of
checking the trolleys. Improvements in overall results have been made during the
year.
Audit
Action
Audit of Management of Pregnant women with clinically significant red
cell antibodies
This audit was carried out to measure compliance with Trust policy.
The results identified that, whilst some criteria of the policy were fully met,
actions were needed to improve the level of compliance with other criteria as
follows:
To improve the updating of the management plans at all stages for women with
significant red cell antibodies:
• Updated plans to be scanned into the new electronic records system
• Paper database of active pregnancies with red cell antibodies to be retained
• Management plan to be printed on “yellow” paper
• Access and training on the SPICE system (NHS Blood and Transplant diagnostic
services reporting system) to be delivered to clinical staff by the Trust’s
Transfusion Lead
• The new electronic maternity records system to be updated with existing cases
and the system to flag up women with significant red cell antibody
Repeat blood tests to be taken in Pregnancy Assessment Unit rather than the
community
• Pregnancy Assessment Unit to arrange appointments for repeat bloods
The audit findings and the need for improvements on Delivery Suite/Pregnancy
Assessment Unit will be included in “Hot Topic” session as well as audit and
teaching sessions.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
65
Audit
Food allergy in children and young people
This project was carried out to assess whether specific IgE blood tests are used
appropriately to diagnose food allergy. It audited compliance with national
guidelines from the National Institute for Health and Care Excellence (NICE).
Action
Results of the audit indicated that actions were required to ensure that specific
IgE blood tests are used appropriately to diagnose food allergy. The following
actions are to be taken to improve the current process.
• Education sessions will highlight the important areas to cover in history
taking.of patients with suspected food allergy
• Education to be given to paediatric doctors in training about cow’s milk protein
intolerance
• To ensure that only patients with IgE mediated symptoms have sigE blood tests
medical staff are to provide the clinical history on the blood request form. The
form must be approved by the appropriate laboratory staff.
Audit
Audit of Management of Suspected Early Onset neonatal Sepsis since the
implementation of NICE Guidelines
An audit to measure compliance with national guidelines.
Action
Results indicated good compliance with NICE Guidance although two areas were
identified for further improvement, as follows
Repeat C-Reactive Protein (CRP) blood test to be taken at 18–24 hours
• Training on and reinforcement of the timing of this repeat test has been given
to all Paediatric medical and Special Care Baby nursing staff. A clear area to
document the repeat CRP has been included on the profoma.
Blood Culture results to be available at 36 hours
• To make certain that the culture incubation starts as soon as possible, a
standard procedure has been developed to ensure porters deliver blood
specimens to the culture incubator as soon as the specimens are available
Audit
Audit of the new Paediatric Early Warning Score (PEWS) chart
Following the introduction of a new PEWS chart at the County Hospital an audit
was performed to measure completion of the chart.
Action
Results indicated that the charts were generally well completed and well
accepted. The frequency of observations documented was a definite increase on
levels achieved with the previous chart. The charts were also found to clearly
highlight parameters and normal ranges for each group.
The need for some slight adjustments to the format of the chart was identified,
to enable further improvements in completion. The chart will be revised, the
updated chart will be implemented and then further audit of its completion will
be performed to measure whether the changes have led to the planned
improvements.
66
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Audit
Reporting of Cancer Resection Specimens
A Key Performance Indicator (KPI) published by the Royal College of Pathologists
(RCPath) concerns the use of datasets in reporting of cancer resections. This was
an audit of the use of such datasets in reports issued at Hereford County
Hospital.
Action
Results showed full completion of the dataset proforma for all relevant surgical
specimens and for malignant melanoma skin specimens. The need for increased
completion of the proforma in two other types of skin specimens was identified.
This has led to the implementation of full separate datasets in the reports on skin
resections.
Audit
Missed Dose Audit
This annual clinical audit was conducted across all in-patient areas within Wye
Valley Trust. The in-patient medication chart(s) were assessed to provide the
results. The audit aims to identify missed medication doses and highlight any
trends within the Trust
Action
Conclusions drawn from the results were that, while the results indicated a high
level of compliance across the Trust there was room for further improvement.
The following actions have been taken:
• Medical and Nursing staff to be informed of the need to complete the allergy
section of the in-patient medication chart
• Issues raised in this audit will be shared with clinical staff at the Medicines
Optimisation refresher session
• All cases of missed doses to be included in the nursing handover
• At weekly medical meeting medical staff to be made aware that, when
completing the inpatient medication charts on a patient’s admission, it should
be ascertained whether Non-Formulary medications are available. If they are
not, then doctors should prescribe an equivalent Formulary medication.
• Promote the review of regular analgesia by medical staff when patients are
declining the medication. Medical staff should explain the need for regular
medication to the patient. If the patient does not wish to take regular
medication, the analgesia should be prescribed within the PRN (to be taken as
required) section of the prescription chart.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
67
Audit
Febrile Neutropenia Re-Audit
This was a repeat audit covering a 12 month period. The first round of the audit
had led to the development of a febrile neutropenic pathway based on guidelines
issued by the National Centre for Health and Care Excellence (NICE).
Action
Overall results of the re-audit have shown an improvement on the previous
round. Further areas of improvement have now been identified resulting in
education of ward staff as follows:
• To ensure all staff familiar with recently introduced observation charts
• The use of the Febrile Immunocompromised ward pathway and NICE standards
required
• Tazocin to be given within one hour
• The use of ice where possible to measure lactate
Audit
Postoperative Urinary Retention after Major Joint Arthroplasty
This audit was undertaken due to significant numbers of patients undergoing
major joint replacements developing urinary retention in the post-operative
period.
Action
Following the results of the audit it was identified that there was a need to
develop strategies to prevent post-operative urinary retention after major joint
arthroplasty
The following actions have been agreed:
• All male patients undergoing major joint replacements are to be catheterised
before operation
• Female patients, if in retention, will be catheterised on the postoperative ward
6 hours after admission
• All catheterised patients will have their catheters removed in the morning
following the operation, and not later than 24 hours after insertion
68
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Audit
Audit of the Appropriate Use of Octaplex
Audit of compliance with British Committee on Standards in Haematology
(BCSH)
Action
Results confirmed that some standards were fully met. However, there were also
areas requiring improvement and the following actions are being taken:
Education to be given in Emergency Department Department regarding the
immediate reversal of warfarin for patients with significant head injury / suspicion
of cerebral bleed.
• A poster will be displayed within the department and in-house training
provided for doctors in training. The training will also be included in staff
induction
A reminder to be added to the Octaplex information on co-administration with
Vitamin K
• The Octaplex information leaflet will be updated.
• Automatic comment on issue of product on compatibility tag
Inform medical staff of the need to administer Octaplex early and in conjunction
with Vitamin K
• Memo to be sent to all medical staff
Audit
Appropriate use of platelets in patients on Clopidogrel
- The audit assessed the appropriateness of requests and whether there was
adherence to guidance on platelet transfusion in patient on Clopidogrel preoperatively.
Action
Results showed that actions were required. The following actions are being
taken:
• Audit findings will be fedback to surgical and orthopaedic colleagues.
• Pre-operative plan for these patients to be agreed for future use
• Investigate all platelet wastage when ordered for patients on Clopidogrel
Audit
Conversion to Subcutaneous Methotrexate: Adherence to Protocol
This was an audit to measure whether local guidance was being followed when
patients were converted from oral to subcutaneous methotrexate.
Action
Results showed that the protocol was followed in all cases in relation to
performance of chest X-ray. However, a need for improvement in the frequency
of blood tests following the change in treatment was identified. To achieve an
improvement, education sessions will be held for local General Practitioners to
highlight the need for increased monitoring. Specialist Nurses are to ensure that
patients are made aware of the frequency of blood tests.
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
69
Record keeping/documentation audits
The Trust carries out audits of clinical record keeping to ensure that the quality of the clinical record facilitates high quality
patient care and that subsequently the health record can justify any clinical decision if required. The following record
keeping audits in 2014/15 indicated that actions were needed to achieve improvements.
Audit
Anaesthetic Record Keeping
The audit included an assessment of record-keeping against criteria defined in
national guidance from the Royal College of Anaesthetists and the Association of
Anaesthetists of Great Britain and Northern Ireland.
Action
Results provided evidence of safe practice at Wye Valley Trust, with relevant
patient, equipment and medication/allergy checks being undertaken in 100% of
cases. Areas where documentation could be further improved were identified
and actions planned as follows:
Recording of operating surgeon and anaesthetist.
• Although this is recorded on the operation notes, it should also be recorded on
the anaesthetic chart. This will be done as part of the safety checklist and
theatre team meeting before the start of each operating list.
Recording of relevant history, examination, ASA grade, medications & allergies
• All patients having planned operations are seen in the consultant-led, nursedelivered pre-operative assessment have thorough assessment documented.
This information is also to be recorded on the anaesthetic chart
Recording of pre-induction values
• This will be covered at education meetings
• The chart will be redesigned to title the first five-minute observations for preinduction values
Recording of post-operative instructions
• Post-operative instructions and any concerns are always communicated verbally
to nurses during the patient’s transit from the operating theatre to the recovery
room.
• A reminder will be issued to also document these on the anaesthetic chart. The
chart will be amended before the next print-run to include a dedicated section
for post-operative instructions
70
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Audit
Medical Inpatient Record Keeping
Action
The results of this regular audit showed that record keeping had improved since
the last round of data, with improvements achieved in all areas. The only area
where the need for action was identified was in documentation during
Consultant ward rounds. This has led to the introduction of a proforma to be
used on Consultant ward rounds.
Audit
Gynaecology Record Keeping
To assess the quality of record keeping within case-notes by medical staff within
Gynaecology.
Action
Results indicated significant improvements compared with the previous audit.
However, there were areas of documentation which required further
improvement. The following actions are planned:
To improve understanding of what is required in the medical notes
• Hand-outs will be created and given to all members of staff
• Record keeping guidance to be added to the Intranet
• Record keeping guidance handout to be included in new starter packs
(including locums)
• A session on the importance of good record keeping to be given to all new
doctors at the start of their rotation to Obstetrics & Gynaecology
Audit
Obstetric Record Keeping
This is a regular audit assessing completion of documentation within the records
of both mothers and babies.
Action
The results of the latest audit showed improvement in record keeping compliance
rates and knowledge around the importance of good documentation with regard
to patient safety. The main areas identified for further improvement were in the
updating of management plans and completion of all entries on the Partogram.
The results, with areas for improvement, will be disseminated in a number of
ways, including:
• Governance meetings
• Audit meetings
• Supervisory networks
• Case reviews
• Key messages at team meetings
• Safety newsletter
• Training forums
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
71
Audit
Occupational Therapy Record Keeping
To evaluate specific areas within local record keeping against core standards from
the British College of Occupational Therapy and Health Professions Council.
Action
Results from previous record keeping audits had shown three specific aspects of
documentation where standards were not being met. It was therefore decided
to limit the current audit to these three aspects, undertaking rapid cycles of
assessing compliance, making necessary changes to achieve improvement before
further assessment.
Results showed that improvements were achieved in two areas but problems
persisted in the signing, dating and timing of documentation errors.
An in-service training session has been arranged when there will be facilitated
discussion around moving forward towards best practice in record keeping. It is
anticipated that through this, all members of the OT department will be more
informed about the expected standards of note writing and actions will be
agreed in specific areas.
Audit
Ophthalmology Record Keeping
This is a regular audit assessing record keeping within the ophthalmology records
against 10 documentation standards.
Action
Compared with the previous audit the results showed that three of the 10 had
not improved. Results to be discussed at the Ophthalmology Governance
meeting to ensure that all staff are aware of the need for:
• A patient label to be inserted on each page of the clinical notes
• Signatures against each entry to be identifiable
• The timing of every entry into the clinical record is recorded
Audit
Physiotherapy Record Keeping (community)
An assessment of the standards of record keeping using criteria based on the
Chartered Society of Physiotherapy documentation standards.
Action
The audit results demonstrated that the majority of notes were of a good
standard with 33 of the marking criteria achieving 60-100%. Only 5 of the
marking criteria achieved less than the 60% target. The following actions are
being taken:
• Results to be fed back to Physiotherapists in the Community and Acute
Hospital service
• Specific feedback to be given to Community Physiotherapy team members on
criteria which need to be improved.
• Spot checks of documentation to be performed on a monthly basis, to ensure
that staff are implementing the required changes
• Availability of specialist training on the importance of good record keeping to
be explored
72
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
3.3 Participation in Clinical Research
The number of patients receiving NHS services provided or sub-contracted by Wye Valley NHS Trust in 2014/15 that were
recruited during that period to participate in research approved by a research ethics committee was 212.
3.4 Use of the CQUIN payment framework
A proportion of Wye Valley NHS Trusts income in 2014/15 was conditional on achieving quality improvement and
innovation goals agreed between Wye Valley NHS Trust and any person or body they entered into a contract, agreement
or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment
framework.
Further details of the agreed goals for 2014/15 are included in Section 2.3.3 and the following 12-month period is
available electronically on the Trust website.
3.5 Statements from the CQC
Wye Valley NHS Trust is required to register with the Care Quality Commission and its current registration is registered with
conditions. Wye Valley NHS Trust has special measure conditions on its registration.
The Care Quality Committee has taken enforcement action against Wye Valley NHS Trust during 2014/15.
3.6 Statement on relevance of Data Quality and your actions to improve your Quality
Wye Valley NHS Trust will be taking the following actions to improve data quality;
• Ensure continuous development and monitoring of all Data Quality action plans through the Information and
Information Technology Management Group.
• Maintain the regular monthly audit activities to ensure accuracy of data within the Patient Administration System for
both Inpatient and Outpatient activity.
• Regularly action and update the Trust’s overall Data Quality action plan.
• Provide Data Quality Team support for the Trust wide Service Line Management project.
3.7 NHS Number and General Medical Practice Code Validity
Wye Valley NHS Trust submitted records during 2014/15 to the Secondary Uses service 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 is:
99.8% for admitted patient care;
99.8% for out-patient care; and
99.9% for accident and emergency care which included the patient’s valid General Medical Practice
Code was:
100% for admitted patient care
100% for out-patient care
96.1% for accident and emergency care
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
73
3.8 Information Governance Toolkit attainment levels
Wye Valley Trust Information Governance Assessment Report score overall score for 14/15 will be 81% and will be graded
Satisfactory.
3.9 Clinical coding error rate
Wye Valley Trust was subject to the Payment by Results clinical coding auditduring the reporting period by the Audit
Commission and the error rates reported in the latest published audit for that period for diagnoses and treatment coding
(clinical coding) were;
• Primary Diagnoses Incorrect 9.5%
• Secondary Diagnoses Incorrect 7.7%
• Primary Procedures Incorrect 8.7%
• Secondary Procedures Incorrect 20.1%
74
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
75
*the palliative care indicator
is a contextual indicator.
(a) the value and banding
of the summary
hospital-level mortality
indicator (“SHMI”) for
the trust for the
reporting period; and
(b) the percentage of
patient deaths with
palliative care coded at
either diagnosis or
specialty level for the
trust for the reporting
period.
1: Preventing People from
dying prematurely
12. The data made available
to the National Health
Service trust or NHS
foundation trust by the
Health and Social Care
Information Centre with
regard to -
Trusts providing relevant
acute services
2: Enhancing quality of life
for people with long-term
conditions
Related NHS Outcomes
Framework Domain &
who will report on them
Prescribed Information
Summary
Hospital-Level
Mortality
Indicator
(SHMI)
Indicator
Title
April 2013 –
March 2014
a) 1.66 – Band 1
b) 23.6%
a) 1.130 – Band 1
b) 23.9%
2014/15
October 2013 –
September 2014
2014/15
Wye Valley NHS Trust
has taken the
following actions to
improve this rate and
so the quality of its
services;
• Please see Priority 3.
Wye Valley NHS Trust
considers that this
data is as described
for the following
reasons;
• Please see Priority 3.
Trust Statement
76
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
(i) groin hernia surgery,
(ii) varicose vein surgery,
(iii) hip replacement surgery,
and
(iv) knee replacement
surgery,
during the reporting period.
PROMS;
patient
reported
outcome
measures.
3: Helping people to recover
from episodes of ill health or
following injury
18. The data made available
to the National Health
Service trust or NHS
foundation trust by the
Health and Social Care
Information Centre with
regard to the trust’s patient
reported outcome measures
scores for -
All acute trusts
Indicator
Title
Related NHS Outcomes
Framework Domain &
who will report on them
Prescribed Information
i)
ii)
iii)
iv)
0.106
N/A
0.509
0.35
0.084
0.102
0.449
0.319
National
i)
ii)
iii)
iv)
0.132
0.15
0.431
0.325
WVT
2013/14
April 2014 –
December 2014
WVT
2014/15
2014/15
0.085
0.93
0.436
0.323
National
Wye Valley NHS
Trust has taken the
following actions
to improve this
rate and so the
quality of its
services;
• Please see
section 2.3.2
Wye Valley NHS
Trust considers
that this data is as
described for the
following reasons;
• Please see
section 2.3.2
Trust Statement
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
77
Readmitted to a hospital
which forms part of the trust
within 28 days of being
discharged from a hospital
which forms part of the trust
during the reporting period.
Patients
readmitted to
a hospital
within 28 days
of being
discharged.
3: Helping people to recover
from episodes of ill health or
following injury
19. The data made available
to the National Health
Service trust or NHS
foundation trust by the
Health and Social Care
Information Centre with
regard to the percentage of
patients aged:
(i) 0 to 15; and
(ii) 16 or over,
All trusts
Indicator
Title
Related NHS Outcomes
Framework Domain &
who will report on them
Prescribed Information
Not available on
Health and Social
Care Information
Centre Indicator
Portal
2014/15
This data is for
Hereford Hospital
NHS Trust.
i) 0.14
ii) 8.81
2002/3 –
2011/12
2014/15
This data is for
Hereford Hospitals
NHS Trust and has
not been updated on
the Health and Social
Care Information
Centre Portal since
2011/12.
Trust Statement
78
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Not available
Responsiveness
to the
personal
needs of
patients.
4: Ensuring that people have
a positive experience of care
20. The data made available
to the National Health
Service trust or NHS
foundation trust by the
Health and Social Care
Information Centre with
regard to the trust’s
responsiveness to the
personal needs of its
patients during the reporting
period.
All acute trusts
2014/15
Indicator
Title
Related NHS Outcomes
Framework Domain &
who will report on them
Prescribed Information
England: 68.7
Wye Valley NHS
Trust: 67.9
2013/14
2014/15
Wye Valley NHS Trust
has taken the
following actions to
improve this rate and
so the quality of its
services;
• Please see section
2.1.5.
Wye Valley NHS Trust
considers that this
data is as described
for the following
reasons;
• Please see section
2.1.5.
Trust Statement
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
79
4: Ensuring that people have
a positive experience of care
21. The data made available
to the National Health
Service trust or NHS
foundation trust by the
Health and Social Care
Information Centre with
regard to the percentage of
staff employed by, or under
contract to, the trust during
the reporting period who
would recommend the trust
as a provider of care to their
family or friends.
All trusts
Related NHS Outcomes
Framework Domain &
who will report on them
Prescribed Information
Staff who
would
recommend
the trust to
their family or
friends.
Indicator
Title
Wye Valley NHS
Trust: 54
All
Organisagtions:
65
All Organisations:
66
Wye Valley NHS
Trust: 55
Staff Survey 2013
2014/15
Staff Survey 2014
2014/15
Wye Valley NHS Trust
has taken the
following actions to
improve this rate and
so the quality of its
services;
• Please see section
2.4.1.
Wye Valley NHS Trust
considers that this
data is as described
for the following
reasons;
• Please see section
2.4.1.
Trust Statement
80
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Patients
admitted to
hospital who
were risk
assessed for
venous
thromboembol
ism.
5: Treating and caring for
people in a safe
environment and protecting
them from avoidable harm
23. The data made available
to the National Health
Service trust or NHS
foundation trust by the
Health and Social Care
Information Centre with
regard to the percentage of
patients who were admitted
to hospital and who were
risk assessed for venous
thromboembolism during
the reporting period.
All acute trusts
Indicator
Title
Related NHS Outcomes
Framework Domain &
who will report on them
Prescribed Information
Wye Valley NHS
Trust: 95%
England: 96%
England: 96%
Wye Valley NHS
Trust: 95%
Quarter 3
(2014/15)
2014/15
Quarter 3
(2014/15)
2014/15
Wye Valley NHS Trust
has taken the
following actions to
improve this rate and
so the quality of its
services;
• Please see section
2.2.2.
Wye Valley NHS Trust
considers that this
data is as described
for the following
reasons;
• Please see section
2.2.2.
Trust Statement
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
81
5: Treating and caring for
people in a safe
environment and protecting
them from avoidable harm
24. The data made available
to the National Health
Service trust or NHS
foundation trust by the
Health and Social Care
Information Centre with
regard to the rate per
100,000 bed days of cases
of C difficile infection
reported within the trust
amongst patients aged 2 or
over during the reporting
period.
All acute trusts
Related NHS Outcomes
Framework Domain &
who will report on them
Prescribed Information
Rate of
C.difficile
infection.
Indicator
Title
Not available
2014/15
Wye Valley NHS
Trust: 16.9
England: 14.7
2013/14
2014/15
Wye Valley NHS Trust
has taken the
following actions to
improve this rate and
so the quality of its
services;
• Please see section
2.2.8
Wye Valley NHS Trust
considers that this
data is as described
for the following
reasons;
• Please see section
2.2.8.
Trust Statement
82
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
5: Treating and caring for
people in a safe
environment and protecting
them from avoidable harm
25. The data made available
to the National Health
Service trust or NHS
foundation trust by the
Health and Social Care
Information Centre with
regard to the number and,
where available, rate of
patient safety incidents
reported within the trust
during the reporting period,
and the number and
percentage of such patient
safety incidents that resulted
in severe harm or death.
All trusts
Related NHS Outcomes
Framework Domain &
who will report on them
Prescribed Information
Patient safety
incidents and
the percentage
that resulted in
severe harm or
death.
Indicator
Title
Severe: 0.1%
Death 0.2%
Death: 0.1%
Patient safety
incidents: 36.47
Patient safety
incidents: 60.47
Severe: 0%
October 2013 –
March 2014
2014/15
April 2014 –
September 2014
2014/15
Wye Valley NHS Trust
has taken the
following actions to
improve this rate and
so the quality of its
services;
• Please see section
2.2.7
Wye Valley NHS Trust
considers that this
data is as described
for the following
reasons;
• Please see section
2.2.7.
Trust Statement
Appendix 1
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
83
84
W ye Va l le y N H S Trus t Q uali ty Ac c ounts 2014/15
Wy e Va l le y NHS Trust Qua lity A cc ounts 2014/15
85
Wye Valley NHS Trust
Trust Headquarters
The County Hospital
Union Walk
Hereford
HR1 2ER
01432 372928
www.wyevalley.nhs.uk