Quality Account
Reporting Period 2009 - 2010
A statement of our commitment
and approach to quality
assurance with a quality account
summary
Contents
Part 1 .............................................................................................................................. 2
1.1
Foreword by Chief Executive ........................................................................................2
1.2
Trust’s commitment to quality assurance ......................................................................5
Part 2 .............................................................................................................................. 6
2.1
Priorities for improvement .............................................................................................6
2.2
Statements of assurance...............................................................................................7
2.3
Review of services ........................................................................................................8
2.3.1
2.3.2
2.3.3
2.4
Safety ......................................................................................................................8
Patient Experience ..................................................................................................9
Patient Reported Outcomes ..................................................................................10
Participation in clinical audits ......................................................................................10
2.5
Research .....................................................................................................................12
2.6
Goals agreed with commissioners ..............................................................................12
2.7
What others say about the Provider ............................................................................14
2.8
Data quality .................................................................................................................14
2.8.1
2.8.2
2.8.3
NHS Number and General Medical Code Validity.................................................14
Information Governance Toolkit attainment levels ................................................14
Clinical coding error rate .......................................................................................14
Part 3 ............................................................................................................................ 15
3.1
Structures for embedding quality in service provision pathways.................................15
3.2
Monitoring and reporting of quality indicators..............................................................16
3.3
A summary of our quality overview .............................................................................16
3.3.1
3.3.2
3.3.3
Safety ....................................................................................................................18
Patient Experience ................................................................................................21
Patient Reported Outcomes ..................................................................................27
3.4
Productive Ward Project..............................................................................................29
3.4
Productive Ward Project..............................................................................................30
3.5
Overview of performance against key national priorities.............................................31
3.6
How to provide feedback on the Account....................................................................31
3.7
Statements from Local Involvement Networks, Overview and Scrutiny
Committees and Primary Care Ttrusts ........................................................................32
1
Part 1
1.1
Foreword by Chief Executive
Barnet, Enfield and Haringey Mental Health Trust’s vision is to lead and influence the
development of person-centred networks to deliver effective, high quality services. With this
aim in mind I am pleased to introduce the first of our Quality Account (2009 to 2010).
Whilst being a legal requirement for all NHS Provider Organisations, this requirement is aligned
with the ongoing commitment of this organisation to improve the quality of our services. I
welcome this opportunity to publish our performance on quality as part of our on-going
commitment to making the services the very best that they can be.
Significant progress has been made in the last year with a number of initiatives, including
1. The development of Patient Experience Tracker Units to monitor the patient experience
on wards and from community teams. Patient experience remains a top priority for the
Trust. Valuable data is taken from these machines and fed-back to teams encouraging
them to reflect on their scores and to develop ways in which this performance can be
developed.
2. A Ward Assurance Programme focussing on key functions in the ward process that will
raise quality and standards of care.
3. The Productive Ward Programme, an initiative developed by the NHS Innovation Centre,
has led to some dramatic improvements in patient contact time on the ward and
improvements in patients’ experience. As the year progresses we will continue to roll this
out across the remainder of all wards.
4. The development of a Compliance approach to ensuring that the Trust is meeting the
quality outcomes described in the Regulatory Framework for all Providers of care, set
down by the Care Quality Commission.
5. We will continue to develop initiatives from this year into next on developing methods to
improve the standard of communication between staff and patients.
We recognise that significant challenges remain. To involve our service users in our governance
systems, and to invite and listen to their comments are also important elements in our overall
drive for quality improvement. The Trust has made a large commitment to eliciting, analysing
and monitoring patient’s views through our Patient Experience Tracking Project. This project
relies upon the use of electronic data gathering units which allow patients, carers and relatives
to provide feedback on the patient experience by responding to a number of carefully selected
questions with a number of answer options to allow for both positive and negative responses.
The question set reflects issues of great concern to us and seeks to provide ongoing monitoring
of points which are also covered in national surveys undertaken by the Care Quality
Commission. These questions are directed at dignity and respect issues and include feedback
on the quality of care received. Dignity, privacy and respect concerns are also the subject of an
ongoing audit, which in its initial phase is focussed on inpatient care. We are delighted that we
able to work in partnership with service user forums in the undertaking and analysis of this
important work
Data from the patient experience audit and survey work will be fed directly into our Quality
Account. The results from all the quality improvement work will be closely monitored at the most
senior level in the Trust, so that actions and resources can be directed at achieving better
2
performance. Our commitment to quality improvement will also lead us to set higher targets
when existing targets are reached.
We have set some ambitious improvement targets to ensure that we address some very
important areas of our quality agenda over the coming year. These will be;
•
Ensuring that all service users, who are admitted to our in-patient services, will receive a
comprehensive physical healthcare assessment. When any healthcare problems are
identified we will ensure that this is comprehensively followed up with the individuals’
General Practitioner. Where an individual is not registered with a General Practitioner
we will offer support to enable this to happen but only where an individual would wish
this to happen. We are aware from the users of our services that physical healthcare
problems remain a significant concern to them. We remain very mindful of the additional
risk mental healthcare problems can have on someone’s life expectancy, compared to
the general population, and the higher risk of illnesses such as Diabetes. We remain
committed to an approach of high vigilance, with interventions, where they are required,
delivered at the earliest opportunity.
•
We recognise the devastating effect depression can have on an individuals’ life and the
risks this can pose. We are committed to ensuring that we assess levels of depression in
the people who use our services so as to ensure we offer effective treatment and
packages of care, and at the same time review the effectiveness of our approaches. We
will work with the users of services to identify effective tools to aid these assessments.
We will gather and collate data on clinical outcomes to allow our governance structures
to monitor the quality of our care thereby enabling operational teams and clinicians to
know how they are doing and effect improvements in services, where these are needed.
•
We recognise that we need to enhance our clinicians’ adherence to certain aspects of
the Mental Health Act Code of Practice. We want to improve, in partnership with the
Care Quality Commission, our performance on assessing service users’ capacity to
consent to treatment also ensuring that our users of services who are subject to the Act
are fully engaged in decisions about their care. We will implement a range of measures
and surveys to generate performance data in order to secure improvements in process
which offer clear benefits to those who are admitted and subject to the conditions and
requirements of the Act.
I commend this report to the patients and users of our services, including their families and
carers, the residents of Barnet, Enfield & Haringey and beyond to whom we serve. I also
commend this to our partners and commissioners without whom the drive to improve quality
would not be possible.
In the relatively short period before publication, the Trust arranged a consultation event and
wrote to all our Commissioners, Overview and Scrutiny Committees (OSC) and Local
Involvement Networks (LINk) to seek their views on the Account.
Monitoring of quality and other performance data at a senior level through clinical governance
groups, the Strategic Management Group and the Governance & Risk Committee which inform
the Board; allows me to provide assurance that to the best of my knowledge and belief the
information provided in this document gives an accurate description of the points included in the
Account.
3
We would welcome feedback on this Account to help us formulate our approach in the following
years. Details of how to do this can be found at the end of the Account.
Maria Kane
Chief Executive
Barnet, Enfield and Haringey Mental Health NHS Trust
4
1.2
Trust’s commitment to quality assurance
The Trust is committed to pursue quality care as defined by Lord Darzi as care which is
"clinically effective, personal and safe".
The Trust’s has committed a significant amount of resource to assuring that quality remains
embedded within everyday Trust activity. Performance management reports of activity related to
quality are regularly provided to Governance meetings, management teams and clinicians in
order that performance is reviewed and driven forward. Recent initiatives also include the
development of internal compliance meetings to ensure that the services are meeting the
outcomes described within the Regulatory Framework as set out by the Care Quality
Commission. There is a programme of Ward Assurance work underway to establish quality
assurance of basic core activities and interventions within all wards and as a result improved
patient experience.
In addition a significant number of roles are responsible for quality within the Trusts; a Director
of Nursing who is a main board member with the full title of Director of Nursing, Safety &
Quality. The responsibility for quality is complemented by the appointment of a Director of
Governance who manages the Clinical Governance process of the organisation and assures the
Trust is compliant with all national requirements. Within the Nursing and Governance
Directorate there are senior appointments that support the quality assurance work of the Trust:
•
Borough Lead Nurses;
•
Assistant Director of Nursing and Safety;
•
National Standards Managers;
•
Lead Nurse Education & Training;
•
Assistant Director Safeguarding Adults;
•
Assistant Director Safeguarding Children;
•
Infection Control Lead Nurse;
•
Trust Resuscitation Officer;
•
Senior Manager for Complaints & Claims;
•
Patient Experience Manager – Safety;
•
Head of Clinical Audit & Effectiveness;
•
Clinical Effectiveness Manager; and
•
Risk Manager.
Service line clinical governance groups meet on a monthly basis and report to the Trustwide
Quality & Clinical governance group, which informs the board via the Governance and Risk
Committee.
5
Part 2
2.1
Priorities for improvement
The Trust recognises that some points in our summary of quality for the year 2009 to 2010 have
been the subject of close monitoring and improvements by our Service Commissioners and by
the Trust for some time, and in certain cases are yielding results that are positive and
encouraging. In keeping with the requirements of the Quality Account and the Trust’s
commitment to improving the quality of the services it provides it is necessary to consider other
priorities for improvement to focus on in the coming year and to replace areas where improved
performance has been achieved.
The following three new priority areas for improvement have been selected following internal
consultation through the Trust’s clinical governance processes:
•
Seek an improvement on 2009-2010 result of 90% for service users, who are admitted to
our in-patient services, that they will receive a comprehensive physical healthcare
assessment;
•
Implementation of the general use of a tool to assess levels of depression in the people
who use our services so as to ensure we offer effective treatment and packages of care
to individuals, and at the same time review the effectiveness of our service provision
•
For people detained under the Mental Health Act we want to improve our documentation
with regard to consent to treatment and ensuring that our users of services are fully
engaged in discussions and decisions about their rights, medication and` planning of
care.
There is a requirement that patients admitted to our wards receive an initial physical health care
assessment within 72 hrs. This is monitored on an ongoing monthly cycle by the local ward
audit. Data is reported centrally to the Audit Department and will be summarised for future
reporting in the Quality Account.
When any healthcare problems are identified we will ensure that this is comprehensively
followed up with the individuals’ General Practitioner. Where an individual is not registered with
a General Practitioner we will offer support to enable this to happen, but only where an
individual would wish this to happen. An audit tool will be developed for this purpose and will be
applied to a sample of appropriate cases.
The Trust has selected a range of assessment tools to assist in recording Patient Reported
Outcome Measures (PROMS) to evaluate the effectiveness of treatment modules such as:
CORE (Clinical Outcomes for Routine evaluations) for use with Psychological Interventions;
QIDS-SR (Quick Inventory of Depressive Symptomatology – 16 point; CORC (Child and
Adolescent Mental Health Service Outcome Research Consortium evaluations); and a
psychosis self-assessment tool.
Documentation for people detained under the Mental Health Act with respect to consent to
treatment and patient involvement in care planning will be made the subject of a revised MHA
audit tool. Results will be reported as part of the Trust’s annual MHA audit and summarised for
reporting in the Quality Account.
6
We recognise that we need to do more on the patient narrative aspect, and we are currently
commissioning a new patient tracker system that will provide more effective gathering of such
information.
A Patient Experience Advisory Group has been established and provides a further means of
determining patients’ experience of services.
2.2
Statements of assurance
These statements serve to offer assurance to the public that our organisation as a whole has
embedded quality within the processes of the organisation because it has achieved full
registration without any conditions being applied for 2010/11. As such the organisation has
proved that in addition to the last two years ratings of excellent for Quality of Services in relation
to the Annual Health Check from the Commission we have continued to maintain excellence in
our provision.
The Trust continues to participate in National Audits in order to successfully benchmark its
effectiveness against other organizations, these have included the following:
•
POMH Prescribing Topics in Mental Health;
•
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness;
•
National Survey of Mental Health Acute Inpatient Service Users 2009; and
•
Count Me In Census 2009.
The Trust has continued to examine and participate in every opportunity to learn from national
initiatives and adopt these within services. These have included this year:
•
The Productive Ward initiative, from the NHS Innovation & Improvement Centre, which
has developed more effective processes ensuring that more time has been made
available to spend with patients in therapeutic activity through minimizing unnecessary
ward routine and administrative tasks.
•
The Trust has continued to participate and engage in learning events concerning
Serious Untoward Incidents, from both regional and nationally known cases. The Trust
is represented at both internal and external feedback events at which the Patient Safety
Manager attends. The Trust has participated in the following seminars: Leading
Improvements and Patient Safety (LIPs); and also hosted Embedding the Learning From
incidents Seminar where there was a NHS London review of homicide legacy cases and
discussion on themes arising from an analysis of BEH severe incidents 09/10 and a
recent independent homicide inquiry report.
•
The Trust has adopted a number of new initiatives to develop the workforce and as a
consequence the services offered. This has included adopting its own version of an
Associate Practitioner role, called the Graduate Mental Health Practitioner, to work
directly with patients on their recovery needs. In addition to this the organisation is well
underway with adopting non-medical prescribing roles in redesigned services offering
7
patients better choice and a more responsive service to their changing mental health
needs.
2.3
Review of services
The Trust provides general Mental Health Services for the population of Barnet, Enfield &
Haringey. It also provides specialist Forensic, Child & Adolescent, Eating Disorder &
Psychological on a regional basis. On that basis careful consideration was given to choosing
indicators which were common and meaningful to such a wide-ranging portfolio. In addition the
Trust was aware that because of an in-year review of Infection Control processes, with
subsequent conditions set down by the Care Quality Commission, that specific and constant
review was required. This enabled the Trust to also address its requirements to operate under
the guidance laid down by the Code of Practice for Infection. Subsequently later in the year the
conditions were lifted by the Commission as the Trust effectively proved it was operating safely.
The indicators chosen within the three domains to comply with National Requirements for
Quality are as follows:
2.3.1 Safety
1. Current rates of Serious Untoward Incidents – The Trust regards patient safety as
paramount to the delivery of an effective quality service. With that in mind the Trust will
focus on ensuring that it investigates and learns from all incidents concerning patient
safety. The Trust will therefore ensure that incidents are managed in line with NHS
Policy Guidance, reported with timescale and there is evidence of learning implemented
and reviewed on a monthly basis. The Trust recognises that the safety of the people who
use our service is of paramount importance. From the rates and information gathered
the Trust will ensure that learning is embedded within the clinical teams and where there
are themes and unusual patterns which emerge, quick and decisive action will ensue to
review both clinical practice and organisational policies and procedures.
2. Infection Outbreaks/Attainment of the Hygiene Code Requirements – The Trust
regards the maintenance of clean environments as critical to aiding patient recovery.
The Trust will therefore ensure that there is on-going audit and attainment with the
requirements of the Hygiene Code and all outbreaks of infection are managed in line
with Policy requirements and in a timely manner. The Trust recognises its need to
address the requirements of the Code of Practice as well as ensure that the
requirements of Care Quality Commission were met.
8
3. Rates for CPA Seven-Day follow up following discharge – It is recognised that the
most vulnerable stage of aftercare is within the first seven days following admission.
There is on-going monitoring and review of the rates of follow-up ensuring attainment of
100%. Where attainment is not reached action plans are developed and reviewed and a
log of lessons learnt is maintained. The Trust recognises that the recommendations from
the National Confidential Inquiry into Homicides & Suicides indicates that the effective
follow up of patients following admission will be in itself the most effective tool in
ensuring that people remain safe.
2.3.2 Patient Experience
1. Outcomes from the Patient Experience Tracker System – The Trust is committed to
ensuring that patient experience remains a critical measure of on-going quality services.
As a result of this commitment the Trust has invested in an electronic database, which
invites users of the services to comment on their experiences on an on-going basis. The
Trust will ensure that regular reporting is embedded in the Trust’s governance structures
and that action plans are developed and implemented where performance is below 70%
attainment of satisfaction. The Trust recognises that patient experience is a core factor
to achieving both a quality service and a responsive service. With that in mind the Trust
has invested into Patient Experience Tracker machines. These machines permit live
feedback on experience. Weekly reports are produced and teams are required to action
plan.
2. National Patient Surveys – Yearly the Care Quality Commission request of all NHS
Trusts a patient survey. The survey is based on pre-determined questions set down by
the Commission. The Trust is committed to addressing the outcome of this survey by
demonstrating year on year improvements to the percentage positive responses given to
the 40 questions in the survey. To that end each Service is to prepare a communication
plan with staff, during the survey period, to ensure best possible results and
understanding of the survey. Each Service Line is to develop an action plan to address
specific deficits upon publication and review. Each Service Line and the Trust as a whole
are to achieve year on year improvement in Survey Satisfaction Score.
3. Dignity and Respect Audit – In order to enhance the understanding of patient
experience an additional audit will take place. This will involve auditors observing and
recording their observation of what happens in wards and departments against a set of
pre-determined questions. Additionally, patients’ responses to a number of relevant
questions will be sought. Each service is to action plan and review response to the
Dignity and Respect Audit. Each service is to show Year on Year Improvements to the
Dignity and Respect Audit. This work will be undertaken by Service User Auditors who
will sit within wards for periods of four to five hours making observational audits against
an audit questionnaire. Feedback on these audits to ward teams will prove invaluable as
they strive to improve dignity and respect within the every process of treatment delivery.
9
2.3.3 Patient Reported Outcomes
1. Patients in receipt of Psychological Interventions – This element involves collating
patients’ reports on improvements in psychological and social functioning following a
course of psychological treatment. The measure used is the CORE Assessment
Schedule employed in the Psychological Therapies services. The assessment process
uses a form completed by the patient before a course of therapy and a form completed
afterwards, with an outcome measurement derived from a comparison of the responses.
The CORE assessment is presently used in adult services within the Barnet, Enfield and
Haringey Directorates. However, the data summarised in the 2009 to 2010 Quality
Account relates to an analysis from data collected during part of the previous business
year and the present reporting period, and is relevant to two service areas, with the subCORE assessments summary from one service area. The Trust has reorganised service
delivery using a service line model, and Psychological Therapy Leads have been
appointed for each service line. These Leads will champion the application of CORE
assessments in their area, or if they are not applicable to the service will be responsible
for identifying and implementing alternative assessment mechanisms.
2. Emergency re-admission within 28 days – The Trust regards readmission to hospital
as both sometimes necessary but at the same time often counter-productive to an
individual’s personal aspiration for effective recovery. The Trust wishes to attain a
position where re-admissions are absolutely necessary and not due therefore to
inadequate Care Packages or Interventions, including any social inclusion needs such
as adequate housing, social support and access to meaningful activity including paid
employment. This indicator will examine the effectiveness of our aftercare treatment/care
plans or indeed whether there have been factors outside of the control or the
organisation such as the lack of appropriate housing or access to employment or work
opportunities.
3. Physical Healthcare – Physical healthcare of patients remains a priority of the Trust for
all its patients. The Trust will therefore ensure that patients report that their physical
health care needs were adequately assessed and interventions and treatment offered.
Patients report that where problems were identified, as an in-patient, the GP was
subsequently in receipt of the information required.
2.4
Participation in clinical audits
During 2009 to 2010 two national clinical audits, two national mental health surveys and one
national confidential enquiry covered the services that the Barnet, Enfield & Haringey Mental
Health Trust [BEHMHT] provides. The audits and enquiries that BEHMHT was eligible to
participate in were:
•
National Audit of Psychological Therapies for Anxiety and Depression – pilot phase
2009;
•
POMH Prescribing Topics in Mental Health;
•
National confidential inquiry into Suicide and Homicide by People with Mental Illness;
10
•
National Survey of Mental Health Acute Inpatient Service Users 2009; and
•
Count Me In Census 2009.
Thus the Trust participated in 50% of the National Clinical Audit Advisory Group identified
audits, 100% of national surveys and 100% of National Enquiries:
The trust has benefited from rejoining the POMH-UK audit programme as it has improved
awareness amongst staff that practice is being monitored and reviewed. Our response to the
National Confidential Inquiry into Suicide and Homicide is complete, although by the nature of
the reporting long delays can occur in notification and response.
During the period April 2009 to 2010 BEHMHT carried out reported on the following eighteen
trust-wide surveys and audits:
*
**
•
Patient Experience Tracking Project;
•
NIMHE suicide prevention audit;
•
Antimicrobial audit*;
•
Dignity and respect audit;
•
NICE Guideline – bipolar audit**;
•
Patients property audit*;
•
Medicines management audit [by Pharmacy Dept.];
•
Mental Health Act audit [by Mental Health Act & Audit Dept.];
•
Monthly ward quality assurance audit [by ward staff];
•
Arrangements for the protection of children at risk audit;
•
NICE Guideline – schizophrenia audit**;
•
Health records – case file audit ;
•
CPA audit;
•
Risk assessment audit;
•
Supervision audit*;
•
Complaints follow up survey; and
•
Non-attendance at appointments [DNA]*.
•
Physical Health Audit
are carried out by health care professionals from the Trust under the Fifteen Minute Audit Programme.
are carried out by Junior Doctors.
11
2.5
Research
The Trust aims to develop an innovative culture focused on achieving the highest quality of care
for patients. We encourage research activity and participation in clinical trials and have been
recognised by the North London Mental Health Research Network as a leading site for
recruitment.
During 2009/10, 273 patients were recruited within the Trust to participate in ethically approved
research studies (189* into NIHR portfolio studies, 21 entered into industry studies and the
remainder into higher degree studies).
Recruitment to portfolio studies increased by 86 compared to the previous year (an 83.5%
increase). This increasing level of participation in research demonstrates the Trust’s
commitment to improving the quality of care we offer and to making our contribution to wider
health improvement.
The Trust engaged in 39 (22 funded) research studies in 2009/10 and, so far, has completed
five within agreed time and to agreed recruitment targets. Of the studies given permission to
start in 2009/10, 100% were given permission to start by an authorised person within 30 days of
receipt of a valid complete application after Research Ethics Committee approval. The
Research Passport was used for seven eligible studies.
In this reporting period the National Institute for Health Research (NIHR) supported 21 of these
studies through its research networks, of which two are connected to North Thames Dementias
& Neurodegenerative Diseases Research Networks.
2.6
Goals agreed with commissioners
The Trust regularly monitors its quality performance with its Primary Care Trust Commissioners
and others. The reporting scheduled is summarised below and the figures are given for the year
against the targets set down within that contract. As can be seen the Trust has performed well
with nearly all aspects at or above the requirements of the contract.
12
Quality Performance Reporting Schedule with Commissioning Partners
STANDARD
Monthly / Bi-Monthly
SUI's numbers and trends
PET Question 1
PET Question 2
PET Question 3
PET Question 4
PET Question 5
Complaint: Cumulative monthly calculation
Corporate Risk Register Reports to Performance &
Risk Committee
Quarterly
Suicides of people in contact with mental health
services
24 Hour CAMHS cover for emergency need:
1. Rota for consultant cover for Barnet
2. Rota for SPR cover for BEHMHT
3. Junior Doctor and other professionals cover for
New Beginning
4. Northgate has 24 hr cover for all professions
BEH TRUST
AVERAGE
TARGET /
REQUIREMENT
57
77%
74%
74%
74%
76%
80%
Full compliance with
reporting requirements
Reduce year on year
70%
70%
70%
70%
70%
75% compliance
Maintain compliance
16
<18.3
Based on National Rates
for Trust Population
Full compliance with
reporting requirements
24 Hour Cover
82%
100%
95% Compliance
Audit December 09
Compliance with CG82
schizophrenia guideline
82%
100%
97%
100%
93%
100%
96%
100%
91%
98%
88%
95%
95%
95%
65%
95%
Discharge letters - % sent to GPs within 21 days
discharge from inpatient stay/services
Compliance with anti-psychotic medication
prescribing guidelines
Six-Monthly
Discharge letters - % sent to GPs within 21 days
discharge from inpatient stay/services
1 Audit if offered oral antipsychotic medication
2 Provided with information on all types of antipsychotic medication
3 Initially prescribed with only one type of antipsychotic medication
Assessment within two weeks of admission
Six monthly review with consultant
Gender specific screening offered
At risk long term patients offered flue and
pneumococcal vaccination
All patients that smoke offered smoking cessation
Diet and exercise offered
Patients with BMI > 30 referred to dietician
Annually
Annual report on race, disability and gender - equality
scheme and action plan
66%
40%
88%
100%
100%
100%
Full Compliance with
reporting requirements
Annual Report
Year on Year Improvement in National Survey Scores
see 3.2 2 Safety
80%
Protection of vulnerable adults
Mixed sex accommodation
Full compliance with
reporting requirements
Exception Reporting
13 Incidents since April
Maintain compliance
Report All
13
2.7
What others say about the Provider
The Trust has performed well under its ratings with the Care Quality Commission over the last
two years for the Annual Health Check receiving Good for use of Resources and Excellent for
Quality of Services. It submitted a fully compliant submission to the Commission for the 2009/10
year. In addition the Trust has been successful in achieving full registration, without any
conditions, for the new Regulatory Framework for 2010/11.
The Trust recognised that during the 2009/10, following an assessment by the Care Quality
Commission under the Hygiene Code it received conditions and a requirement to improve the
quality of services at St Ann’s Hospital. Subsequent action planning by the Trust and a
reassessment by the commission meant that these conditions were lifted in December 2009
having been placed in March of the same year. The Trust will continue to ensure that increased
vigilance and management arrangements will avoid any repetition of this matter in the future.
2.8
Data quality
2.8.1 NHS Number and General Medical Code Validity
Barnet, Enfield and Haringey Mental Health NHS Trust submitted records for February 2010
return sent to the Secondary Uses service (SUS) for inclusion in the Hospital Episode Statistics
(HES) which are included in the latest published data. The percentage of records in the
published data which included the patient’s valid NHS number was:
96%
95%
For admitted patient care
For out patient care
The percentage of records in the published data which included the patient’s valid General
Medical Practice Code was:
94%
93%
For admitted patient care
For out patient care
2.8.2 Information Governance Toolkit attainment levels
Barnet, Enfield and Haringey Mental Health NHS Trust’s score for 2009/10 second quarter
completed on 30 October 2009 for information Quality and Records Management, assessed
using the Information Governance Toolkit was 68%.
2.8.3 Clinical coding error rate
Barnet, Enfield and Haringey Mental Health NHS Trust was not subject to the Payment by
Results clinical coding audit during 2009/10 by the Audit Commission.
14
Part 3
3.1
Structures for embedding quality in service provision pathways
Our new initiative to improving all aspects of our service delivery is based upon the need to
build quality assurance into our service delivery processes, rather than to rely entirely on quality
control procedures. To achieve this assured quality in our delivery of care it is necessary to
define all stages of care and care process and to identify critical points, which if not addressed
correctly have the ability to cause a non-compliance with an outcome of the Regulatory
Framework.
This project to embed quality at a local level currently has two mains aspects:
1. To use an internal compliance unit to constantly assess compliance by the organisation
against the 16 quality outcomes within the Regulatory Framework. This takes the form of
lead nurse assessments of each ward and community team against the outcome. A
report is produced indicating the areas for improvement required. Secondly the
assessments are taken into a meeting with all Service Leads to ensure that they are
managing and following up the areas for improvement identified.
2. The Trust has established a monthly audit against a number of core service provision
points which is entrusted to inpatient ward staff, and is complementary with an ongoing
Productive Ward Development Programme. This approach provides learning at a local
level and is carried out against a time-frame that for control purposes approaches a real
time scenario. This allows for corrective action to be applied quickly, when something is
identified as not being correct, hopefully within the final deadline for the requirement to
be met. The intention is to implement this project in a suitable format to all care teams
during 2010-2011.
Auditing at a local level, by the persons working in that area, is not regarded as ideal in classical
audit approaches. However, it is our judgement that the local learning and the ability to monitor
and control critical points greatly outweighs the perceived disadvantages. The Clinical Audit &
Effectiveness Department will periodically carry out selected assessments to check on
submitted audit results as part of normal quality control check procedures.
To gain a measurement of the patient’s view of service provision two sources of information are
used:
•
Patient Experience Tracking [PET] using electronic and other survey means; and
•
Building a data set based upon Patient Reported Outcome Measures [PROMs].
The survey approach, which relies heavily upon questions relating to dignity, privacy and
respect issues, and PROMs are used as a means of feeding data directly into our Quality
Account.
15
3.2
Monitoring and reporting of quality indicators
The monitoring and reporting of quality indicators takes place in a number of ways depending
upon both the nature and source of the data. Regular reporting of complaints, serious untoward
incidents, audit outcomes and clinical effectiveness initiatives is received by the main clinical
governance group for the Trust [Quality & Clinical Governance Group]. Representation at that
Group is designed to allow for consideration of outcomes, recommendations and action
planning. Issues requiring further support of operational managers can be referred to the Senior
Management Team Meetings.
Other data required for quality reporting not available by the above means is provided by
specifically designed audit and survey work. A number of ongoing projects also provide data for
the Quality Account:
•
The Patient Experience Tracker [PET] Project which has 40 electronic data gathering
units configured to elicit patients views of the care they receive and how it is provided
and to collect Patient Reported Outcome Measures [PROMs]; and
•
A Dignity, Privacy and Respect audit has been set up which uses a two part structured
approach.
3.3
o
Part one is based upon a visit to a ward by a representative of the Clinical Audit
& Effectiveness Department [usually the Service User Audit Assistant] or a
Service User Group representative, who observes the ward in operation over a
two to three hour period, and fills in an observation sheet against a number of
points relevant to dignity, respect and privacy.
o
Part two involves the auditor engaging in discussion with inpatients and recording
their views on a number of pre-determined points.
A summary of our quality overview
Our performance against our own quality targets set for 2009 to 2010.
The Trust has selected nine Core Quality Standards within the three Domains of Quality as a
means of describing its quality performance with regard to safety, patient experience and patient
related outcome measures. These are defined in the table below.
16
Core Quality Standard
2009 to 2010
result
Target %
1. Safety Standard
1.1
1.2
1.3
Current rates of Serious Untoward Incidents
Infection Outbreaks / Attainment of the Hygiene Code
Requirements Cases:
1. MRSA [ all acquired elsewhere]
2. C. Diff.
3. Others
Rates for CPA Seven-Day follow up following discharge
58 Severe
Incidents to end
of Feb
Year on year
reduction
8
0
5
Target is zero
cases
99%
100%
2. Patient Experience Standard
2.1
2.2
2.3
- Outcomes from the Patient Experience Tracker
System
1. Being treated with dignity and respect
2. Being sufficiently involved in discussions about care
3. Given enough information about condition,
treatment and medication
4. Did the range of services offered to you meet needs
5. Rating of the care received
- National Patient Surveys - 2009 Inpatient Survey:
Rating of overall care as excellent/good
Rating from internal survey results [includes results
from after survey time)
-Dignity and Respect Audit:
Overall positive score for being treated with dignity and
respect question set
Overall positive score for communication and
involvement question set
Overall positive score for individual needs question set
Overall positive score for privacy, cleanliness and
hygiene question set
79%
77%
77%
All to be >
70%
77%
78%
59%
>70%
78%
71%
63%
All to be >70%
69%
85%
3. Patient Reported Outcomes Standard
3.1
3.2
3.3
Patients in receipt of Psychological Interventions Statistically reliable improvement based on pre-therapy
and post therapy CORE assessment
Emergency re-admission within 28 days - % satisfaction
levels with care planning and needs, housing,
employment, support groups or further help from care
team
Re-admission within current business year - %
satisfaction levels with care planning and needs,
housing, employment, support groups or further help
from care team
Physical healthcare check carried out on ward
53%
Maintain /
Improve
Figure
42%
Year on Year
Improvement
44%
Year on Year
Improvement
90%
100%
17
3.3.1 Safety
Current rates of Serious Untoward Incidents – Incidents are managed in line with Policy
Guidance, reported with timescale and there is evidence of learning implemented and reviewed
on a monthly basis. In addition further data on suicide rates of those known to services are
compared to the national expected average.
Current rates of Serious Untoward Incidents
SUI Monthly Trend 2009-2010
12
10
10
8
7
6
6
6
6
4
4
4
4
4
2
2
2
Feb-10
Mar-10
2
0
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Serious Untoward Incidents 2009 to 2010 – Monthly Trend (all incidents have been
investigated and are up to date)
18
April 09 - Mar 10
Number of Severe Incidents across the Trust
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
25
16
12
3
1
CAMHS
NLFS
Barnet
Enfield
Haringey
Serious Untoward Incidents 2009 to 2010 – Across Trust
Based on National statistics from the National Confidential Inquiry, one can construct an
estimated figure for the number of suicides that would be expected from the number of service
users in contact with the Trust. As may be seen, our figures are below those that might be
expected on this basis.
Comparison of actual & expected suicides
7
6
5
4
3
2
1
0
Q1 June 09
Q2 Sep 09
Number of suicides
Q3 Dec 09
Q4 Mar 10
Expected suicides
Comparison of actual and expected suicides.
19
Infection Outbreaks/Attainment of the Hygiene Code Requirements
There is on-going audit and attainment with the requirements of the Hygiene Code and all
outbreaks of infection are managed in line with Policy requirements and in a timely manner. As
can be seen from the data, rates of C-difficile and MRSA remain very low for the organisation. In
respect to MRSA these are mainly imported in from situations where the users of our services
have been exposed to acute hospital stays. There have been no reported Trust cases of Cdifficile in the last seven years.
BEH-acquired
MRSA Cumulative Data
(Bacteraemia cases= Nil)
Elsewhere-acquired
Jan- March 2010
Oct-Dec09
Jul-Sept 09
April –June 09
Jan-March 09
Oct - Dec 08
Jul - Sept. 08
Apr - June 08
Jan-March 08
Oct-Dec 07
Jul-Sept 07
Apr - June 07
Jan.-March 07
Oct.-Dec. 06
July-Sept. 06
April-June 06
Jan.-March 06
Oct.-Dec. 05
July-Sept. 05
April –June 05
Jan-March 05
Oct-Dec 04
July-Sept 04
April-June 04
Jan-March 04
Oct-Dec 03
July-Sept 03
May-June 03
7
6
5
4
3
2
1
0
Quarter
Infection control – infection outbreaks trend graph 1
BEH-acquired
Elsewhere-acquired
C.difficile-associated diarrhoea
3
2
1
Infection control – infection outbreaks trend graph 2
20
Jan- March 2010
Oct - Dec 09
July-Sept 09
April –June 09
Jan-March 09
Oct - Dec 08
Jul - Sept. 08
Apr - June 08
Jan-March 08
Oct-Dec 07
Jul-Sept 07
Apr - June 07
Jan.-March 07
Oct.-Dec. 06
July-Sept. 06
April-June 06
Jan.-March 06
Oct.-Dec. 05
July-Sept. 05
April –June 05
Jan-March 05
Oct-Dec 04
July-Sept 04
April-June 04
Jan-March 04
Oct-Dec 03
July-Sept 03
0
Rates for CPA Seven-Day follow up following discharge
There is on-going monitoring and review of the rates of follow-up ensuring attainment of 100%.
Where attainment is not reached action plans are developed and reviewed and a log of lessons
learnt is maintained. The graph below shows good performance for the first three quarters of the
year, with a lower result for the Forensic Services in Quarter 4. However, this last quarter
contains data from January 2010 only, and will be updated as soon as the complete data
becomes available.
Seven day follow up by quarter 2009 to 2010
100
Percentage
90
80
70
60
50
Q1
Q2
Q3
Q4
Seven day follow up
3.3.2 Patient Experience
Outcomes from the Patient Experience Tracker System
Results are analysed and action plans are developed and reviewed where performance is below
70% attainment of satisfaction. Below is the data from the measures to judge performance and
quality from the tracker system against the five key questions set by the Trust, arrived at from
the five worst performing questions from the National Survey, later mentioned. The run rate line
in pink denotes Trust performance outcome and the blue line is the expected performance from
commissioners. The final column chart gives a summary.
21
Patient Experience Tracking - Question 1
Treated with Dignity and Respect
85%
82.00%
80%
80.00%
80.00%
80.00%
79.00%
77.00%
79.00%
77.00%
76.00%
75%
74.00%
70%
68.00%
65%
60%
55%
50%
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Patient Experience Tracking - Question 2
Sufficiently involved in discussions about your care
85%
80%
79.00%
78.00%
78.00%
77.00%
77.00%
75.00%
75%
73.00%
72.00%
73.00%
70%
69.00%
65%
62.00%
60%
55%
50%
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
22
Patient Experience Tracking - Question 3
Given enough information about your condition and treatment / medication
85%
80%
79.00%
77.00%
77.00%
76.00%
75%
74.00%
72.00%
72.00%
74.00%
73.00%
71.00%
70%
69.00%
65%
60%
55%
50%
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Patien Experience Tracking - Question 4
Range of servcies offered met needs
85%
80%
78.00%
77.00%
76.00%
75%
74.00%
77.00%
74.00%
74.00%
72.00%
70%
70.00%
70.00%
70.00%
65%
60%
55%
50%
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
23
Patient Experience Tracking - Question 5
Rate the care you have received
85%
80%
80.00%
78.00%
78.00%
78.00%
76.00%
75%
75.00%
76.00%
74.00%
73.00%
73.00%
71.00%
70%
65%
60%
55%
50%
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Patient Exprience Tracking
Trust Response Average 2009-2010
80%
78%
76%
75%
74%
75%
74%
70%
65%
60%
55%
50%
Being treated with dignity & Being sufficiently involved
respect
in discussions about care
Question 1
Question 2
Given enough information
about condition, treatment
& medication
Range of services offered Rating of the care received
meet needs
Question 3
Benchmark
Question 4
Question 5
Trust average results
24
National Patient Surveys
Each Service Line is to prepare a communication plan with staff, during the survey period, to
ensure best possible results and understanding of the survey. Each Service Line is to develop
an action plan to address specific deficits upon publication and review. Each Service Line and
the Trust as a whole are to achieve year on year improvement in Survey Satisfaction Score.
The graph below summarises the results from the national patient surveys for the last four
years. The figures shown for each year are averages of the positive responses for all the
individual questions. From 2006 to 2008 the survey focussed on community patients, and the
Trust put in place a comprehensive action plan to address what it judged to be poor results from
the 2006 survey. The success of this action planning may be seen in the year on year
improvement for 2007 and 2008. In 2009 the national survey targeted inpatients and yielded
poorer results. The poorer results for inpatient surveys have also been identified by internal
survey work, and a detailed action and improvement plan has been implemented. This
performance improvement planning is closely monitored by clinical governance groups and the
Senior Management Team Meetings. The action plan includes a number of elements:
•
Monthly ward quality assurance audits with local action planning;
•
Productive ward project;
•
Targeted questions used in the patient experience tracking project [Dr. Foster system];
•
Purchase and introduction of a new patient experience tracking system [Meridian] to
complement the present system; and
•
Use of an ongoing dignity and respect audit which is being undertaken with the help of
service user group representatives.
Percentage overall score
National patient survey results
72
70
68
66
64
Community
Community
Community
62
60
58
56
54
Inpatient Year 1
2006
2007
2008
2009
2010
Dignity and Respect Audit
Each Service Line is to action plan and review response to the Dignity and Respect Audit. Each
Service Line is to show year on year improvement to Dignity and Respect Audit. Summary
reports will be written during the year with results shown for inpatient units, and these reports
will be forwarded to clinical governance meetings and directly to the service areas for local
action planning. Outcomes of this work will also be taken to the Patient Experience Advisory
Group for consideration. This group has a membership which includes service user group
representatives.
25
Dignity, Respect & Privacy Audit - 2009 - 2010
Positive
Response
Question
Average
Dignity & Respect
When you are at the ward were you treated with dignity and
respect
71%
Do the staff treat you in a friendly manner
67%
Were staff understanding, caring and supportive
66%
Is your privacy maintained
71%
Do staff attitude make you comfortable in the ward
67%
Are you been called by the name you prefer
86%
71%
Communication & Involvement
Do staff listen carefully to you
Do staff communicate in a way which respects you as an
individual
Do you feel involved in making decision about your care and
treatment
Were you asked if a medical / nursing student could be present
during consultation
66%
69%
54%
55%
Do you feel comfortable if a medical/nursing student present
during your consultation
68%
Has your consultation been interrupted by other member of staff
/calls
59%
Do you feel your personal information is kept confidential
68%
63%
Individual Needs
Do you feel that consideration is given to your individual values,
beliefs and personal relationship
65%
Were you able to express your needs and wants
73%
69%
Privacy, Cleanliness & Hygiene
During your inpatient stay, have you ever had to share a
sleeping area, for example a room or bay, with patients of the
opposite sex?
99%
During your stay do you feel that all your hygiene needs were
met
79%
Are your comments on ward cleanliness taken into account
78%
85%
26
3.3.3 Patient Reported Outcomes
Patients in receipt of Psychological Interventions
This element involves collating patients’ reports on improvements in psychological and social
functioning following a course of psychological treatment. The measure used is the CORE
Assessment Schedule employed in the Psychological Therapies services. The assessment
process uses a form completed by the patient before a course of therapy and a form completed
afterwards, with an outcome measurement derived from a comparison of the responses. The
CORE assessment is presently used in adult services within the Barnet, Enfield and Haringey
Directorates.
Between 1st July 2008 and 31st July 2009 a total 165 Barnet service users completed both the
pre-therapy and the post-therapy Clinical Outcomes for Routine Evaluation measure. Over a
similar time period 26th July 2008 to 27th July 2009 a total of 44 Haringey service users
completed both the pre and post CORE measure.
Of the total of these 209, 111 clients (53%) achieved a statistically reliable improvement in their
mental health as measured by the CORE by the end of their course of therapy. A further 95
showed no statistically reliable change, and scores for three clients indicated a reliable
deterioration.
The only available figure for Clinically Reliable Improvement taken from a small sample of
Mental Health Trusts lies between 50-55%.
Statistically Reliable Change
120
110
100
90
Frequency
80
70
60
50
40
30
20
10
0
111
95
3
Statistically Reliable
Improvement
Statistically Reliable
Deterioration
No statistically reliable change
The following analysis of data relates to information collected and analysed from one service
area of the Trust. The statistics obtained from the outcome measure toolkit are broken up into
four subscales to provide an overview of Statistically Reliable Changes as follows:
•
Subjective Wellbeing;
•
Life Functioning;
•
Problems/Symptoms; and
•
Risk/Harm.
27
Overview of Statistically Reliable Changes on CORE Subscales
136
Problems/Symptoms
Life Functioning
Risk/Harm
Frequency
160
Subjective Well-being
140
120
100
93 93
79
64 68
80
60
26
40
20
8
4
4
82
3
0
Statistically Reliable
Improvement
Statistically Reliable
Deterioration
No Statistically Reliable
Change
Subjective Well-being
93
8
64
Problems/Symptoms
93
4
68
Life Functioning
79
4
82
Risk/Harm
26
3
136
Emergency re-admission within 28 days
Patients report that re-admission is not due to inadequate Care Packages or Interventions,
including any social inclusion needs such as adequate housing, social support and access to
meaningful activity including paid employment. Patients that been readmitted within a period of
28 days from a previous admission were selected and asked to complete a questionnaire with
regard to their previous admission to monitor satisfaction with care planning and assistance with
housing and employment, the facilitation of access to support groups and the receiving of
further help from the care team. An overall average of the responses to these questions is
shown in the figure below. A similar survey was carried out for people who had been admitted to
inpatient care, but not as a readmission as described above. As may be seen the general
satisfaction levels for both groups is very similar.
Overall satisfaction score
Satisfaction with care planning etc.
50%
40%
30%
20%
10%
Emergency readmission within 28
days
General admission
28
The Trust wishes to attain a position where admissions are absolutely necessary and not due to
inadequate discharge Care Packages or Interventions. This indicator will examine the
effectiveness of our aftercare treatment/care plans or indeed whether there have been factors
outside of the control or the organisation such as the lack of appropriate housing or access to
employment or work opportunities.
Physical Healthcare
This element monitors patients’ reporting that their physical health care needs were adequately
assessed. From a sample of patients surveyed on this point, 90% reported that they had
physical health checks carried out whilst they were inpatients. This figure compares favourably
with data shown in the graph below which summarises results from the last two reports from a
six monthly physical healthcare audit. This audit is carried out by the Trust using patient case
records.
Aspects of physical health monitoring
100%
80%
60%
Jun-09
40%
Dec-10
20%
0%
Physical health
check
Six monthly
review
Patients
offered
smoking
cessation
Diet & exercise
offered
29
3.4
Productive Ward Project
This project which began in 2008 is an important contributory element in our drive to build
quality assurance into our care provision.
Productive Ward is a project developed by the National Institute for Innovation and Improvement
to make the most of time and resources resulting in increased time spent on direct patient care.
Productive Ward provides guidance to ward teams in developing quality assurance
measurements and localised service improvement. The project includes input from service
users and carers on the wards and quality measures are displayed in public ward areas to
promote interest and involvement from visitors to the ward.
The project is made up of a series of Process Modules. The first two modules to be
implemented on every ward prepare the groundwork for providing safe and high quality patient
care. Teams are asked to measure and display ward quality data and to develop a system for
monitoring information relating to the patients pathway to discharge. Other modules include
Patient Wellbeing and Therapeutic Interventions, promoting the Trust’s objectives of
implementing the Recovery Approach and access to Psychological Therapies, and Admissions
and Planned Discharge, aiming to reduce inpatient stays and promote discharge planning.
The first wards to implement Productive Ward, Lovell and Thames, have been collecting data on
the impact of the Productive Ward, and have already produced identified improvements, for
example in reduced incidents of violence and unplanned sickness as demonstrated in the figure
below resulting in patients benefiting from a safer ward environment and more reliable staffing
ratio.
Sickness and aggression - aggregated data for two wards
sickness
agression
60
50
40
30
20
10
0
Nov08
Dec08
Jan09
Feb09
Mar09
Apr09
May09
Jun- Jul-09 Aug09
09
Sep09
Oct09
Nov09
Dec09
Jan10
Feb10
30
3.5
Overview of performance against key national priorities
Quality Standard
2009 to 2010
Trust Result
Suicides of people in contact with BEHMHT
15
Expected suicide numbers based
national rates and population statistics
on
-
2009 National inpatient survey
•
•
3.6
Overall rating of care received
Sharing of mixed sex accommodation
National Result
18.3
Threshold for
highest
performing 20%
Trusts score
45%
63%
92%
95%
• Medical tests for physical health whilst
inpatient
83%
91%
Physical health check carried out on
inpatients
90%
100%
How to provide feedback on the Account
The Trust values feedback from it’s service users, carers, the public, it’s stakeholders,
commissioners and prospective members to enhance the quality of services delivered.
If you would like to make any comments on this report or would like to make suggestions
for 2010-2011 you may do so in the following manner:
Email:
communications@beh-mht.nhs.uk
In writing to:
Communications – Quality Account
Barnet, Enfield Haringey Mental Health NHS Trust
Trust Headquarters
Block B2
St Ann’s Hospital, London, N15 3TH
31
3.7
Statements from Local Involvement Networks, Overview and Scrutiny
Committees and Primary Care Trusts
A copy of the draft Quality Account was completed and copies were sent to our partner
organisations; Joint PCT Commissioner, OSC and LINKs on 29th April 2010 with a request that
they provide us with a formal statement on the contents of the Account for publication.
32
Health Overview & Scrutiny Committee
14th June 2010
QUALITY ACCOUNT STATEMENT ON BARNET, ENFIELD AND
HARINGEY MENTAL HEALTH TRUST
The Committee accepts the Trust’s Quality Account and wishes to place on record the following
comments:
•
The Committee urges the Trust to continue to work closely and share learning with
partners and stakeholders on mental and physical health connectedness, including Safer
Neighbourhoods Teams and housing stakeholders.
•
Initiatives around early intervention are strongly supported by the Committee.
•
Whilst acknowledging the improved performance of the Trust, the Committee requests
that trend and benchmarking data be included in all future Accounts in order to allow
stakeholders to ascertain the direction of travel in priority areas, and to quantify levels of
performance.
•
The Committee urges that the issue of MRSA and other hospital acquired infections be
treated as a priority by the Trust. Consideration should be given to including an MRSA
test as part of a healthcare assessment upon admittance.
•
The Trust is asked to focus on avoiding unnecessary bureaucracy where possible.
Jeremy Williams
Acting Overview & Scrutiny Team Leader
Corporate Governance Directorate
London Borough of Barnet, North London Business Park, Oakleigh Road South, London N11 1NP
Tel: 020 8359 2042
Mobile: 07949 753 721
Barnet Online: www.barnet.gov.uk
33
34
35