CONTENTS
Part 1
Contents
Page 2
Glossary
Page 3
Chief executives statements of quality
Page 4 – 6
Part 2
Page 7
Prioritising Quality Improvements
Page 7 - 8
Participation in Clinical Audits
Page 8 – 12
Commissioning for Quality Innovation and
Page 13- 23
Improvement
Care Quality Commission
Page 23 – 24
Data Quality
Page 24 - 25
Privacy & Dignity
Page 25 - 28
Part 3
Page 28
Mortality Rates
Page 28 – 30
Health Care Associated Infections
Page 30 – 32
Venous Thromboembolism
Page 32
Falls
Page 33 – 36
Identifying Deteriorating Patients
Page 36 - 37
Patient Experience
Page 38 – 41
Complaints
Page 42 – 45
Serious Untoward Incidents
Page 46 - 47
Compliance with Stroke Pathway
Page 48 - 49
Smoking During Pregnancy
Page 52 -53
Compliance with NICE
Page 53 - 56
Feedback
Page 57 – 59
Amendments
Page 61
2
GLOSSARY
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A & E ( Accident & Emergency)
APMS (Alternative Provision of Medical Services)
BTS (British Thoracic Society)
CABG(coronary artery bypass graft)
CBSA (Commissioning business Support Agency)
C-Diff (Clostridium Difficile)
CEMACH (Confidential Enquiry into Maternal and Child Health)
CMPD (Case Mix Programme Database)
CQC (Care Quality Commission)
CQR (Clinical Quality Review)
CQUIN (Commission for Quality and Improvement)
DANHO (Data for Head and Neck Oncology)
Dare (Directorate of Audit, Research and Evidence Based Practice)
DVT (Deep Vein Thrombosis)
GTT (Global Trigger Tool)
HCAI (Health Care Associated Infections)
HSMR (Hospital Standardised Mortality Ratio)
ICNARC (Intensive Care National Audit & Research Centre)
MEWS (Modified Early Warning Score)
MINAP (Myocardial Infarction Audit Project)
MRSA (Methicillin-resistant Staphylococcus aureus)
NAPTAD (National Audit of Psychological Therapies for Anxiety and
Depression)
NBOCAP (National Bowel Cancer Audit Programme)
NCEPOD (National Confidential Enquiry into Patient Outcome and Death)
NDA (National Diabetes Audit)
NHFD (National Hip Fracture Database)
NICE (National Institute for Health and Clinical Excellence)
NJR (National Joint Registry)
NLCA (National Lung Cancer Audit)
NNAP (National Neonatal Audit Programme)
NPSA (National Patient Safety Agency)
OPD (Out Patient Department)
PCT (Primary Care Trust)
PE (Pulmonary Embolism)
PROMS (Patient Reported Outcome Measures)
SBAR (Situation, Background, Assessment, Recommendation)
SfBH (Standards for Better Health)
SIRI (Serious Investigations Requiring Investigation)
SUI (Serious Untoward Incident)
TARN (Trauma Audit & Research Network)
VTE (Venous Thromboembolism)
WHO (World Health Organisation)
3
PART 1
CHIEF EXECUTIVE’S STATEMENT OF QUALITY
The George Eliot Hospital NHS Trust is delighted to present their first Quality
Accounts. The production has been a journey that started in April 2008 when the
Trust publically outlined its commitment to improve quality through the
implementation of its five point plan to reduce Hospital Standardised Mortality Rates
(HSMR) by:
•.prevention of infections
•.reduction of potentially harmful events
•.patients being in the right ward with the right skills available
•.cleanliness of the hospital
•.improve coding of patients treatment
The success of the plan is due to the commitment and dedication of staff who have
measured the quality of the service they provide to patients and set improvement
goals. This culminated in their efforts being recognised through a national award for
patient safety by the Nursing Times in November 2009.
We strive to create an open and just culture that values knowing where we are in
terms of the quality of care we provide, learning from events when things go wrong
and rewarding high performing teams who demonstrate continuous improvement. It
is only through being transparent about the quality of care we provide and listening to
feedback from the people we serve that we can ensure continuous improvement of
the services we provide.
Overview
At George Eliot Hospital our mission is to improve the health and wellbeing of our
local communities by providing excellent services to meet their healthcare needs, as
close to home as possible, through innovation and collaboration with professional
health and social care partners.
The George Eliot Hospital NHS Trust is a single site hospital on the outskirts of
Nuneaton, Warwickshire. We provide a range of traditional district general hospital
health services including medical, surgical and maternity care. However, the
hospital’s management and clinical teams are committed to delivering the
Department of Health’s vision to provide care closer to people’s homes and are
currently developing an exciting strategy for the future of the hospital and the way it
provides care to local people.
The Trust was awarded a 5 year ‘Alternative Provision of Medical Services (APMS)’
contract, to deliver a GP led health centre in Camphill from 1st October 2009. The
development of this service has enabled the Trust to deliver our strategy to be the
provider of choice, delivering fully integrated care provision closer to home.
We serve a population of approximately 250,000 from the surrounding areas of
Nuneaton and Bedworth, North Warwickshire, South West Leicestershire and
Northern Coventry and work closely with other hospitals for services like cancer,
pathology and coronary heart disease, amongst others. The hospital also provides
some services such as physiotherapy and occupational therapy in the community.
4
The Trust has achieved notable successes in 2009/10. The Trust won the Patient
Safety category at the Nursing Times awards and gained ‘highly commended’ in the
same category at the Health Service Journal. These recognitions highlight the
innovative ways we are providing and embedding best practice into the everyday
working life at the hospital. We were rated 4 out of a possible 5 for Patient Safety in
the Dr Foster Hospital Guide 2009.
Mortality rates, both standardised and actual have dropped to an all time recorded
low and Hospital Standarised Mortality Rate (HSMR) reduced to below 99 in
2009/10, better than the national benchmark of 100. The reduction in HSMR is a
reflection of improvements in patient care, reduction in healthcare associated
infections (HCAI), and improved patient safety. This is evidenced by a reduction in
the number and severity of falls and the audited data which positively shows the
embedding of systems within the Trust to identity deteriorating patients at an early
stage.
We have strict cleanliness standards and carry out frequently audits of compliance
against these standards. Regular meetings of key managers, senior Nursing staff,
and Doctors, enhances communication of information to all staff. This has ensured
that best practice is maintained and innovation encouraged. As a result the number
of Health Care Associated Infections (HCAI) e.g. C-Diff and MRSA bacteraemia for
2009/10, is at its lowest level since the data was recorded within the Trust.
In 2009/10 the Trust met the majority of national targets including those set for
Cancer treatment and 18 week referral to treatment pathways. The Trust is mindful
that in addition to maintaining and improving the good practice that already exists,
our priorities for 2010/11 must be to improve quality of care in these areas.
We have been registered with the Care Quality Commission (CQC) regulations with
no conditions set.
Our governance structure has undergone a strengthening process over the past
year, with better defined delegation and progression of responsibility and assurance
up to Board Level. Patient Safety, care and experience, is a standing agenda item
and is reported monthly through the Patient Safety Group to the Board of Directors in
the Integrated Performance Report.
The Trust is committed to the importance of internal and external audits. Outcomes
of audits can give assurance that the Trust is following best practice but these also
serve to highlight areas of weaknesses or poor practice. These can then be reviewed
and re-audited when appropriate action has been taken. However, the Trust
acknowledges that there are significant weaknesses in the current system. The Trust
has implemented a system of registration for all audits which is managed by the
DARE Department (Directorate of Audit, Research and Evidence Based Practice)
Staff and Patient survey results have highlighted areas for improvement, particularly
communication across the Trust.
Our aim is to empower our patients and staff to give feedback, whether this is
positive or negative. The Trust wants to encourage a listening culture and to be
proactive rather than reactive in our approach to improving patient care and
experience and staff experience working within the Trust.
A contract has been agreed with North Warwickshire and Hinckley College to deliver
a customer care programme for all front line hospital staff.
5
In the last 6 months we have carried out service reviews in every speciality to ensure
clinical viability and compliance with National Standards and requirements.
To the best of my knowledge the information contained in this Quality Account
is accurate.
Sharon Beamish
Chief Executive
6
PART 2
PRIORITISING QUALITY IMPROVEMENT
How we have prioritised our quality indicators 2010/11
The quality accounts indicators have been selected by the Trust’s Board of Directors
following analysis of the previous year’s performance. These have been chosen
specifically to reflect the Trust’s recognition of the need to prioritise and target
improvements over the next year. These indicators are consistent with the Trust’s
intention to improve what it perceives to be the three most important clinical areas
within the hospital:
1.
2.
3.
Patient safety
Effectiveness of care
Patient experience.
Within each of these areas, the Trust has chosen a series of specific priorities to
demonstrate improvement. Over the next few pages, next to each area, there will be
a summary of the Trust’s position, looking back at the past year (and longer if
applicable) and looking forward to the coming year, stating how the organisation
plans to achieve its targets. The Trust recognises that greater formal public
engagement is required and the Quality Account priorities for 2010/11 are to be
presented and discussed at community borough forums that are taking place across
the county.
PRIORITY 1: PATIENT SAFETY
A. Mortality rates – Standard and actual
B. Healthcare associated infections e.g. C-Diff & MRSA
C. Venous Thromboembolism
D. Patient falls
E. Identification of deteriorating patients
PRIORITY 2: PATIENT EXPERIENCE
A. National & Local Patient survey results
B. Complaints
C. Serious untoward incidents
PRIORITY 3: EFFECTIVENESS OF CARE
A. Compliance with Stroke pathway
B. Smoking during Pregnancy
C. Compliance with NICE guidelines
D. Audit of compliance with NICE Recommendations
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REVIEW OF SERVICES
During 2009/10 the George Eliot Hospital NHS Trust provided and sub-contacted 33
NHS services.
The George Eliot Hospital NHS Trust has reviewed all the data available to them on
the quality of care in 15 of these services.
The income generated by the NHS services reviewed in 2009/10 represents 84% of
the total income generated from the provision of NHS services by the George Eliot
Hospital NHS Trust for the period of 2009/10.
Participation in clinical audits
During 2009/10, 17 national clinical audits and 2 national confidential enquiries
covered NHS services that George Eliot Hospital NHS Trust provides.
During that period George Eliot Hospital NHS Trust participated in approximately
53% national clinical audits and 100% national confidential enquiries of the national
clinical audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that George Eliot
Hospital NHS Trust was eligible to participate in during 2009/10 are as follows:
Type of Audit
Continuous;
all patients
Name of Audit or Confidential Enquiry
NNAP: neonatal care
NDA: National Diabetes Audit
ICNARC CMPD: adult critical care units
NJR: hip and knee replacements
NLCA: lung cancer
NBOCAP: bowel cancer
MINAP (inc ambulance care): AMI & other ACS
Heart Failure Audit
NHFD: hip fracture
National Elective Surgery PROMS: Four operations
National Continence Audit
British Thoracic Society respiratory diseases audit
• BTS Oxygen
• BTS Asthma
• BTS NIV
• BTS Pneumonia
single audit all
patients
Sentinel stroke audit
CEMACH: perinatal mortality
NCEPOD
National Mastectomy and breast reconstruction
National Oesophago-gastric cancer audit
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The national clinical audits and national confidential enquiries that George Eliot
Hospital NHS Trust participated in during 2009/10 are as follows:
Type of Audit
Continuous;
all patients
Single audit all
patients
Single audit all
patients
Name of Audit and Confidential Enquiry
NNAP: neonatal care
ICNARC CMPD: adult critical care units
NJR: hip and knee replacements
NLCA: lung cancer
NBOCAP: bowel cancer
MINAP (inc ambulance care): AMI & other ACS
Heart Failure Audit
NHFD: hip fracture
National Elective Surgery PROMS: Four operations
National Continence Audit
British Thoracic Society respiratory diseases audit
• BTS Oxygen
• BTS Asthma
• BTS NIV
• BTS Pneumonia
Sentinel stroke audit
CEMACH: perinatal mortality
NCEPOD
National Mastectomy and breast reconstruction
National Oesophago-gastric cancer audit
The national clinical audits and national confidential enquiries that George Eliot
Hospital NHS Trust participated in, and for which data collection was completed
during 2009/10, are listed below alongside the number of cases submitted to each
audit or enquiry as a percentage of the number of registered cases required by the
terms of that audit or enquiry.
Type of Audit
Name of Audit and confidential enquiry
Continuous;
all patients
NNAP: neonatal care
ICNARC CMPD: adult critical care units
NJR: hip and knee replacements
NLCA: lung cancer
NBOCAP: bowel cancer
MINAP (inc ambulance care): AMI &
other ACS
9
% of no of
registered cases
required by the
terms of the audit
or enquiry
100%
100%
100%
100%
100%
100%
Single audit all
patients
Single audit all
patients
Heart Failure Audit
NHFD: hip fracture
National Elective Surgery PROMS: Four
operations
National Continence Audit
British Thoracic Society respiratory
diseases audit
• BTS Oxygen
• BTS Asthma
• BTS NIV
• BTS Pneumonia
Sentinel stroke audit
CEMACH: perinatal mortality
NCEPOD
National Mastectomy and breast
reconstruction
National Oesophago-gastric cancer
audit
80%
100%
84.8%
Every two years
100%
100%
100%
100%
The reports of 9 national clinical audits were reviewed by the provider in 2009/10 and
George Eliot Hospital NHS Trust intends to take the following actions to improve the
quality of healthcare provided;
Audit or Confidential
Enquiry
NNAP Neonatal Care
Actions planned or taken
Improve neonatal transfer
arrangements
ICNARC CMPD: adult
critical care units
CEMACH: perinatal
mortality
report awaited. Action plan to be
developed.
Improve awareness of perinatal
Risk – specific focus on
gestational diabetes and patient
education.
NLCA: lung cancer
MDT strengthened and a more
defined care pathway
developed. More efficient in
relation to radiology and
imaging.
NJR: hip and knee
Hip and knee pathways defined
replacements
and all joint replacements
registered.
MINAP (inc ambulance Coronary care unit care pathway
care): AMI & other ACS now published with specific
patient information programmes
10
Progress
Action completed
ongoing
completed
completed
completed
completed
NHFD: hip fracture
developed by specialist nurses
Hip fracture pathway
implemented including
osteoporosis screening now in
place.
Completed
National Elective
Surgery PROMS: Four
operations
National Continence
Audit
Participating rate last April –
October 84.8% (national
average 48.2%).
Awaiting national report- data
submitted
To increase participation
rates for varicose veins
and groin hernias.
Completed
Sentinel stroke audit
Actions implemented following
participation in 2008.
Data to be submitted 2010
National Mastectomy
and breast
reconstruction
National Oesophagogastric cancer audit
Single Audit
Single Audit
The Trust does not participate in the following audits due to the fact that we do not
provide these services within the Trust.
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Congenital heart disease : paediatric cardiac surgery
Renal registry: renal replacement therapy
DAHNO: head and neck cancer
Adult cardiac surgery: CABG and valvular surgery
Pulmonary hypertension audit
NAPTAD: anxiety and depression
TARN: severe trauma
NHS Blood and transplant: intra-thoracic liver and renal transplants
NHS blood and transplant: potential donor audit
Adult cardiac interventions
Audits where we do provide the service but have not participated in the audit.
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NDA and National Diabetes Audit – data collected but not submitted
National dementia care (registered to participate 2010-11)
National falls and bone health audit (registered to participate 2010-11)
National kidney care audit
College of emergency medicine: pain in children: asthma, fracture
National Comparative audit of Blood Transfusions.
Action plans in place to ensure future participation
11
Local Clinical Audits
The reports of 17 local clinical audits were reviewed by the provider in 2009/10 and
George Eliot Hospital NHS Trust intends to take the following actions to improve the
quality of healthcare provided
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Increase provision of guidelines on Trust intranet
Collection of adverse medication error data for teaching
Improve emergency way pathways for sepsis, pneumonia, coronary care and
emergency assessment.
Increase awareness of hospital infection control
Improve implementation of NICE guidance in the Trust
Improve VTE (Venous Thromboembolism) treatment and education
Improve provision of WHO (World Health Organisation) Surgical checklist
Improve treatment of high glucose patients
Participation in clinical research
The number of patients receiving NHS services provided or sub-contracted by
George Eliot Hospital NHS Trust in 2009/10 that were recruited during that period to
participate in research approved by a research ethics committee was 430.
This increasing level of participation in clinical research demonstrates George Eliot
Hospital NHS Trust commitment to improving the quality of care we offer and to
making our contribution to wider health improvement.
George Eliot Hospital NHS Trust was involved in conducting 11 clinical research
studies. George Eliot Hospital NHS Trust completed 70% of these studies as
designed within the agreed time and to the agreed recruitment target.
George Eliot Hospital NHS Trust used National systems to manage the studies in
proportion to risk. Of the 15 studies given permission to start 100% were given
permission by an authorised person less than 30 days from receipt of a valid
complete application.
100% of the studies were established and managed under National model
agreements and 100% of the two eligible researchers involved used a research
passport.
On 2010 reporting period the National Institute for health Research (NIHR) supported
5 of these studies through its research network.
12
Commissioning for Quality Innovation and Improvement (CQUIN)
Goals agreed with commissioners
Use of the CQUIN payment framework:
• A proportion of The George Eliot Hospital NHS Trust income in
2009/10 was conditional on achieving quality improvement and
innovation goals agreed between The George Eliot Hospital NHS Trust
and Warwickshire PCT through the Commissioning for Quality and
Innovation payment framework.
• Further details of the agreed goals for 2009/10 and for the following 12
month period are available on request from The Commissioning
Department, George Eliot Hospital NHS Trust.
CQUIN PERFORMANCE INCENTIVE SCHEMES
Ref
Indicator
6a
1. All inpatients to have a discharge plan
including:
• Estimated date of discharge
within 2 days of admission
• Evidence that discussed with the
patient and family
2. Appropriate discharge planning
demonstrates reduction in
readmission and excess bed days.
90% of patients ready to leave hospital
will have the necessary
documentation/information within 4 hours
of the decision to discharge ie GP Letter,
patient information, medication, transport
arrangements & follow-up appointments
in hospital and/or community
25% of all patients are surveyed on their
experiences by year end resulting in
demonstrable change
All pregnant women, who smoke, are
encouraged to quit or reduce intake:
• 100% record of smoking history
taken, and smoking advice given
at booking
• Record of patient
accepting/refusal to smoking
cessation services
• Referral to smoking cessation
services
6b
6c
6d
Quality
Domain
Safety
Experience
Indicator Type
Effective discharge
planning aims to:
Reduce the length of stay,
Decrease excess bed days
Reduce readmission rates
and
Improved user experience.
Process
Outcome
Improved patient
experience through timely
and comprehensive
discharge arrangements
Weighting
30%
20%
Process
Experience
Effectivenes
s
Patient Survey
Process
Outcome
Reduction in the women
who smoke, or a reduction
in the frequency/amount of
smoking during pregnancy
in order to improve the
baby’s safety during
gestation and postnatal
period, as a result of
referral processes
Process
100% of smokers who are willing are
referred on to smoking cessation
services:
• Demonstrate increases in
13
20%
15%
6e
referrals to the smoking cessation
service
Development and implementation of a
Dementia Pathway for the acute elements
of the pathway in partnership with all key
stakeholders including:
• Participation in all aspects of the
pathway development
• Co-operation and joint working with
stakeholders
• Implementation of the acute aspects
of the pathway
Innovation
Develop and implement in
partnership with key
stakeholders a Dementia
Pathway
15%
Process
Outcome
Detailed Indicator Form – Discharge Planning
Indicator ref
Indicator name
Quality domain
Indicator type
Weighting
Indicator definition
Numerator
Denominator
Rationale for inclusion
Data source
Organisation responsible for data
collection
Frequency of collection/reporting
6a
Effective Discharge Planning
Effective discharge planning resulting in a reduction in the length
of stay, excess bed days and readmission rates and also
improved user experience.
Safety
30%
1. All inpatients to have a discharge plan including:
• Estimated date of discharge within 2 days of admission
• Evidence that discussed with the patient and family
2. Appropriate discharge planning demonstrates reduction in
readmission and excess bed days.
1. 90% of inpatients with an estimated discharge date within
2 days of admission.
2. Audit against the care plan of evidence discharge
discussed with family & patient in 90% of cases
3. Audit demonstrating 90% assessments for completion
has met agreed standards reporting exceptions and
reasons
4. By exception written evidence to demonstrate joint
working to resolve barriers and blockages to discharge.
5. Number of readmissions month on month
6. Number of excess bed days by ward
Number of elective and non-elective inpatients (excluding day
cases, maternity & deaths) discharged per month
To improve discharge planning arrangements, with the aim to
reduce length of stay, reduce excess bed days, reduce number of
inappropriate readmissions to hospital
Numerator – provider internal audits against patient records,
activity data and written documentation to demonstrate joint
working (to be developed and agreed)
Denominator - CBSA
• Acute trust to provide information against above numerator
• Contract monitoring information from CBSA for excess bed
days and readmission rates
Collected monthly and reported quarterly to the Clinical Quality
Review Group
14
Baseline period / date
Baseline information for Discharge plan will need to be developed
during first 6 months 09/10
Baseline value (incl 95% CIs)
Final Goal Value for this CQUIN = 30% of tbc =
By end of Quarter 4
Part 1 Discharge Plan (100% of CQUIN 1 value):
Final goal value
90% of all inpatients through 09/10 have a discharge plan. A
reduction in payment of 0.9% will be made for every 1%
underachieved
Part 2 Demonstrate appropriate discharge planning reduces
readmission and excess bed days (data collected but no financial
consequences)
Final goal period / date
Final goal reporting date
End of financial year value
if goal not set for end of financial year
End of financial year reporting date
2009/2010
April 2010
tbc
31 March 2010
Assessment of goal achievement for
indicators with substantial inherent
variability
Inherent variability unlikely.
1% variation accounted for in numerator standard 7 to allow for
bed capacity difficulties.)
Rules for partial achievement of
indicator goal
To agree a sliding scale within the first year but 95% achievement
will be required in subsequent years any exceptions will need to
demonstrate continual improvement and learning.
In-year milestone 1
• Gather baseline information for
monitoring documented discharge
date
• Evidence of raising awareness and
implementation plan to achieve the
scheme
• Establish an agreed process for
monitoring compliance
• Define and agree weighting for
achievement and consequence of
breach
In-year milestone 2
• Q3 – 75% compliance (within Q3)
(95% numerator 7).
• Q4 – 95% compliance (within Q4)
(99% numerator 7).
Value
Period / date
Reporting date
To be agreed
April 09 – Sept 09
Monthly update at CQR
To be agreed
Oct 09 – March 10
Monthly update at CQR
15
Detailed Indicator Form – Effective Discharge
Indicator ref
Indicator name
Quality domain
Indicator type
Weighting
Indicator definition
Numerator
Denominator
Rationale for inclusion
Data source
Organisation responsible for data
collection
Frequency of collection/reporting
Baseline period / date
6b
Communication and patient information to support effective
discharge
Improved patient experience through timely and comprehensive
discharge arrangements
Experience
20%
Complete and timely information is available to patients within
agreed timescales prior to discharge.
90% of patients ready to leave hospital will have the necessary
documentation/information within 4 hours of the decision to
discharge ie GP Letter, patient information, medication, transport
arrangements & follow-up appointments in hospital and/or
community
(monthly audit of 2 high turnover wards, one surgical and one
medical)
Number of elective and non-elective inpatients (excluding day
cases, maternity) discharged per month from the identified wards
To improve patient experience when being discharged from
hospital resulting in more effective and safe discharges
Numerator – provider internal audits against patient records (to be
developed and agreed)
Denominator – provider audit
Data collected by provider and quarterly reported to CQR.
Acute trust to provide information against above numerator
Collected snapshot audits monthly and reported quarterly to the
Clinical Quality Review Group
Baseline information to be developed during first 6 months 09/10
Baseline value (incl 95% CIs)
Final Goal Value for this CQUIN = 20% of tbc =
Final goal value
Quarter 3 – 70% of patients have appropriate discharge
information
Quarter 4 - 90% of patients have appropriate discharge
information
Sliding scale for compliance starting at 50% rising to 90%
50% is 50% CQUIN 6b value rising by each % value for each %
achieved, up to 90% achievement when 100% of CQUIN value is
achieved
Less than 50% results in 0% CQUIN value
Final goal period / date
Final goal reporting date
End of financial year value
if goal not set for end of financial year
End of financial year reporting date
2009-10
April 2010
tbc
16
Assessment of goal achievement for
indicators with substantial inherent
variability
Rules for partial achievement of
indicator goal
31 March 2010
Inherent variability unlikely
To agree a sliding scale within the first year but 100%
achievement will be required in subsequent years any exceptions
will need to demonstrate continual improvement and learning.
In-year milestone 1
• Gather baseline information for
monitoring
• Evidence of raising awareness and
implementation plan to achieve the
scheme
• Establish an agreed process for
monitoring compliance
• Define and agree weighting for
achievement and consequence of
breach
In-year milestone 2
• Q3 – 70% compliance (within Q3)
• Q4 – 90% compliance (within Q4)
Value
Period / date
Reporting date
To be agreed
April 09 – Sept 09
Monthly update at
CQR
To be agreed
Oct 09 – March 10
Monthly update at
CQR
In-year milestone 3
Detailed Indicator Form – Patient Experience
Indicator ref
Indicator name
Quality domain
Indicator type
Weighting
6c
Improved patient experience through patient survey
To improve patient experience when under the care of the Acute
Trust resulting in more effective, safe, care and high quality
patient experience.
Experience
17
Indicator definition
Numerator
Denominator
Rationale for inclusion
Data source
Organisation responsible for data
collection
Frequency of collection/reporting
Baseline period / date
20%
25% of in patients are surveyed by year end resulting in
demonstrable change. A proportion/number of other attendees
(eg OPD, A&E) may also be surveyed (numbers to be agreed).
Self completion patient surveys:
• Surveys of patients undertaken in all areas.
• Survey results and recommendations documented and
discussed with ward/area team.
• Survey results communicated to appropriate committees.
• Actions from surveys carried out.
25% patients will have a survey or local equivalent in each
specialty.
Recommendations and action plan to be developed and
monitored following survey discussion at team meeting.
Total number of survey respondents and response rate.
To improve patient experience when admitted/attending the
hospital resulting in more effective, safe care and high quality
patient experience.
Numerator – provider internal surveys against specific criteria (to
be developed and agreed)
Denominator – provider inpatient statistics
CQC - inpatient survey.
PROMS.
National Surveys.
Local Surveys.
Trust – Numbers, action plans and themes.
Acute trust to provide information against above numerator
Collected once for each specialty in year, one speciality to be
reported quarterly to the Clinical Quality Review Group
Observation tool to be agreed with the PCT in first quarter prior to
commencement
Baseline value (incl 95% CIs)
Final Goal Value for this CQUIN = 20% of tbc =
By Quarter 4 – 25% of patients surveyed and action plan agreed
Final goal value
Final goal period / date
Final goal reporting date
End of financial year value
if goal not set for end of financial year
End of financial year reporting date
Assessment of goal achievement for
indicators with substantial inherent
variability
Between 20% to 24% of patients surveyed, results in 50% of total
CQUIN value
25% of patients surveyed results in 100% of CQUIN 6c value
Below 20% results in 0% of CQUIN 6c value
2009/10
April 2010
tbc
31 March 2010
Reporting variability unlikely.
Outcome ie >1 identification of unsatisfactory interaction may
result. Assessing achievement of the goal will be linked to an
agreed action plan and non re-occurrence (if necessary further
observational exercises on that ward to demonstrate non reoccurrence.)
18
Rules for partial achievement of
indicator goal
In-year milestone 1
• Actions for any surveys in
quarter 4 may not be carried
out by end of quarter 4
To be achieved in year. Any exceptions will need to demonstrate
continual improvement and learning.
Value
Period / date
Reporting date
To be agreed
April 2010
Monthly update at CQR
Detailed Indicator Form – Smoking in Pregnancy
Indicator ref
Indicator name
Quality domain
Indicator type
Weighting
Indicator definition
6d
Reduction in Smoking During Pregnancy
Reduction in the women who smoke, or a reduction in the
frequency/amount of smoking during pregnancy in order to
improve the baby’s safety during gestation and postnatal period,
as a result of referral processes.
Effectiveness
15%
All pregnant women, who smoke, are encouraged to quit or
reduce intake:
• 100% record of smoking history taken, and smoking
advice given at booking
• Record of patient accepting/refusal to smoking cessation
services
• Referral to smoking cessation services
100% of smokers who are willing are referred on to smoking
cessation services
Demonstrate increases in referrals to the smoking cessation
service
Numerator
Denominator
Rationale for inclusion
Data source
100% of all recording of smoking status.
100% of smokers given smoking advice.
100% of smokers offered smoking cessation services.
100% of smokers who are willing are referred on to smoking
cessation services.
Number of maternity bookings per month (excluding DNAs)
To improve information and advice in order to encourage
attendance at smoking cessation services, with a view to reducing
prevalence of smoking in pregnancy.
Numerator – provider internal audits against patient records and
% of people referred onto smoking cessation services
Denominator – provider database (eg evolution or similar)
19
Organisation responsible for data
collection
Acute trust to provide information against above numerator
Data collected by provider and quarterly reported to CQR.
Collected monthly and reported quarterly to the Clinical Quality
Review Group
Baseline information for smoking cessation will need to be
developed during first 3 months 09/10
Frequency of collection/reporting
Baseline period / date
Baseline value (incl 95% CIs)
Final Goal Value for this CQUIN = 30% of tbc =
100% Recording of data (50% of this CQUIN value)
100% Referral of willing participants (50% of this CQUIN Value)
Final goal value
If 80% or less are referred this results in 50% less of this CQUIN
value.
Sliding scale starts at 50% of CQUIN paid for 80% of referrals
Final goal period / date
Quarter ending March 2010
Final goal reporting date
End of financial year value
if goal not set for end of financial year
End of financial year reporting date
Assessment of goal achievement for
indicators with substantial inherent
variability
Rules for partial achievement of
indicator goal
In-year milestone 1
• Gather baseline information
for monitoring
• Establish an agreed process
for monitoring compliance
• Define and agree weighting
for achievement and
consequence of breach
April 2010
tbc
31 March 2010
Inherent variability unlikely
To agree a sliding scale within the first year but 95%
achievement.
Value
Period / date
Reporting date
To be agreed
April 09 – Sept 09
Monthly update at CQR
Detailed Indicator Form – Dementia Pathway
Indicator ref
Indicator name
Quality domain
Indicator type
6e
Dementia Pathway
Develop and implement in partnership with key stakeholders a
Dementia Pathway
Innovation
20
Weighting
Indicator definition
Numerator
Denominator
Rationale for inclusion
Data source
Organisation responsible for data
collection
15%
Development and implementation of a Dementia Pathway, for the
acute elements of the pathway in partnership with all key
stakeholders including:
• Participation in all aspects of the pathway development
• Co-operation and joint working with stakeholders
• Development of a documented, agreed, pathway and action
plan for implementation
• Demonstrate patients with dementia, in the Trust, are
following the pathway, and care is given according to the
pathway (threshold to be agreed)
• Dementia awareness training commissioned and commenced
as part of the pathway development – to be implemented year
2.
Development of a documented, agreed, pathway and action plan
for implementation
st
• 1 draft of pathway developed
• Pilot of pathway
• Revisions to pathway agreed
• Further testing of pathway
Demonstrate 90% of patients with dementia are following the
pathway, and care is given according to the pathway
50% of clinical staff trained in Dementia awareness
Pathway developed
Number of patients with Dementia, and Numbers receiving care
following the pathway (on all wards and A&E)
Number of clinical staff in Trust
To improve dementia patients’ experience by ensuring that safe
and effective care is given, communication channels are clear,
and cross boundary working is achieved.
Implementation of the national Dementia strategy within Coventry
and Warwickshire.
(This is also aligned to our partner PCT’s [NHS Coventry’s] world
class commissioning project for Dementia, developing a multidisciplinary pathway for Dementia patients.)
Pathway documentation
Provider internal audits against care plan (to be developed and
agreed)
Acute trust to provide information against above numerator
•
•
•
•
Frequency of collection/reporting
Baseline period / date
st
1 draft of pathway developed – September 2009
Pilot of pathway – October 2009 – January 2010
Revisions to pathway agreed – January 2010 – February
2010
Further testing of pathway – March 2010 onwards
Pathway report to the Clinical Quality Review Group
Summary report of progress of development of pathway quarterly
to the Clinical Quality Review Group
Pilot audit data of implementing of the pathway during quarter 3,
st
1 pilot testing during quarter 4
Further testing from Quarter 1 2010/2011
Pathway to be developed during first 9 months 09/10
Baseline information to be developed during first 9 months 09/10
Baseline value (incl 95% CIs)
Final goal value
Final Goal Value for this CQUIN = 15% of tbc =
21
Quarter 2 end – Completed pilot pathway developed (100%)
Quarter 4 end - 50% implementation of pathway (allowing for
piloting and amending with a view to 100% implementation from
2010/2011).
st
Quarter 4 – 50% of clinical staff (in post as at 1 February 2009)
st
have had training by 31 March 2009 (excluding leavers, those on
maternity leave, long-term sick, secondment or sabbatical, or
PCT/SS/PFI staff working for the Trust)
Failure to achieve pathway development is 50% of CQUIN value.
Failure to pilot test pathway is 50% of CQUIN value.
Final goal period / date
Final goal reporting date
End of financial year value
if goal not set for end of financial
year
End of financial year reporting
date
Assessment of goal achievement
for indicators with substantial
inherent variability
Rules for partial achievement of
indicator goal
Quarter ending March 2010
April 2010
tbc
31 March 2010
Full participation in the development process expected.
Implementation threshold agreed at 50% for year end, in order to
allow for piloting. Further negation for 100% may be required for
subsequent years.
Threshold for training accounting for staff on leave etc.
To agree a sliding scale within the first year but 100%
achievement will be required in subsequent years any exceptions
will need to demonstrate continual improvement and learning.
In-year milestone 1
• Negotiate and plan for pathway development
• Evidence of implementation of the pathway
• Establish an agreed process for monitoring
compliance
• Define and agree weighting for achievement
and consequence of breach
In-year milestone 2
• Q4 – 50% compliance for implementation
training (within Q4)
Value
Period / date
Reporti
ng date
To be agreed
April 09 – Sept 09
Monthly
update
at CQR
To be agreed
Oct 09 – March 10
CARE QUALITY COMMISSION (CQC)
George Eliot NHS Trust Hospital is required to be registered with the Care Quality
Commission. The George Eliot NHS Hospital Trust’s current registration status is as
of 31st March 2010 that it is registered without qualifications or improvement notices.
The Trust is registered to carry out regulated activities at George Eliot NHS Hospital,
Eliot Way, Nuneaton CV10 7DJ and at Camphill GP led Health Centre, Ramesden
Avenue, Nuneaton CV10 9EB as shown:
Regulated Activity
Location
Treatment of disease, disorder or injury
George Eliot Hospital &
22
Monthly
update
at CQR
Camphill GP led Health Centre
Assessment or medical treatment for persons
detained under the Mental Health Act 1983
George Eliot Hospital
Surgical procedures
George Eliot Hospital &
Camphill GP led Health Centre
Diagnostic & screening procedures
George Eliot Hospital &
Camphill GP led Health Centre
Maternity and midwifery services
George Eliot Hospital
Termination of pregnancies
George Eliot Hospital.
The Care Quality Commission has not taken enforcement action against George Eliot
NHS Hospital Trust during 2009/2010.
George Eliot NHS Hospital Trust was subject to periodic reviews by the Care Quality
Commission and the last review was on 9th June 2009. The CQC’s assessment
following that review was that the George Eliot Hospital NHS Trust had not provided
sufficient evidence to support a declaration of compliance for the full year (2008/09)
with Standard for Better Heath C04b – Safe use of medical devices.
The CQC’s assessment was that there was inadequate evidence to demonstrate
reasonable assurance that the training in the use of medical devices provided to staff
was reviewed and audited; and there was limited audit activity evidence to
demonstrate that single use items are not reused.
As a result of this feedback The George Eliot NHS Hospital Trust, has taken the
following action by introducing training evaluation forms in relation to training in the
use of medical devices and developing a data-base is being developed that will
improve the management and delivery of that training. Further development work will
continue into 2010/11. In addition, the terms of reference of the Trusts’ Medical
Devices Management Group have been revised to include monitoring of compliance
with Standards for better health (SfBH) C04b (now CQC registration standard:
Outcome 11); and existing audit tools have been modified to ensure that single-use
devices are not reused. The George Eliot Hospital NHS Trust completed all the
above actions by the 31st March 2010.
Hygiene Code
On 25th November 2009, the CQC provided a report from an assessment which took
place on 4th November 2009 of the Trust’s compliance with the Code of Practice on
Healthcare Acquired Infections. The CQC found no evidence that the Trust had
breached the regulation to protect patients, workers and others from the risks of
acquiring a healthcare-associated infection.
23
George Eliot NHS Hospital Trust has not participated in any special reviews by the
Care Quality Commission during 2009/10.
DATA QUALITY
George Eliot Hospital NHS Trust submitted records during 09/10 to the secondary
uses service for inclusion in the hospital episodes statistics which are included in the
latest published data. The percentage of the published data which include the
patient’s valid NHS number was:
•
•
•
99.6% for admitted patient care
99.5% for outpatient care
98.6% for accident and emergency care
INFORMATION GOVERNANCE TOOLKIT.
George Eliot Hospital NHS Trust score for 09/10 for information quality and records
management assessed using the information governance toolkit was:
•
84.0 %
CLINICAL CODING ERRORS
George Eliot Hospital NHS Trust was subject to the payment by results clinical
coding audit during the reporting period 09/10 by the Audit Commission and the error
rates reported in the latest published audit for that period for the diagnosis and
treatment coding were:
•
•
•
•
primary diagnosis incorrect 31.0%
secondary diagnosis incorrect 31.7%
primary procedures incorrect 15.1%
secondary procedures incorrect 22.0%
This is below the standard expected and the Trust is taking steps to improve
coding in 2010/2011.
PRIVACY & DIGNITY
Treating individuals with dignity and respect are core values of the NHS and as such
are fundamental principles of care. It is everyone’s responsibility to ensure that
standards of privacy are maintained and that dignity in care is preserved.
Whilst there are many opportunities to promote dignity there are also challenges to
overcome. Embedding dignity and respect at every level of the organisation is
essential and should not been viewed as the sole the responsibility of any one group
of staff. This second audit provides evidence that actions are being taken to improve
standards of privacy and dignity.
24
The Essence of Care benchmark audit provides useful insight into issues that impact
on the ability to provide dignified care. The findings can be cross referenced with
other important sources of information e.g. national patient surveys, staff surveys and
complaints in which everyone has a part to play.
The 7 factors included in the Essence of Care Privacy and Dignity audit examine the
following areas:
•
•
•
•
•
•
•
Attitudes and Behaviours
Personal World and Personal Identity
Personal Boundaries and Space
Communicating with Staff & Patients
Confidentiality of Client Information
Privacy, Dignity & Modesty
Availability of an Area for Complete Privacy
Privacy & Dignity Comparison April 2009 & 2010
120%
100%
80%
60%
40%
20%
0%
09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10 09 10
A&E / Adam Alex
SAU Bede
Bob Caterina CCU
Dolly
DPU
Eliz
EMU
Felix
ITU
Mary Melly Nason
Garth
OPD OPD D
Vic
Total 62 92 93 100 80 93 93 98 97 100 93 100 97 100 88 100 95 95 93 97 98 97 100 97 90 100 94 100 87 98 97 100 91 100 86 89
Themes identified in the audit
The themes identified in the audits fall into three broad categories:
• People relating to factors 1, 2, 3 and 4 i.e. behaviours, attitudes
• Places relating to factors 3 ,6 and 7 i.e. physical environments,
organisational culture
25
•
Processes relating to factors 4, 5, 6 and 7 i.e. care giving activities
Analysis of the results has identified some common themes also identified in
February’s audit of communication. The need to promote good communications
between staff, patients and carers to ensure that care is personalised and that
personal choice is supported with clear information is a challenge that needs to be
addressed consistently across all staff and professional groups.
People
At the time of last years audit the Privacy and Dignity policy had still to be approved.
However, this has been available since October 2009 and is available on the
SharePoint web site. Staff are frequently reminded to refer to the policy and check
their performance against its content.
The use of interpreters and the need to maintain patient confidentiality was raised as
a potential area of concern for some areas. In general staff do identify when
interpreters are needed outside of using family members but are sometimes unclear
how to access services outside of normal working hours.
The Champions for Older People Study day focuses on individualised care and the
promotion of dignity. The Royal College of Nursing Defending Dignity resource
materials provide the framework to enable staff to think about the topic in relation to
their roles and identify where small changes can make a big impact on patient
satisfaction.
The way forward
Work towards completion of the delivering same sex accommodation programme
within the Trust is an important step forward to improving care environments.
Arrangements for the identification of single gender washing and toilet facilities were
implemented last year and measures to be taken this year involves a dedicated
estates improvement plan.
Protecting the privacy of patients behind curtains is a perennial challenge for staff not
only in terms of stopping interruptions and removing the risk of exposing patients
whilst care is in progress but also terms of maintaining patient confidentiality. A ward
culture which respects that drawn curtains signify the need to maintain privacy is by
far the most effective means of ensuring that staff uphold the patient’s privacy and
dignity. The issue of confidentiality and begin able to carry out sensitive discussions
in ward areas behind closed curtains is more problematic.
The limitations of physical ward environments in relation to having accessible quiet
areas for breaking bad news requires thought and planning to overcome. Ward
offices are normally multifunctional and used by lots of people, avoiding interruptions
is within the gift of the nurse in charge to deliver. Ward managers are required to
look creatively at their areas to identify solutions where possible.
As identified in last months Hygiene audit, by encouraging the use of bathroom and
shower facilities to promote independence and self care, privacy and dignity is also
maintained. Promoting patient centred care and assisting patients to access these
26
facilities routinely for washing and toileting rather than at the bedside is a leadership
responsibility for qualified nurses. In view of the environmental work which is about to
begin on ward bathrooms and shower rooms it is vital that staff and patients are
involved in looking at accessibility, safety and privacy.
INITIATIVES 2010/11
INITIATIVE
Promote privacy
whilst carrying out
caring duties to
protect patients
dignity when using
washing and toilet
facilities
To carry out
environmental
assessments of
washing and toileting
facilities to look at
privacy and dignity,
accessibility and
safety
Encourage patients
to wear day clothes
where appropriate
Encourage staff to
become Dignity
Champions and rise
to the Dignity
Challenge
Review environments
to identify how
private spaces can
be created to support
patients and carers
when sensitive or
difficult conversations
need to take place
without being
overheard
ACTION
OWNER
DATE
Privacy & dignity
essence of care audit
first completed in
April 2010. The first
re-audit is due in July
2010 and then
October 2010
As above
Ward managers
Review by end of
July 2010
Ward managers
Matrons
Review by end of
July 2010
Ward managers
Review at the end of
July 2010
Matron for older
people
October 2010
Nursing staff to
identify suitable
patients and invite
them to wear day
clothes if appropriate
and relatives / carers
are able to provide
and launder extra
clothing throughout
the patients stay
Bi monthly
Champions study
days scheduled for
2010/11 dealing with
the core elements of
the Dignity
Challenge.
Champions for Older
People Link meetings
scheduled on a
monthly basis.
Minutes and
progress against
projects circulated.
Second evaluation
report due October
2010
Ward office spaces
to be included in
local ward actions
which need to be put
into place on an
individual case : case
basis as situations
arise.
Ward managers
27
PART 3
PRIORITY 1: PATIENT SAFETY
1A - MORTALITY RATES
The rationale
The Hospital Standardised Mortality Rate (HSMR) is an indicator of healthcare
quality that measures whether the death rate at a hospital is higher or lower than you
would expect. The national benchmark is 100 and all Trust’s aim to keep their rate as
low as possible.
Current status
The Trust’s HSMR for 2009/10 was 98.6 which is below the Nation benchmark of
100.
The Chart below shows hospital deaths rates against the National target.
Aim
Reduce the Trust’s HSMR to below 90 by March 2011.
Areas for improvement
•.Improvements to rates of Health Care Associated Infections(HCAIs) (see priority B),
• Increase in Venous Thromboembolism (VTE) risk assessments, (see priority C)
• Reduction in patient falls, (see priority D)
28
• Improvement in the identification of deteriorating patients (see priority E).
•.Improvements in patient coding.
Initiatives in 2009/10
•.Monitoring of standardised mortality rates by consultant and specialty.
• Auditing of notes using the Global Trigger Tool (GTT) and 3 x 2 matrix
•.Investigation of Dr. .Foster alerts.
•.Involvement of NHS Warwickshire in mortality meetings.
Initiatives for 2010/11
Initiative
Introduction of early
warning electronic
detection software.
Training of additional
staff on the use of
the GTT a tool used
to identify adverse
events in patient care
from the patients
notes.
Action
Trial commencing in
September 2010 on
emergency
assessment unit.
Wireless network
upgrade to be
undertaken to
support technology.
Identify individuals to
undertake further
training.
Identify training.
Owner
Associate Medical
Director
Date
September 2010
September 2010
Director of Nursing
and Associate
Medical Director
March 2011
Completed June
2010
Staff identified and
training undertaken.
1B - HEALTH CARE ASSOCIATE INFECTIONS
The rationale
Health Care Associated Infections (HCAIs) are infections acquired in hospitals or as
a result of health care interventions. The Trust has a zero tolerance policy in relation
to HCAIs and works tirelessly to eliminate this.
Current status
In 2009/10 the Trust had five cases of MRSA and 79 of Clostridium Difficile.
The Trust also met its hygiene code target for 2009/10.
Aim
• To achieve the MRSA objective figure for 2010/11 of 2 or less post 48 hour
MRSA Bacteraemia cases.
• To achieve the local stretch objective for 2010/11 of 46 or less post 48 hours
Clostridium difficile Infection (CDI) cases
Cumulative C diff graph 2009/10
29
Cumulative C.diff graph 2009-10
120
100
N
um
b
erofcases
80
60
40
20
0
Apr09
May- Jun09
09
Jul09
Aug- Sep09
09
Oct09
Nov09
Dec09
Jan10
Feb10
Mar10
Month
Cumulative C.difficile figures
SHA Target cumulative
Internal stretch target cumulative
Cumulative MRSA graph 2009/10
Cumulative MRSA bacteraemia rates 2009/10
12
11
10
No. of cases
9
8
7
6
5
4
3
2
1
0
April
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
Cumulative MRSA Bacteraemia cases
Areas for improvement
•.Further reduction in incidence of HCAIs.
•.Improvement in the Trust’s antibiotic policy compliance.
Initiatives in 2009/10
30
Jan
Feb
Mar
SHA/PCT Target
•.Introduction of cleaning audits.
•.Introduction of new method of deep cleaning known as ‘fogging’
• Hand hygiene compliance audits
• Insertion and ongoing care of peripheral line cannula and urinary tract
catheters audits
• Monitoring of Antibiotic usage.
• Isolation of symptomatic patients with diarrhoea/vomiting into side-rooms and whole
bay cleaning.
All audits are reported at ’Back to Basics’ Meetings, with the exception of the
monitoring of Antibiotic usage audit, which is reported at the monthly Hospital
Infection Prevention and Control Committee.
Initiatives for 2010/11
INITIATIVE
New deep clean
programme.
Continued
refurbishment of
clinical areas.
Increase in en-suite
facilities in ward side
rooms.
raising and
monitoring cleaning
standards
Management of
Invasive Devices
Action
To have an annual
deep clean
programme
Integrated into the
estates plan
Owner
Director of Ops
Head of Hotel
Services
Director of Ops
Head of Estates
Integrated into the
estates plan
Director of Ops
Head of Estates
31.03.2011
Participation in the
internal and external
P.E.A.T audits.
Weekly auditing
using the national
cleanliness
standards and
weekly feedback of
scores at back to
basics meeting.
Ongoing staff
training.
The use and audit of
the high impact
intervention care
bundles e.g.
Peripheral line
insertion and
ingoing care.
Director of Ops
Head of Hotel
Services
31.03.2011
Medical Director
Clinical Directors
31.03.2011
Central line
insertion and
ongoing care
Urinary catheters
insertion and
ongoing care
31
Date
31.03.2011
31.03.2011
1C - VENOUS THROMBOEMBOLISM
The rationale
Venous Thromboembolism (VTE) is a condition in which a blood clot (thrombus)
forms in a vein. Blood flow through the affected vein can be limited by the clot and
may cause swelling and pain. This can in turn lead to a pulmonary embolism (PE).
Current status
The Trust did not carry out an audit of VTE risk assessments in 2009/10. No
statistics are currently available for 09/10 as to risk assessments carried out or
details of thromboprophylaxis (medication given as a precautionary measure to
prevent blood clots) prescriptions.
However, the Trust has in 2010/11 carried out two audits, and further audits will be
carried out on a regular basis. Compliance with completing risk assessment forms
remains low.
Aim
From 1 June 2010, 90% of patients must receive a VTE risk assessment and
thromboprophylaxis prescribed and administered where clinically indicated.
Areas for improvement
•.More robust risk assessments, prescription and administration of
Thromboprophylaxis
•.Audits to confirm compliance with NICE guidelines
Initiatives in 2009/10
•.Development of risk assessments and prescribing regimes
•.Introduction of anticoagulants for hip and knee replacement surgery
Initiatives for 2010/11
INITIATIVE
Implementation of a
National Risk
Assessment Tool,
based on NICE
Guidelines
Improved monitoring
of VTE policy
compliance.
ACTION
NATIONAL RISK
ASSESSMENT
TOOL
IMPLEMENTED
OWNER
ASSOCIATE
MEDICAL
DIRECTOR
DATE
01/06/10
COMPLIANCE
WITH RISK
ASSESSMENT
IMPLEMENTED
AND RESULTS
ASSOCIATE
MEDICAL
DIRECTOR
01/06/10
32
Monitoring and root
cause analysis of all
patients developing
a VTE or PE within
90
days of admission
DVT thromboprophylaxis
awareness event
th
planned for 19 May
2010 for all staff
Implementation of
updated Antiembolism Stocking
Policy, in line with
current guidance
WILL BE
REPORTED
THROUGH THE
THROMBOSIS
GROUP
RCA TO BE
COMPLETED ON
ALL PATIENTS
WHO DEVELOP
VTE / PE WITHIN
90 DAYS OF
ADMISSION
OUTCOME
REPORTED VIA
THE
THROMBOSIS
GROUP
ANTI- EMBOLISM
STOCKING
POLICY HAS
BEEN UPDATED
AND RATIFIED .
IMPLEMENTATION
PLAN TO BE
DEVELOPED AND
POLICY ROLLED
OUT
CHAIR OF THE
THROMBOSIS
GROUP
01/07/10
EVENT TOOK
PLACE AS
PLANNED ON
19/05/10
ANTICOAGULATION 30/09/10
NURSING TEAM &
THROMBOSIS
GROUP
1D - PATIENT FALLS
The rationale
Incidence of patient falls have a direct impact on patient length of stay and morbidity
and mortality rates. 20 – 30% of falls on average are preventable.
Existing falls prevention strategies have resulted in a 20.5 % reduction in falls since
2007.
33
Current status
The Trust’s emphasis on reducing inpatient falls has resulted in a 20.5% reduction
over the period 2007-2009.
Chart below – Falls chart April 06-February 2010
F a l ls
Av e ra g e
St a ti sti ca l l im i ts
M i d d l e th ird
120
110
100
90
80
70
60
50
40
30
20
Jan-10
Oct-09
Ju l-09
Ap r- 09
Jan -09
Oct-08
Jul-08
Apr-08
Jan-08
Oct -07
Ap r- 07
Jan -07
Oct-06
Jul-06
Ap r- 06
0
Ju l-07
10
Chart showing number of no harm to patient fall incidents reported;
Total number of falls reported April 2009 - March 2010
70
number of falls
60
50
40
red incidents
30
No harm incidents
20
10
0
Apr- May- Jun09
09
09
Jul09
Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar09
09
09
09
09
10
10
10
months
Aim
To reduce incidences and severity of patient falls by 30% in 2010/11 compared to
2009/10.
34
To reduce the number of incidents suffered by high risk frequent fallers, following
multi-factorial assessment, intervention and through effective deployment of falls
prevention interventions and equipment
Areas for improvement
•.Improving access to the Trust’s falls clinic.
Initiatives in 2009/10
The introduction of fall prevention mats for vulnerable patients, that alert ward staff if
they are trying to climb out of bed. All ward staff have been trained on the use of the
mats.
Initiatives for 2010/11
Initiative
Action
Improved training
and better use of risk
assessments
Changes to nurse’s
documentation
To contribute data to
the National Falls
and Bone Health
Audit in older people
To review existing
services and develop
improvements, in line
with Warwickshire
Falls and Bone
Health Strategy.
Falls risk
assessments / care
planning included as
part of the weekly
nurse sensitive
indicator audit /
programme.
Falls prevention
training included as
part of the bi-monthly
Champions for Older
People training.
Ad-hoc training
provided on request
for areas
experiencing
difficulties with
particularly high risk
patients or increased
incidents of falls.
Assessment and
core care plans
reviewed. No change
required.
Organisational audit
begins September
2010
Data input
September –
December 2010.
Liaison with
community services
and PCT. County
wide review of
Warwickshire
strategy.
Falls service (clinic)
review.
Owner
Date
Matron for Older
People
Next review
December 2010
Matron for Older
People
July 2011
Matron for Older
People until such
time as Ortho –
geriatrician or other
clinical lead
identified.
September 2010
Matron for Older
People
Project Manager
General Manager for
Medicine
September 2010
35
Warwickshire Falls and Bone Health Implementation Plan 2010 – 2013
The current work of the Falls Group is looking at how the Trust can meet the
objectives of the Warwickshire Falls and Bone Health strategy which outlines three
broad principles:
• Reducing avoidable hip fractures in older people by 10% through
developing and implementing an effective county wide Falls & Bone
Health Care Pathway
• Health promotion across the general population and awareness raising
regarding how to stay in good health in later life
• To develop integrated Falls and Osteoporosis services
External agencies e.g. Falls Co-ordinator, PCT representative and Camp Hill Centre
Manager are invited to the meetings for their specialist contribution to the project
which is being facilitated by Paula Crosby. This work will also feed into the
improvement plan project for fractured neck of femur.
National falls and Bone Health in Older People Audit 2010
The Trust has enrolled in this years’ audit beginning in September 2010, which is
focusing on two groups of patients:
• Group 1 Non – hip fragility fractures
• Group 2 Hip fractures
•
It is hoped that this will coincide with the appointment of an Orthogeriatric Consultant
who will be able to lead on aspects of the audit
1E - IDENTIFYING DETERIORATING PATIENTS
The rationale
When there is a failure to detect changes in patients who are becoming more acutely
unwell, this may contribute to an increase in the number of hospital cardiac arrests
and poor patient outcomes. A subsequent, unplanned admission to critical care or
return to theatre, may lead to significant increased length of stay and costs.
Current status
The Trust currently carries out regular MEWS (Modified Early Warning Score) and
the SBAR (Situation - Background - Assessment - Recommendation) communication
tool was introduced in 2009. Results of these audits are reported at ‘Back to Basic’
Meetings weekly.
The Critical Care Outreach Team at George Eliot NHS Trust faced the same
challenges in empowering ward staff to recognise the deteriorating patient in acute
care as many other teams around the UK. As a result, the team worked hard to come
up with a way of extending the work already done with Early Warning Scoring
Systems (EWS) by looking at how observations were charted in the Trust and how
they could be enhanced.
36
The National Patient Safety Agency (NPSA) identified the common themes of
deterioration and resuscitation as areas where specific incidences have occurred, the
Critical Care Outreach Team concentrated their efforts around deterioration primarily
by:
•
•
•
•
Improving recognition of patients at risk.
Improving recognition of those who have deteriorated.
Ensuring help is summoned early.
Responding to calls for help.
Aim
All deteriorating patients are recognised in a timely manner and appropriate action
taken. Zero tolerance.
Areas for improvement
Situation, Background, Action & Recommendations (SBAR) communication training
tool, is currently being undertaken by all nursing staff who take patient observations.
Initiatives in 2009/10
•.The introduction of a review for all unplanned admissions to intensive care.
•.The Trust will audit 20 sets of patient notes a month using the global trigger tool
(GTT) and 3x2 matrix to identify the rate of adverse incidents.
•. Modified Early Warning System (MEWS) currently used within the Trust and its use
audited.
Initiatives for 2010/11
INIIATIVE
Role out of the SBAR
communication tool
across the Trust.
Robust feedback and
action plans
developed, based on
the findings of the
GTT and
MEWS audits.
Action
owner
Identify the format of
the SBAR tool.
Role out by ward
Audit completion of
SBAR
Utilise the Institute
web based data
base.
Identify forum for
feedback.
date
Matron for ITU and
Critical Care
March 2011
Associate Medical
Director
March 2011
PRIORITY 2: PATIENT EXPERIENCE
2A - PATIENT SURVEY RESULTS (NATIONAL AND LOCAL)
The Trust participated in the National and Local Patient Surveys
37
Current status
National Surveys 2009/10
The Trust participated in the National Inpatient and Outpatients survey in 2009/10 the
results from which were published in May 2009 and February 2010.
Inpatient Survey
The majority of comments were very positive, praising staff and the service they
provided. Improvements were reported against the overall discharge process and
patients’ feeling they were being treated with respect and dignity. A number of areas
achieved similar results as in previous years but reduced satisfaction reported in
areas around bathroom facilities, security and overall care and communication.
Outpatient Survey
Patient comments reflected the positive side of the department focusing on the
pleasant manner, helpfulness and attitude of staff.
Generally our results demonstrated an improvement in some standards; however,
these fell below national trends in many areas. Trends identified for improvement
include environment, all aspects of communication to include clear reasons for
delays, patient information and signposting following the appointment.
The Trust is taking a number of steps to resolve the trends identified during 2009/10
and will continue throughout 2010/11.
Aim
To improve the patient experience and be in the top 10% of Trust’s nationally in
relation to the outcomes of National Patient Surveys.
Initiatives for 2009/10
•Signs have been placed on bathroom doors to make clear the gender of the facility.
•Department of Anaesthesia has introduced a checklist procedure to ensure that
patients receive all required information pre-operatively.
• Issues around noise at night taken forward with nursing staff at regular ‘back to
basics’ meetings
As a result of the Inpatient and Outpatient National Surveys and other patient
feedback the following are planned.
Initiatives for 2010/11
Initiative
Communication skills
and customer care
training is currently
being developed in
partnership with
North Warwickshire
ACTION
To role out across
the Trust
OWNER
Head of Training &
Development
38
DATE
September 2010
and Hinckley College
and will be offered to
all staff.
Ward information
available on some
wards and being
developed in other
wards
about discharge
and after care
Increased cleaning
schedule in the
outpatient
department
Review of outpatient
departmental working
practices
Improved seating
plan in the outpatient
department and
provision of
information screen
and television
Ensure patients
receive medication
prior to discharge
from hospital
Ensure customer
care is on all team
agendas, including
anonymous feedback
from any complaints
or rationales.
Patient Information
kiosks (4) have been
provided at various
locations. These will
be actively promoted
with information in all
departments.
Information Booklets
for bedsides
Deputy Director of
Nursing
Cleaning schedule to
be improved
Hotel services
Manager and Matron
for Outpatients
Work in progress
Matron for
outpatients
Deputy Director of
Operations
Matron for
outpatients and
Estates and Facilities
Manager
Work in progress
December 2010
December 2010
December 2010
Work in progress
Chief Pharmacists,
Director of Nursing
and Matrons
December 2010
Corporate strategy
for agenda on all
wards.
Preset proforma
Deputy Director of
Nursing
November 2010
Provide information
leaflets in all
departments and
communication to all
staff.
Patient advice and
liaison Manager
01.09.2010
I kiosk to be moved
to provide feedback
Local Survey 2009/10
Impressions Software
The Trust has an online survey linked to the web page. Although this has been
extensively promoted only 239 responses were logged. These results, although
small, reflected the findings of national surveys with poor communication and
insufficient patient information featuring as the main rationales.
Local Patient Satisfaction Survey 2009/10
A telephone survey commenced in June 2008 to obtain immediate feedback on
patients thoughts regarding their care whilst an inpatient at the George Eliot Hospital
NHS Trust (GEH). The purpose of this is to highlight areas of concern and good
39
practice, thus enabling the organisation to learn from these experiences and take
appropriate action rapidly.
Patient discharge details are gathered on a daily basis with a view to contacting
patients 24 hours following discharge.
Results are collated to identify trends and these are forwarded to Medical Director for
inclusion in the monthly Board Report and for reports to Patient Safety Group and
Patient Experience Group. Copies are also sent to ward areas so that they can
display results on their notice boards and take relevant action where applicable.
Survey outcomes 2009/10
•Patients discharged during this period total 5,000
•Patients contacted 2,500 (50%)
•Patients contacted – message left on answer phone 1,000 ( 20% )
•Patients contacted – No Answer phone facility / incorrect telephone number
recorded 1,500 (30%)
•Outpatients Department – Patients contacted 134 for a period of 3 months (27%)
long delays
Trends arising from feedback;
•
•
•
•
•
Lack of Communication between clinical staff, patients and families.
Staff attitudes - nursing staff / HCSW comments that were deemed to be
unacceptable to the patient.
A lack of advice regarding aftercare for patients on discharge by medical &
nursing staff for surgical procedures.
Rationales with hospital acquired pressure areas not being explained and
passed correctly to community nurse.
Wounds requiring intervention from other agencies not communicated
properly
COMPARISONS WITH 2008/09
NATIONAL SURVEY RESULTS 2008 Vs LOCAL 2008/2009
Question
National survey
Local survey
The patient felt they were
always treated with respect
and dignity
The rating for doctors and
nurses working well together
was excellent
The rating for the care
received was excellent
The patient was asked to give
74%
90%
29%
90%
37%
90%
7%
90%
40
their views on the quality of
care during their hospital stay
The patient saw posters /
leaflets in hospital explaining
how to complain
The patient wanted to
complain about the care
received in hospital
24%
Not asked
13%
Not asked
Overall Survey findings 2009/10
The national survey of adult in patients conducted by the Care Quality Commission
does not reflect similar responses from that of the local GEH survey (telephone).
The questions we ask are in a different format so it is considered that the response
rate has been very positive towards the care, treatment and environment compared
with those from the national survey.
Initiatives for 2010/11
Initiative
Action
Introduction of
Questions have
electronic data
been developed
capture before
and are being
patient discharge,
piloted using a
with questions more
paper based
closely aligned to the
system before any
National Patient
modifications
are
Survey.
made and they will
then be uploaded
on to electronic
hand held devices.
Plan to commence
electronic data
collection
Owner
Head of Patient
involvement /
PALS & Volunteers
Date
Pilot commenced
24/06/10
01/09/10
2B - COMPLAINTS
The rationale
The Trust welcomes feedback about the services it provides and indeed encourages
patients and visitors to provide feedback when they have had a positive experience
at the Trust and also when things did not meet their expectations.
41
Issues highlighted by complaints are used to review the services the Trust provides
and make changes and improvements where appropriate.
Aim
To reduce the number of patient complaints received.
Current status
The Trust received 294 complaints in 2009/10, five of which were withdrawn by the
complainants, therefore 289 were investigated. 96 of these complaints were
responded to within 25 days.
Between April and September 2009 there were some staffing issues within the
Customer Services Department which resulted in a re-organisation of the
Department. This, in conjunction with significant internal changes in the way
complaints were investigated at Divisional level, resulted in a reduction in the number
of complaints responded to within our 25 working day time limit.
There were periods during the year when the general management/deputy General
Managers were not up to establishment and this also contributed to response times
falling outside of the 25 working days. (The response times have now significantly
improved).
As per the NHS Complaints Policy, where complaint responses are not going to meet
the 25 working day time limit, a ‘holding’ letter should be sent to the complainant
requesting an extension of time for the investigation to be completed. This is usually
in cases where the complaint is particularly complex and/or involves numerous
members of staff and where the complaint involves more than one
Trust/organisation. Since September 2009 the Customer Services Department has
written to all complainants where the investigation would not be completed within the
25 working days.
There was a significant increase in the number of complaints regarding the A&E
Department, which alleged missed fractures, concerns over diagnosis and some
issues of staff attitude. These were reviewed by a team led by the Medical Director –
at the time findings concluded there was a shortage of senior doctor cover and high
locum usage. CQC commented during their visit in November 2009 that our
numbers of A&E complaints is well below the national average.
The complaints received for the out-patients department relate to five out-patient
areas, and relates to issues such as waiting times for appointments, delays in clinics,
delays in clinic letters going to GPs, communication, concerns around clinical
advice/treatment given and attitude of staff.
Trends that were identified as a result of complaints were ‘aspects of clinical
care/treatment’, ‘aspects of nursing care/treatment’ and ‘communication’.
42
35
30
25
20
10
5
0
AP
70
60
50
40
30
20
10
0
15
Areas
TOTAL
NUMBERS
R
IL
M
AY
N
E
LY
NO. OF COMPLAINTS AND RESPONSE S WITHIN 25 DAYS
ST
BE
R
BE
R
BE
R
BE
R
N
U
AR
Y
10
BR
FE
U
AR
Y
M
A
R
C
H
NO . CO MP LA INTS RE C'
D
RE SP OND ED W IT HIN 25 D AYS
Waiting time for operation/procedure
JA
Waiting time for appt
Waiting time for emergency surgery
M
Test results
E
Staff attitude/behaviour (other)
C
Staff attitude/behaviour (admin)
E
Staff attitude/behaviour (nursing)
D
Staff attitude/behaviour (medical)
M
VE
Smoking on site
O
Referrals/process
N
Pain relief
Records not available
TO
O/P appt letters
C
Lack of staff
Lost property
O
Infection control
In-patient in DPU
EM
PT
CATEG O RY
Hotel services
U
G
Drug error
Environment
U
Dignity, respect & privacy
MO NTH
Del ay issuing Death Cert
Delays/waiti ng time to be seen
SE
Confidentiality
Delay in clinic letters to GPs
A
Communication
JU
Car parking/charges
JU
Cancelled appts
Cancelled operation/procedure
9
'0
Aspects of clinical care/treatment
Aspects of nursing care/treatment
COMPLAINTS BY CATEGORY
43
Out-Patients departments – delays in clinics, delays in clinic letters going
to GPs, communication, concerns around clinical advice/treatment given
and attitude of staff.
A ll aspects of care/treatment
Analysis
Aids, appliances & equipment
The Trust analyses complaints by area/speciality and by category looking for
trends and themes. The main areas identified by complainants within the
Trust are:
•
Adms, discharge, transfer arrgmnts
•
A&E – alleged missed fractures and concerns over diagnosis.
•
Day Procedures Unit – cancelled operations/procedures, waiting time to
go in for procedure, in-patients in DPU and staff attitude.
•
Lydgate – environment and nursing care/treatment.
COM PLAINTS BY AREA/SPE CIALITY
70
60
NUMBERS
50
40
30
20
AREA/SP ECIALITY
Areas for improvement
Areas of concern highlighted from complaints during 2009/10 were:
•Various Aspects of clinical care/treatment.
•.Various Aspects of nursing care/treatment.
•.Communication.
Initiatives in 2009/10
A number of actions have been taken in response to trends identified from patient
complaints:
•.A review of complaints relating to A&E, led by the medical director, following a
significant increase in complaints.
•.The MRI request form revised to identify potential patients not suitable for the Trust
scanner along with information being sent out to Trust clinicians to remind them of
restrictions of the scanner.
•.A complaint folder has been piloted on one ward for all staff to review complaints
received relating to that area.
44
Victoria
Switchboard
Surgical Appliances
Security/Porters
S.A.U.
S.C.B.U.
Romola
Radiology
Pharmacy
Physiotherapy
Paediatrics
Patient Services
O PD
Orthopaedic
Melly
Nason
Medical Records
Mary Garth
Maternity/Obstetrics
I.T.U.
Lydgate
Hosp Mgment
Hotel Servi ces
Gynaecol ogy/OPD
G.U.M.
G eneral Surgery
Felix Holt
E.M.U.
Estates/Facilites
Elizabeth
DPU
Drayton
C.C.U.
Dolly Winthrop
Caterina
Bob Jakin
Breast Surgery/Unit
Alexander
Anaesthetics
A&E
Adam Bede
0
A udiology
10
Initiatives for 2010/11
Initiative
Review and update
the Trust’s
complaints policy.
Improve awareness
of the policy and the
systems in place
Improve the number
of complaints
responded to within
25 days.
Benchmarking of
complaint data,
comparing the Trust
with other
comparative Trusts.
Monitor actions taken
as a result of a
complaint to reduce
the likelihood of
similar themes
occurring.
Improved analysis of
complaint trends and
themes
Action
Update existing
Trust Policy.
Owner
Customer Services
Manager
Date
1 August 2010
Present at
Corporate
Induction
Programme.
Talk at ward/
departmental
meetings.
Ensure complaints
remain high priority
for the Division.
Customer Services
Manager
1 January 2010 ongoing
Chase as
appropriate and
provide support, as
necessary.
Approach
equivalent sized
Trusts, i.e.
Warwick and
Burton, for data on
6-monthly rolling
basis
Send out action
sheets for
completion with
each new
complaint.
Customer Services
Manager
General Managers/
Deputies to
complete action
sheet and ensure
actions undertaken
Analysis of
complaints rec’d by
area, by type and
also specifically by
individual staff
members.
Divisional
General/Deputy
Managers
Divisional
General/Deputy
Managers
Customer Services
Manager
1 July 2010 (for
last 6 months of
data for 2009/
2010)
Customer Services
Manager
1 July 2010
Customer Services
Manager
45
1 July 2010
1 January 2010 ongoing
2C - SERIOUS UNTOWARD INCIDENTS (SUI’S)
The rationale
The Trust has a strong incident reporting culture, with 3160 incidents being reported
during 2009/10. All members of staff are actively encouraged to report any incident
that potentially poses a threat to patient safety or services delivered within the Trust.
Of the 3160 incidents reported, a small number of these (37) are considered serious
as defined by the National Patient Safety Agencies categorization, and therefore are
reported as an SUI. The rest of the incidents reports are no harm incidents.
All reported incidents are appropriately investigated depending on the severity of the
incident. Actions developed and lessons learnt and shared across the organisation.
However, serious SUI’s require a full root cause analysis (an in-depth comprehensive
investigation to identify all contributing factors).
In order to prevent a similar event from reoccurring it is important that such incidents
are robustly investigated and the outcomes shared within and beyond the
organisation. All identified SUI’s within the Trust are reported to the Strategic Health
Authority and Primary Care Trust as per policy.
Current status
During 2009/10, the Trust reported 3160 incidents via its internal reporting system. Of
these incidents, 37 were SUI’s that were externally reported.
Please see graph below for monthly breakdown of SUI’s
46
SUI's By Month 2009/10
9
8
7
Incidents
6
5
4
3
2
1
0
Apr-09
Jun-09
Aug-09
Oct-09
Dec-09
Feb-10
Month
Aim
To reduce the number of patients who experience harm as a result of adverse
incidents within the Trust.
Areas for improvement
•The two main trends identified during 2009/10 for SUI’s, were Clostridium Difficile
(C-diff, 22 cases) where noted on the death certificate and MRSA (bloodstream
bacteraemias, 5 incidences).
•Timeliness of completion of root cause analysis investigations.
Initiatives in 2009/10
•Continued efforts to reduce HCAIs (see area 1 priority B).
•Falls reduction programme (see priority area priority1D)
47
Initiatives for 2010/11
INITIATIVE
Updating SUI policy,
to ensure that it
closely aligns with
PCT and SHA SUI
policy. To include the
change from SUI to
the new term ‘SIRI’
(serious incidents
requiring
investigation).
Education and
training in carrying
out robust ‘root
cause analysis
training’ for all
Managers within the
appropriate time
frame.
ACTION
OWNER
DATE
Update existing
policy to ensure
aligns with PCT, SHA
& NPSA policies and
only incidents that
match the criteria are
considered as
serious incidents
requiring
investigation.
Further develop
incident investigation
training to ensure all
leads are
comfortable with
using the NPSA
template for
investigation
paperwork.
Risk/ H&S Manager
July 2010
Risk/ H&S Manager
July 2010
Introduce facilitation
of SIRIs centrally.
PRIORITY 3 - EFFECTIVENESS OF CARE
3A: COMPLIANCE WITH THESTROKE PATHWAY
The rationale
Stroke patients spending most or all of their time on a dedicated stroke ward are
statistically more likely to receive the most appropriate care in a timely manner and
therefore rehabilitate to their maximum ability, post stroke episode.
Current status
38.21% of stroke patients discharged in 2009/10 spent 90% of their stay on the Felix
Holt dedicated stroke ward.
Aim
80% of admitted patients spending 90% of their time on a dedicated stroke ward.
Areas for improvement
•.Increasing awareness of the direct admission initiative so all patients suffering from
a suspected stroke are admitted to the stroke ward and are immediately placed in
48
the care of the specialist stroke team.
• All stroke patients receive CT scan within 24hrs of admission.
• Increase the percentage of stroke patients, spending 90% of their stay on the Felix
Holt dedicated stroke ward.
Initiatives in 2009/10
•.All patients suffering from a suspected stroke are now brought directly on to the
specialist stroke ward.
Initiatives for 2010/11
INITIATIVE
ACTION
Continue to audit length
of stay for stroke
patients.
Continue to develop the
Trust’s stroke outreach
team to rehabilitate
more stroke patients in
the community
OWNER
All discharges are
audited as part of the
monthly Vital Signs,
information is issued by
Allan Davis and Check
by Maggie Hall for any
anomalies
The Stroke Out Reach
Team currently offers
every Stroke
discharge, an
assessment at home
from the most
appropriate member of
the team.
An individual therapy
programme is devised,
this includes
Physiotherapy,
Occupational Therapy,
Speech Therapy,
Swallow Assessments
and Dietary Advice,
Psychological
Support.
Increase the
percentage of patients
receiving their CT scan
within 24hrs of
admission, in line with
National Targets.
Audited monthly as part
of the Vital Signs
Direct Admissions to
Felix Holt,
All Stroke CT request
forms Stamped for easy
recognition.
Liaison with the CT staff
to arrange scan when
24 hours deadline is
approaching.
Increase the
percentage of patients
spending 90% of their
time on the stroke ward,
in line with National
Targets.
Audited monthly as part
of the Vital Signs.
Direct Admissions to
Felix Holt, enables a
more effective pathway
and prompt access to
investigations.
10 Stroke beds
49
DATE
Monthly
Head of Information
Management
Stroke Co-ordinator
Therapy manager
Dietetic Manager
SALT Manager
Psychology Manager
ongoing
Monthly
Head of Information
Management
Stroke Co-ordinator
Sisters Stroke Unit
CT Radiographers
Monthly
Head of Information
Management
Stroke Co-ordinator
Manager Felix Holt
Ward
Clinical Sister Felix Holt
and Adam Bede Ward
available on Adam
Bede Ward. Aiming to
improve the flow from
Felix Holt Ward to
Adam Bede, by daily
liaison between the 2
wards,
Ensure joint working
through,
joint weekly MDT
meeting, training
sessions and stroke
strategy meetings.
50
3B: SMOKING DURING PREGNANCY
The rationale
The links between smoking and numerous health problems are well known as are the
affects that smoking can have on a baby both during and after pregnancy. Smoking
during pregnancy has been shown to have a negative impact on the development of
a child’s brain and body. Research has also shown that if all pregnant women gave
up smoking, the number of stillbirths and cot deaths could be reduced by around
10%.
Current status
Between July 2009-February 2010 17.3% of maternity clients were smokers at the
time they gave birth (see graph for breakdown).
Smoking at Delivery
120.00%
100.00%
80.00%
Yes
60.00%
No
40.00%
20.00%
0.00%
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Areas for improvement
Encouraging expectant mothers and other family members, to stop smoking so as to
promote a healthy environment for the new born.
Aim
To increase the numbers of pregnant mothers who have stopped smoking by the
time they deliver their babies.
Initiatives in 2009/10
Changing the referral process for pregnant mothers who smoke so referral to the
smoking cessation service was ‘opt out’ rather than ‘opt in’.
Initiatives for 2010/11
INITIATIVE
Further training for
midwives on
encouraging
ACTIONS
Community
midwives have
been trained
OWNER
SHA SMOKING
CESSATION
LEAD
51
DATE
31/12/10
expectant mothers
to stop smoking.
Midwives to take a
more persistent
approach to
promote the
benefits
of stopping
smoking.
Promotion of a
‘smoke free home’
for babies
In house training
to assist clients
with their
endeavors to stop
smoking and are
supporting the
client group
Midwives are
HOM/HR
linking with
occupational
health to reduce
staff smoking and
then encourage
client group by
leading by
example to stop
smoking.
Reviewing the
trust policy and
re-enforcing the
fact that the site
is non smoking
for clients and
staff.
Issuing cot death ALL MIDWIFERY
leaflets to all ante STAFF
natal & post natal
clients. Referring
other family
members along
with the mother
for stop smoking
support where
they are open to
this to ensure that
there is support in
place to
encourage a
smoke free
environment for
baby.
3C: COMPLIANCE WITH NICEGUIDELINES
The rationale
52
30/10/10
01/06/10
The National Institute for Clinical Excellence (NICE) was set up as a special health
authority for England and Wales in 1988 with a remit to provide patients, health care
professionals and the public with authoritative, robust, reliable guidance on current
best clinical practice. All members of Trust staff have a responsibility to work
according to the best evidence available to them, including NICE guidance.
Aim
To be compliant with NICE guidelines that are relevant to the services provided by
the Trust.
Current status
There are processes in place to ensure implementation of NICE Guidance as far as
possible and identify barriers to implementation.
Intervention
procedure
guidance
Clinical
guideline
Technology
appraisal
Public
Health
guidance
Total
Not
Relevant1
34
Not
Relevant2
4
Implemented Awaiting
response
1
0
4
2
0
5
1
5
4
2
7
4
0
3
0
1
0
0
43
6
14
5
9
Areas for improvement
•.Auditing of compliance
•.Early resolution of difficulties in fully implementing the guidance
•.Ensuring action planning and tracking
Initiatives in 2009/10
•.Review of NICE implementation policy
•.Proactive approach to compliance and report back to DARE
•.Feedback from clinical networks to confirm compliance
Initiatives for 2010/11
Initiative
Action
Owner
53
Date
Pending3
NICE guidelines
implementation to
be delegated to a
named senior
clinician within the
directorate to
ensure
responsibility and
accountability.
Moving forward, it
will be the role of
the General
Manager to
monitor progress
of the
implementation
and ensure audit
of compliance
using an
implementation
tracking sheet and
it will be the
responsibility of
the clinical director
to ensure NICE
guidance is
implemented and
audited.
Monthly
meetings with
GMs
Attendance at
Directorate
meetings
Attend staff
induction
Monthly
meetings with
GMs
Attendance at
Directorate and
Back to Basics
meetings
Clinical Audit
Officer
Education &
Research
Manager
Audit &
Effectiveness
Nurse
Clinical Audit
Officer
Education &
Research
Manager
Audit &
Effectiveness
Nurse
Ongoing
1st Oct 2010
Ongoing
1st Oct 2010
3D: AUDIT OF COMPLIANCES WITH NICE RECOMMENDATIONS
The rationale
Clinical audit is the review of clinical performance against agreed standards and the
appropriate refining of clinical practice as a result of the audit. As such, it is now
recognised as an effective mechanism for improving quality of care patients receive.
Aim
•.Audits will be in place to confirm compliance with NICE guidance
•.Base action plans on outcomes of audits performed and re-audit appropriately
Current status
•.Registration, monitoring and reporting of clinical audits is currently very weak
Areas for improvement
•.All areas
Initiatives in 2009/10
•.review of policy and amendment of procedural documents
Initiatives for 2010/11
54
Initiatives
Regular audit
management
meetings through
DARE
Work will
commence to
embed a ‘clinical
audit culture’ into
the organisations
as a
whole and to
ensure protected
time is provided
for the
implementation
of NICE
guidance and
clinical audit of
compliance
Correct use of
Consultant
‘supporting
activity’ time
Work to ensure
the registration,
monitoring and
reporting of
clinical audit is
improved to
ensure they are
professionally
undertaken and
completed.
Action
Directorate and
Trust-wide
meetings to be
combined
Attend staff
induction
Monthly meetings
with GMs
Attendance at
Directorate and
Back to Basics
meetings
Attendance staff
and F1/F2
Induction
Introduction to
DARE workshops
DARE Newsletter
Job plans
Online form
Publicly available
(read only)
database with
recommendations
Owner
Education &
Research
Manager
Clinical Audit
Officer
Education &
Research
Manager
Audit &
Effectiveness
Nurse
Date
Notes
st
1 Oct 2010 Discussion
with CDs
specialty and
audit leads
Ongoing
DARE
1st Oct 2010 Workshop to
include section
on report
writing
General
Managers &
CDs
a.s.a.p.
Clinical Audit
Officer
Education &
Research
Manager
Clinical
Director
1st Oct 2010 DARE
Workshop to
include section
on report
writing
Feedback received from Overview & Scrutiny committee, Patient Forum
and NHS Warwickshire.
GEORGE ELIOT PATIENT FORUM
To whom it may concern:
Ref Quality Accounts 2009/2010
55
Thank you for inviting the George Eliot Patient Forum to comment on the Quality
Accounts. As there is very little overlap between the detail in the Accounts and the
Forum’s Work plan we feel unable to make significant comment.
However, we would like clarification on two issues.
1. page 3 Chief Executive Statement of Quality. The population for the area
served by the Trust is quoted as 250,000. We feel this is a gross
understatement. 250,000 represents the population of Nuneaton and Bedworth
only. At least 400,000 is a more realistic figure to include North
Warwickshire, South West Leicestershire and North Coventry.
2. page 25 Clinical Coding Errors. As laymen, we are rather alarmed that the
error rate for both primary and secondary diagnosis is 31%. This seems a very
high figure to us but may be our lack of understanding. Please clarify.
Signed:
Derek Kenny
(Chairman)
Margaret Cooper
(Administrator)
Overview and Scrutiny Committee feedback
George Eliot Hospital NHS Trust
The Warwickshire Health Overview and Scrutiny Committee welcomes the
opportunity to comment on this draft Quality Account. Having considered the
document at its meeting on 24th May 2010 it wishes to make the following
observations which it believes will be of assistance to the trust.
•
The committee was generally impressed by the report, by the work being
undertaken by the trust and by the improvements to service that have been
made. The committee was particularly pleased to see that the document
provided an explanation of why indicators had been selected.
In terms of improving the document:
56
•
•
•
•
•
•
•
•
•
•
•
•
The Quality Account relies very heavily on the use of acronyms. Whilst the
committee recognises that these have their uses it feels that the document
should at the least contain a glossary of terms.
The document currently contains no reference to consultation with
stakeholders. This should be addressed.
The section concerning complaints (p36) would benefit from expansion. For
example whilst 96 complaints were responded to within 25 days what of the
193 that were not. There may be a valid reason for this but the Quality
Account should explore the matter further for the reader to fully understand it.
The same section (complaints) would benefit from the inclusion of trend data.
Benchmarking data should be included where appropriate to enable the
reader to compare performance with peer organisations. An example of
where this approach would be helpful can be found on page 25 - Clinical
Coding Errors. Is “31% primary diagnosis incorrect” good or bad? How does
this compare with other similar hospitals?
Trend data should be used to illustrate year on year performance
Although to most readers the charts are easily understood others may find the
absence of labels on the axes confusing. SUIs on page 39 is an example.
Some of the charts do not reproduce well in monotone. Consideration should
be given as to how this might be addressed.
Data should be included on no harm patient safety incidents. Perhaps this
could be allied to 1D – Patient Falls.
Patient dignity requires a specific section.
The account should make more explicit the links between what has happened
and what will happen in the future. There are instances in the document
where plenty of attention is given to explaining the challenge but little detail is
provided on how it will be addressed. An example of this is patient falls where
on p31 it states that there will be changes to nurses documentation but does
not expand on what these will be or how they will improve the situation.
Related to the preceding point is the need for an action plan to be included.
The committee considers that as well as looking back on what has been
achieved the Quality Account should be clear on what actions are proposed,
when they will be undertaken, the target(s) they seek to meet (outputs and
outcomes) and who will be responsible for them. This will enable public and
partners to hold the trust to account when, in a year’s time, this process is
undertaken again.
STATEMENT FOR GEORGE ELIOT HOSPITAL NHS TRUST
NHS Warwickshire and NHS Coventry (the commissioners) have reviewed the
Quality Account provided by George Eliot Hospital NHS Trust (GEH). In relation to
information and data within the document that relates to items contractually
discussed throughout the year at Clinical Quality Review meetings both
commissioners can corroborate this Account. Attendance and engagement at these
meetings have been excellent.Information provided within this Account that does not
form part of those Quality Review meetings cannot be corroborated by either
commissioner.
The commissioners are concerned about the public and staff reported experience of
services provided by GEH as seen in the National Inpatient Survey and National Staff
Survey. Commissioners will work with the Trust to improve performance in these
areas over the forthcoming year. GEH has improved stroke targets over the year but
commissioners will be working with the Trust to improve them further.
57
The commissioners closely monitor their providers’ management of serious untoward
incidents (SUIs) (those resulting in serious harm or death) and has seen
improvement in GEH management of SUIs. The Trust is now compliant with best
practice.
George Eliot Hospital NHS Trust was subject to a number of external reviews in
2009/10 by both NHS Warwickshire and other reviewing bodies. Any actions arising
from such reviews are monitored through monthly quality review meetings with the
Trust. Summary details of those visits can be found below:
• NHS Warwickshire Unannounced Emergency Care Pathway Visit – May 2009
The visiting team ‘walked through’ the emergency pathway from the reception
desk through the different areas ranging from minor to major emergencies. Seven
recommendations were made and an action plan developed by the Trust which is
monitored through the clinical quality review process although concerns remain
about the difficulty to recruit medical staff to this area.
• NHS Warwickshire Review of the Stroke Pathway at George Eliot Hospital
NHS Trust The visit identified that overall the Trust has a very good Stroke Unit and Pathway.
The visiting team felt that if the recommendations were embraced and
implemented the service would be an exemplar in the Region. Recommendations
were made in relation to improving stroke targets.
• Neonatal Network review-September 2009
The report identified some areas for development and the Trust has developed an
action plan in response to this.
• West Midlands Quality Review Service: Care of the Critically Ill and Critically
Injured Children Peer Review visit – October 2009
This review found four immediate risks, two of which were immediately rectified by
the Trust. The remaining two risks are being addressed through alternative
pathways for admitting children and are being monitored by regular review
through the clinical quality review process.
• Care Quality Commission (CQC) Healthcare Acquired Infection reportNovember 2009
Of the fifteen measures inspected, CQC had concern in one area; this area has
subsequently been addressed to the satisfaction of CQC.
• NHS Warwickshire Themed Review of Capacity and Discharge PlanningNovember 2009
No immediate risks were identified although a number of recommendations for
improved practice were made. These will be monitored by the commissioners
through 2010/11. NHS Warwickshire is working with GEH and Warwickshire
County Council to improve the transfers of care from hospital to community care
and hopes this will allow GEH to improve on the timeliness of its discharge of
patients.
• NHS Warwickshire Themed Review of Children’s Safeguarding ServicesJanuary 2010
Overall the panel was delighted with the exemplar progress made and found
the quality of evidence provided of an exceptionally high standard
58
Warwickshire LINKS
Warwickshire LINK welcomes the invite to comment on the Quality Account. We also
welcomed the joint meeting held with the Health Overview and Scrutiny Committee to
discuss the accounts. We recognise that this is the first year of this process and that
the timetable was short.
Warwickshire LINK would like to make the following commentary to the account
•
We would like to see greater proactive efforts on the part of the Trust to
establish a stronger relationship with the LINK.
•
The LINK agrees with the Health Overview and Scrutiny comments regarding
the need for a glossary of terms explaining acronyms, better use of charts.
•
Greater reference to how stakeholders are involved in the work of the Trust
through consultation needs to be addressed.
•
The need for benchmarking data where appropriate will enable readers to
compare performance with peer organisations.
•
Trend data should be incorporated to allow year on year performance in
future Accounts.
•
Patient dignity is an important area that warrants a specific section.
•
Action plans need to be included.
When the reports are presented next year we would hope to see further progress
against action plans and performance measures, where specified.
Amendments following Feedback received:
•
•
•
•
•
•
A glossary has now been included in the accounts
Consultation with constituents regarding the priorities set by the Trust for
2010/11 and future priorities are being addressed at locum community form
meetings across the area.
Complaints – expansion on information around complaints not answered
within 25 working days included. Graph showing trends on page 39.
Page 41 refers to no harm events regarding patients. Page 31 includes a
chart showing no harm incidents reported April 2009 – March 2010.
A specific section on Patient Privacy and Dignity has been included on pages
27 – 29.
Action Plans included for all sections with timescales and owners
59