Quality Account
Herefordshire PCT:
Provider Services
2009 - 2010
Our Mission
‘To deliver high quality, safe and sustainable health and well being services
tailored to meet the needs of our local community.’
Headquarters:
Vaughan Building, Ruckhall Lane, Belmont, HEREFORD HR2 9RP
PART 1
Content
PART 1
MANAGING DIRECTOR’S STATEMENT
STATEMENT OF ACCURACY
PART 2
1 LOOKING FORWARD - The Next 12 Months in Herefordshire
Page
5
1.1 Our Quality And Safety Priorities For 2010/2011
5
1.1.1 Patients/ Service Users as Partners
5
1.1.2 Improving Quality Through Local Service Partnership
6
1.1.3 Continuing to Improve the Recording of Incidents in All Services
and the Sharing of Lessons Learned
7
1.1.4 New Patient Information System
8
1.2 2010 – 2011 CQUINs
8
1.2.1 Community Service Goals
8
1.2.2 Mental Health Service Goals
9
2 Statutory Statements of Compliance
10
2.1 Records
10
2.2 Audit
10
2.3 CQUIN Payments
10
2.4 Information Governance Tool Kit
10
2.5 Payment by Results
11
2.6 Statutory Visits
11
2.7 Research
11
2.8 CQC Registration
11
PART 3
3 LOOKING BACK – Our Services and their Achievements 2009 - 2010
12
3.1 Demographic Context
12
3.2 Organisational Context
13
4. PATIENT SAFETY
14
4.1 Key Safety Indicators
14
4.2 Reducing Serious Untoward Incidents
15
4.3 Compliance with MRSA Screening Process
16
4.4 MRSA Rates
16
4.5 Clostridium Difficile (Cdiff) Rates
17
2
5. CLINICAL EFFECTIVENESS/ QUALITY MEASURES
17
5.1 Essence of Care
18
5.2 Reducing Mixed Sex Accommodation
18
5.3 PEAT (Patient environment action team)
18
5.4 Compliance with NICE Guidance
5.5 Comply with National Target for 18 Weeks from Referral to Treatment in
Consultant Lead Services
5.6 Compliance with CQUIN Requirements
5.7 Service Specifications Written and Quality and Performance
Indicators/Activity Indicator Metrics Agreed
5.8 Improve Data Quality
19
20
20
20
21
6. PATIENT EXPERIENCE
21
6.1 Mental Health Services
21
6.2 Sexual Health Services
21
6.3 MacMillan Nurses
21
6.4 Recruiting Student Health Visitors and School Nurses
22
6.5 Physiotherapy – Patient Reported Outcomes Measures
22
6.6 Parkinson’s Nurses
22
7. SERVICES REVIEW
22
7.1 Service Review by Care Quality Commission
22
7.2 Delays in Discharges from Inpatient Care
23
7.3 Management of Complaints
23
8. SERVICE IMPROVEMENT
24
8.1 Podiatric Surgery
24
8.2 Community Hospitals and Intermediate Care
25
8.3 MacMillan Nurses
25
8.4 Community Intermediate Care
26
8.5 Physiotherapy
26
8.6 Occupational Therapy Service
26
8.7 Intermediate Diabetes Service
26
8.8 Acute Mental Health Services
27
8.9 Apprenticeships
27
8.10 Change Champions
27
8.11 What Others Say About Us
8.12 Herefordshire Council: Health Scrutiny Committee - Commentary on
Herefordshire PCT provider Services Quality Accounts
28
29
3
PART 1
Managing Director’s Statement
April 2009 saw the introduction of NHS Herefordshire Provider Services as an
arms length provider organisation from Herefordshire Primary Care Trust.
Through the year 2009/2010, Provider Services Board, Senior Managers and
front line staff have been working to deliver safe, quality care for the people of
Herefordshire, and this is reflected in our first Quality Account.
We are proud of the progress we have made against our core objectives,
whilst acknowledging that we have a challenging agenda and there is no room
for complacency. We know that there is a lot of work to do and we shall need
to continue to push ahead in the next year to bring these to fruition.
We trust that this report helps demonstrate that we are listening to what
patients and carers are telling us; we have continued to deliver the excellent
infection control performance we inherited from our parent organisation; and
we are committed to monitoring and improving patient safety. We are also
committed to making patients, their families and the wider public, partners in
the delivery of health and social care in Herefordshire.
Our Quality Account 2009/10 establishes a baseline against which we will
monitor our progress in 2010/11 against our safety and quality targets and
sets out our vision for the future.
Richard Carroll
Interim Managing Director of Provider Services
Statement of Accuracy:
All Services (see section 4.2) delivered by NHS Herefordshire Provider
Services have been included in the scrutiny and assurance process. To the
best of my knowledge the information contained within this Quality Account is
accurate.
Lynda Steele MPhil, DCR(R), SRR, MHSC (cert)
Associate Director of Quality and Clinical Effectiveness
4
PART 2
1
Looking Forward – The Next 12 Months in Herefordshire
The next 12 months promise to be no less challenging and interesting than
the last. We and our partners in local health and social care delivery are
currently consulting with the people of Herefordshire on the way services shall
be provided in the future as part of the Shaping Health and Wellbeing in
Herefordshire programme. Whatever the outcome, the closer working
relationships which have been developed during the last 12 months to
improve patient care will become even stronger. Safe, quality cost-effective
services can only be delivered in a co-ordinated and co-operative way and
this is well recognised by the organisation and our partners.
In an economic climate which dictates even closer scrutiny of every penny
spent, it is vital that the patient remains at the centre of the care package, and
remains our focus. We intend to do this whilst continuing to focus our attention
on the services around that person, and to reduce duplication and
unnecessary steps which can lead to poorer care and increased cost.
As part of this drive for efficiencies, in 2010 Podiatric Surgery are starting to
use a Productive Operating Theatre Programme, (which is similar to the
Releasing More Time to Care programme – see section 8.2) using LEAN
methods to work out how they could work in a more efficient way.
1.1
Our Quality and Safety Priorities 2010/2011
The organisational form which evolves from the consultation and the
economic climate will create a need to more clearly define the key priorities
for the next 12 months. For this reason the priorities which are outlined in this
report are broad and will continue to be shaped by the formation of new
organisational boundaries. There are three areas where we will be focussing
attention:
1. Patients/ Service Users as Partners
2. Improving Quality through local
service partnerships.
3. Continuing to improve the recording of
incidents in all services and the
sharing of lessons leaned.
There are a further two areas where we will
also be looking to improve:
4. Improving Clinical engagement with
our key priorities.
5. Continuing
to
improve
patient
information systems.
1.1.1 Patients/ Service Users as Partners
One of our targets is to improve the
collection, analysis and use of patient
experience. A programme manager has
Success Story
A 14 year old young person
with Cerebral Palsy, having
limited mobility, had an
operation resulting in the
person not being able to stand
or walk.
Surgeons thought it would take
up to 2 years for maximum
function to return.
Daily support from specialist
Children’s
Physiotherapists
meant that in 6 weeks the
young person was walking
independently.
5
PART 2
recently been appointed and started work in Herefordshire in April 2010 and is
focussing on the best way to improve the consistency and collection of patient
experience information and comments. She will also set in place processes to
improve the sharing and use of that information across the organisation, to
enable services to improve in response to patient experience.
We will be taking patient experience forward in line with the Darzi Next Stage
review 2008, and will seek to populate the report required in 2011 with data
we are starting to capture now.
We will take a two strand approach to the generation of the report, looking at
both the measures from metrics (generated from the service and user and
carer questionnaire) and the narratives from patient voice information, across
both health and social care.
We will be working closely with as many groups as we can, to ensure that
their voice is heard, and that we use this to develop meaningful improvements
in patient focused care.
We will also be working towards the CQUIN target, which is a method for
Commissioners to reward Providers of services, based on good patient
experiences and we hope our service users will feel confident in telling us
when we have met their needs. We also aim to expand in the year the use of
NHS choices as part of our patient experience work.
1.1.2 Improving Quality through Local Service Partnerships
This year we will implement the care pathway work undertaken in 2009/10.
During the last 6 months Provider Services has been working with local
partners to deliver care in a more co-ordinated manner which more closely
considers the delivery of care closer to home. Clinical staff from all
organisations have come together to consider national guidance and local
needs and they have taken all information available to determine how the best
most effective care can be provided for the people of Herefordshire.
The following areas have developed new care pathways which will transform
care delivery:
• Low Back Pain
• Stroke
• Frail Elderly
• Diabetes
• Respiratory Conditions
Mental Health Services are currently exploring working as partners with
another provider service, and this new way of working should allow for a
broader service to be delivered to people who require support.
Subject to the outcome of local consultation a new provider organisation will
potentially be in place by 1st April 2011, and services may begin to change
towards that new organisational structure in the autumn of 2010.
6
PART 2
Our Training Team will be supporting the development of our current and
future workforce. Apprenticeships will continue to be supported by our
organisation as we recognise the future stability of the local services depend
on recruiting people locally.
To further enhance our connections with local young people and to help
develop skills amongst the local workforce, money has been successfully
obtained to develop a facility to help young people understand the work of the
NHS. This consists of a training environment including a “mock up” of
someone’s home with working equipment to show them what really happens
if you are caring for someone at home and how to react in a medical
emergency situation. This facility will also be used to support training and
development for our own and hospital staff. This will be the first time such
advance training facilities have been available locally, and this means we will
not have to send people away for training, cutting travel costs, CO2 emissions
and can train and develop more people for the same cost.
1.1.3 Continuing to Improve the Recording of Incidents in all Services
and the Sharing of Lessons Leaned
The Corporate Risk and Quality Teams are supporting the development of the
team leaders in the organisation to enable them to better support all staff in
the reporting and management of incidents. They will also be improving the
way that information is made available to teams so that teams are able to see
trends that need to be addressed. They will also be training staff and
supporting the investigation of incidents and complaints using the Root Cause
Analysis methods, which help to clearly identify system failures and support
the development of the improvement of these systems.
Three training sessions will be delivered to staff Team Leaders and ad hoc
support will be offered when required. One report will be delivered to each of
our service directorates every three months, trends and issues will be
identified and actions identified. We will
Success Story
also be producing information sheets to
highlight areas of good practice and 4 out of the last 5 clinical
lessons learned, to share with other assistants
in
community
services. All such lessons will also be Psychology
have
gained
shared through governance meetings places on Doctoral Courses
across the organisation.
due to the support and
example of local team and
In liaison with the Infection Control Team mentorship of local Clinical
and our service partners we will ensure Psychologists.
we learn lessons from incidents which
occur and use our learning to further The most recent assistant won
improve the safety of patients, their a place with only 20 on offer
families, the general public and our own and in competition against 200
staff.
others.
7
PART 2
1.1.4. New Patient Information Systems
Herefordshire is in the early group of Trusts introducing new patient
information systems in the next few years. In 2010 – 11 the Podiatric Surgery
and Children’s Safeguarding teams will be pioneering the use of a new
national IT system called Lorenzo, which will connect teams together and link
to the general health information held within existing national confidentiality
and Information Governance requirements. Clinical leaders and Information
programme planners are working very closely to make this a successful
transition.
1.2
2010 – 2011 CQUINs
In the next 12 months there are a number of targets (Goals) which have been
added to the requirements for reporting on new services and improved
effectiveness. These are listed in the CQUIN for the next year:
1.2.1 Community Services Goals
1 Patient Experience - Improving the experience of Patients receiving
Community Hospital services and patients receiving community based
health services.
2 Percentage of smokers/tobacco users attending outpatient clinic
appointments receiving a brief intervention to reduce tobacco use
including being given written advice.
3 To implement best practice care in hospitals in the West Midlands for the
care of inpatients with a secondary diagnosis of diabetes and as a
consequence reduce associated healthcare costs.
4a All patients on admission (and within a minimum of 24 hours) should be
assessed by a suitable competent and experienced Registered Nurse for
their risk of developing a pressure ulceration using a recognised evidence
based tool. (Exclusions would be paediatrics, day cases, maternity (if any).
4b Inpatients assessed to be at risk of ulceration or who currently have a
pressure ulcer will have preventative actions taken and documented in
their care plan.
4c Percentage decrease on numbers of hospital acquired grade 2, 3 and 4
ulcerations demonstrated by Q4 against baseline level established in Q1.
4d All hospital acquired ulcerations of grade 2, 3 or 4 will be recorded on the
appropriate system and a Root Cause Analysis commenced within 5
working days.
4e All ulcerations which show deterioration from grade 2 to 3 or 3 to 4 will be
recorded as a serious untoward incident on the appropriate system.
5 Patients will have a falls risk assessment completed on admission to
Community Hospital (within a maximum of 24 hours) or initial contact with
community team. For those identified at risk, an individualised falls care
plan will be implemented.
8
PART 2
6 Patients will have a nutrition assessment completed on admission (within a
maximum of 24 hours) to Community Hospital or initial contact with
community team, using a nationally recognised tool.
7 The number of patients who have died whilst on a GSF register, have a
supportive care plan and have been managed on a supportive care
pathway.
8 To promote effective Discharge Planning. Development and completion of
a standardised discharge care plan.
9 To improve patient safety management in relation to medication
administration.
1.2.2 Mental Health Service Goals
1
Productivity and Pathways Improvement Programme.
2 Patient Experience - Improving the experience of Patients receiving
Community Mental Health services and patients receiving hospital based
Mental Health Services.
3 Percentage of smokers/tobacco users attending outpatient clinic
appointments receiving a brief intervention to reduce tobacco use
including being given written advice.
4 Supporting Social Inclusion Opportunities by assessing
accommodation and employment status and security.
patients’
5 All Patients have the opportunity to be treated in their own home.
6 Failure to administer prescribed medicines as a result of non-availability of
the medicine.
7 Dementia Pathway Development. Development of a Dementia Pathway for
the mental health trust elements of the pathway in partnership with all key
stakeholders. Ensuring people are following the Dementia Care pathway.
8 Ensuring that use of leave from hospital admission is a clinically managed
part of all patients’ in-patient length of stay.
9 Reducing the incidents of broken engagement with service users of
Assertive Outreach Teams.
9
PART 2
2
Statutory Statements of Compliance
2.1
Records
“Herefordshire PCT Provider Services did not submit records during April
2009 – March 2010 to the Secondary Uses service for inclusion in the
Hospital Episode Statistics which are included in the latest published data.”
2.2
Audit
During the period April 2009 to April 2010 Herefordshire PCT Provider
Services participated in one national clinical audit and one national
confidential enquiry of the national clinical audits and national confidential
enquiries in which it was eligible to participate.
The national clinical audits and national enquiries that Herefordshire PCT
Provider Services participated in, and for which data collection was completed
during October 2009 was for the National Clinical Recordkeeping Audit. All
teams in the organisation scrutinised 10 sets of patient records and
information was analysed and provided as part of the Information Governance
Tool Kit.
There were three national confidential enquiries which occurred in 2009/10:
•
National Confidential Enquiry into Patient Outcome and Death
(NCEPOD);
•
Centre for Maternal and Child Enquiries (CMACE); and
•
National Confidential Inquiry (NCI) into Suicide and Homicide by
People with Mental Illness (NCI/NCISH).
2.3
CQUIN Payments
A proportion of NHS Herefordshire Provider Services income in April 2009 –
March 2010 was conditional on achieving quality improvement and innovation
goals agreed between NHS Herefordshire Provider Services and NHS
Herefordshire Commissioners and any person or body they entered into a
contract, agreement or arrangement with for the provision of NHS services
through the Commissioning for Quality and Innovation payment framework.”
“Further details of the agreed goals for April 2009 – March 2010 and for the
following 12 month period are available on request from the Clinical
Governance lead for NHS Herefordshire Provider Services.
2.4
Information Governance Toolkit
NHS Herefordshire Provider Services score for April 2009 – March 2010 for
Information Quality and Records Management, assessed using the
Information Governance Toolkit was 93%.
10
PART 2
2.5 Payment by Results
“Herefordshire PCT Provider Services was not subject to the Payment by
Results clinical coding audit during year April 2009 to March 2010 by the Audit
Commission.”
2.6 Statutory Visits
The Mental Health Service has participated in a special review by the Care
Quality Commission during 2009/10. The special review was conducted by
the Mental Health Act Commissioner on Jenny Lind Ward, Stonebow Unit, on
23rd January 2010.
The Mental Health Service intends to take the following action to address the
conclusions or requirements reported by the CQC:
• Development of Patient Information Pack.
• Ensure Care Co-ordinators attend ward reviews regularly.
• Develop formal system of supervision.
• Ensure corridor toilets are gender specific.
• Day rooms are identified for gender specific use.
The Mental Health Service has made the following progress by 31st March
2010 in taking such action;
• Patient Information Packs have been completed and are in all patient
rooms.
• Action plan for the development of formal supervision is being
developed.
• Corridor toilets are gender specific.
• Day rooms are identified for gender specific use.
2.7 Research
The number of patients receiving NHS services provided or sub-contracted by
Herefordshire PCT Provider Services from April 2009 to March 2010 that
were recruited during that period to participate in research approved by a
Research Ethics Committee was nil.
2.8 CQC Registration
Herefordshire PCT is required to register with the Quality Commission and its
current registration status is: ‘Registered without conditions’. The Care
Quality Commission has not taken enforcement action against Herefordshire
PCT during the period between April 2009 and March 2010.
11
PART 3
3
LOOKING BACK - Our Services and Achievements 2009 - 2010
NHS Herefordshire Provider Services was established in 2009 as an arms
length provider organisation. At the outset it set as its vision ‘to be recognised
by the local and wider communities as the health and well-being services
provider of choice.’ With a mission ‘to deliver high quality, safe and
sustainable health and well being services tailored to meet the needs of our
local community.’
3.1
Demographic Context
Herefordshire is a predominantly rural county with six centres of population:
With a population density which is the 4th lowest in England this means that
many key services are further away from residents compared to other parts of
the country so only about half of residents
are within 4km of a GP (48%) and one
Success Story
third (34%) within 4km of a supermarket. The Falls Prevention Team
Coupled with limited public transport it is
particularly important therefore that we started Staying Steady Groups
work hard at ensuring that local services in Ledbury, Leominster and
are delivered as close to residents as
Hereford. In January they
possible.
started more groups in Ross
The Black and Minority Ethnic (BME)
population is steadily rising; however, it and Bromyard. This has lead
represents 4% of the Herefordshire to improved independence for
population compared to 16% nationally.
many people across the
county
12
PART 3
3.2
Organisational Context
Provider Services delivers care across the county. The organisation is led by
a Managing Director and operationally has five Directorates:
•
•
•
•
•
Adult and Older People Services
Mental Health Services
Specialist Services
Children’s Services
Social Care.
Adult and Older
People Services
Children’s
Services
Specialist
Services
Mental
Services
3
Community
Hospitals
Safeguarding
Children
Podiatric Surgery
Acute
Mental
Health Services
Intermediate Care
Beds
Intermediate Care
in Community
Respite Care
Dental Care
Substance Misuse
Health Visitors
Lymph oedema.
Occupational
Therapy
School Nurses
Diabetes care.
Physiotherapy
Audiology
District Nursing
Paediatric
Occupational
Therapy
MacMillan/Palliative
Care
Sexual Health
Children
&
Adolescent Mental
Health Services
Older
People’s
Mental
Health
Services (DMHOP)
Recovery Services
Community Stroke
Team
Falls Service
Paediatric
Physiotherapy
Looked
After
Children Nurses
Paediatricians
Health Psychology
Children’s Centre
Continence Service
Adult Health Visitor
Adult Social Care
Learning
Disabilities
Services
Adult Social Care
Health
Community
&
Primary
Care
Mental
Health
Services
Parkinson’s
Podiatry
Acquired
Brain
Injury Service
Musculo-skeletal
Service
Multiple Sclerosis
Service
These services are supported by central functions including Training, Finance,
Human Resources, Risk Management and Quality.
13
4
Patient Safety
For 2009/10 the Provider Board agreed that there would be a certain number of
indicators which would support their knowledge of the services and their
performance. In respect of safety the following indicators were identified:
4.1
Key Safety Indicators
Indicator
Reduce Serious Untoward Incidents
MRSA screening compliance
MRSA bacteraemia rates
Clostridium Difficile rates
Source
Local
HCAI reduction plan
HCAI reduction plan
HCAI reduction plan
Glossary:
MRSA:
Methicillin-resistant Staphylococcus aureus; a bacterium
responsible for several difficult-to-treat infections in humans.
HCAI: Healthcare acquired Infections.
4.2
Reducing Serious Untoward Incidents
The National Patient Safety Agency (NPSA) report that: ‘Every day more than a
million people are treated safely and successfully in the NHS. However, the
advances in technology and knowledge in recent decades have created an
immensely complex healthcare system. This complexity brings risks, and
evidence shows that things will and do go wrong in the NHS; that patients are
sometimes harmed no matter how dedicated and professional the staff.’
The Seven Steps are core to patient safety in healthcare organisations. The
NPSA provide guide documents which provide a checklist to help staff to plan
their activities and measure patient safety performance.
The Steps are:
1 Build a safety culture
2 Lead and support your staff
3 Integrate your risk management activity
4 Promote reporting in primary care
5 Involve and communicate with patients and the public
6 Learn and share safety lessons
7 Implement solutions to prevent harm
In Herefordshire PCT Provider Services we have set
out to build a Safety Culture by encouraging reporting
of incidents and supporting the recognition of lessons
that can be learned from incidents and ensuring that
lessons are shared and implemented to improve safety
for all patients.
Success Story
Dental Therapist, Gilly Hunt,
based at the Dental Access
Centre at Gaol Street in
Hereford has been named the
British Association of Dental
Therapist; Therapist of the
year 2010.
Gilly has been a hard working
member of staff for many
years and is an inspiration to
the team.
14
PART 3
Chart to compare of the number of serious incidents reported over the last 2 years
8
7
6
5
2008-2009
4
2009-2010
3
2
1
m
ar
ch
ja
nu
ar
y
fe
br
ua
ry
oc
to
be
r
no
ve
m
be
r
de
ce
m
be
r
au
gu
st
se
pt
em
be
r
ju
ly
ju
ne
m
ay
ap
ril
0
Herefordshire PCT is below average in its level of reported incidents as recorded
by the NPSA.
During the last 12 months the total number of incident reports has remained
similar (slightly more than 2000 incidents) across all directorates. The number of
Serious Untoward Incidents was small 12 months ago but there has been a
decrease in the number of these reported during the year (2008/09 = 34 2009/10
= 21).
4.3
Compliance with MRSA Screening Process
Published in 2006 Essential Steps to safe, clean care1 translated existing
guidance on infection control into a format that could be easily measured and
applied. This process of self assessment has been used in Herefordshire across
the Community Hospitals and inpatient intermediate care units to support the
delivery of safe care for all patients. Assurance has been provided to the board
through a monthly surveillance report.
In order to contain infection and reduce the risk of cross infection of all patients it
is necessary to screen certain categories of
people for MRSA when they arrive at the
Success Story
Community Hospital or Intermediate Care Unit.
Work of the Diabetes
Nursing team has reduced
Across the year there has been a noted
hospital admissions for their
improvement on the understanding of the
patients by 50%
usage of the tool and the application of it, and
we have seen a steady and marked
improvement in screening. When we have seen
lower numbers we have investigated the
1
Essential steps to safe, clean care: reducing healthcare-associated infections
15
reasons in detail and put actions in place to improve compliance.
MRSA Screening Compliance
Sep-09
Ross CH - Merlin
100%
Ross
CH
Peregrine
100%
Leominster CH
43%
Bromyard CH
64%
Hillside Centre
86%
Cantilupe ward
100%
Jenny Lind Ward
100%
Mortimer Ward
64%
Podiatric Surgery
100%
4.4
Oct-09
100%
Nov-09
100%
Dec-09
100%
Jan-10
100%
Feb-10
100%
Mar-10
100%
100%
74%
93%
89%
100%
100%
58%
100%
100%
73%
90%
96%
100%
100%
100%
100%
100%
40%
93%
100%
100%
100%
85%
100%
100%
94%
91%
96%
100%
100%
100%
100%
100%
96%
97%
96%
100%
100%
92%
63%
100%
100%
100%
100%
100%
100%
100%
90%
MRSA Rates
The MRSA data captures new diagnosis of MRSA infection and colonisation
within the Trusts inpatient areas March 2010 compared against the previous 12
months figures.
Over a number of years the Community Hospitals have been working with the
Infection Control Team to reduce the levels of infection and to fully explore the
origin of infections. Root Cause Analysis investigation is undertaken for every
occurrence. The lessons learned from such investigation is shared with
colleagues and new processes initiated if necessary.
2009/10 has seen the lowest number of MRSA incidents for the last 5 years.
16
PART 3
4.5 Clostridium Difficile (Cdiff) Rates
The data below captures new diagnosis of Clostridium difficile infection within the
Trusts inpatient areas March 2010 compared with the previous 12 months
figures.
C.Diff incidents are treated in the same way as for MRSA; all incidents are
investigated and lessons learned shared. 2009/10 has seen the lowest number of
incidents in the last five years.
5
Clinical Effectiveness/ Quality Measures
Essence of Care undertaken for each National
clinical Area
Reduce Mixed Sex Accommodation
Mixed Sex Accommodation reduction
plan
Compliance with NICE guidelines
National
Comply with CQUIN requirements
Regional
Service specifications written and
Local
quality and performance indicators /
activity performance indicators metric
agreed
Improve data quality
Data quality improvement plan
Glossary:
NICE National Institute for Clinical Excellence
CQUIN: Commissioning for Quality and Innovation
PIP: Productivity Improvement Programme
17
5.1
Essence of Care
During the past 12 months nursing teams
have been reviewing the Essence of Care2
benchmarks to determine if they have
improved or changed the way they are
working. Teams who have not previously
taken part in the exercise have started to
measure their service delivery using the
benchmarks. In the first instance teams
have looked at the benchmarks for ‘Privacy
and Dignity’. All teams have now
benchmarked their service against ‘Privacy
and Dignity’. This has lead to changes
being made to the way we do things to take
account of the personal privacy and dignity
of patients/ service users.
5.2
Success Story
105 Apprentice placements
were offered in services
around Herefordshire (60 more
than last year).
65 have been offered advance
placements for further training
and learning next year
80% of Apprentices take up
work in the care sector.
Reducing Mixed Sex Accommodation
Herefordshire Provider Services were able to declare their virtual compliance with
the national target for single sex accommodation.
During the past 12 months work has been undertaken to address the concerns
about mixed sex accommodation. In the Mental Health inpatient area structural
work has been undertaken, to provide single sex bathrooms and toilets.
In Intermediate Care Facilities and Community Hospitals work has been
undertaken related to the planned use of facilities to reduce the occasions where
different genders have to share the same facilities. Where it has not been
possible to ensure that people of one gender will not be walking through an area
occupied by people of the opposite gender this has been limited to areas such as
corridors. Toilets and bathrooms are clearly designated as being for one gender
only.
5.3
PEAT (Patient Environment Action Team)
PEAT is an annual assessment of inpatient healthcare sites in England with more
than ten beds. The assessment was established in 2000 (managed by the NPSA
since 2006) and is a benchmarking tool to ensure improvements are made in the
non-clinical aspects of a patient’s healthcare experience. PEAT highlights areas
for improvement and shares best practice across the NHS.
The annual assessment took place in February. Amongst the assessors is a
patient representative. All scores are supplied to the National Patient Safety
Agency.
2
Essence of Care: Patient-focused benchmarks for clinical governance
18
PART 3
Site
Leominster
Bromyard
Ross
Hillside
Stonebow
Cleanliness/Envi
ronment
Good
Good
Good
Good
Good
Food
Good
Excellent
Good
Excellent
Good
Privacy
Dignity
Good
Good
Good
Good
Good
&
All in patient facilities assessed early in 2010 in Herefordshire Provider Services
were scored as ‘Good’ or ‘Excellent’. This included Community Hospitals and
Inpatient Mental Health Services, and shows NHS Herefordshire’s commitment to
improving its Estates and premises to improve cleanliness, environment, food
and privacy and dignity.
5.4
Compliance with NICE Guidance
The National Institute for Health and Clinical Excellence (NICE) provides
guidance, sets quality standards and manages a national database to improve
people’s health and prevent and treat ill health. Implementing NICE guidance
benefits everyone - patients, carers, the public, the NHS. It helps ensure
consistent improvements in people'
s health and equal access to healthcare.
During the period from April 1st 2009 and 31st March 2010, 65 pieces of guidance
have been issued by the National Institute for Clinical Effectiveness. The
guidance falls into 5 categories:
•
•
•
•
•
Cancer service guidance
Clinical guidelines
Interventional procedures
Public health guidance
Technology appraisals
Of the guidance issued in the 12 months 16 documents have been determined as
relevant to the services delivered in the organisation. All of these have been
circulated to relevant clinical leaders. There are 12 documents where it was
determined that we met the standard or for which we have taken steps to meet
the standard.
There have been matters within the guidance which have caused us to take steps
to change what we are doing in order to come into line with the recognised
standards. There are 3 documents where we still have steps to take to meet the
standard. These are:
Guidance name
What we are doing
Low back pain
Vagus nerve stimulation for
treatment-resistant depression
Venous thromboembolism reducing the risk
The guidance is currently being reviewed with the Musculoskeletal Service and the Integrated Commissioning team. All
Provider Physiotherapy Services are compliant
An action plan has been agreed, and is being implemented
Assessments are currently being completed.
19
5.5
Comply with National Target for 18 Weeks from Referral to Treatment
in Consultant Lead Services
The 2004 NHS Improvement Plan set out the idea for reform: “By 2008, no one
will have to wait longer than 18 weeks from GP referral to hospital treatment.”
The 18 week referral to treatment (RTT) pathway is about improving patients’
experience of the NHS - ensuring all patients receive high quality elective care
without any unnecessary delay. The 18 week maximum wait for an assessment
applies to pathways that involve consultant-led care, setting a maximum time of
18 weeks from the point of initial referral up to the start of any treatment
necessary for all patients where it is clinically appropriate and where patients
want it.
Across the year provider services were 100% compliant with this target.
5.6
Comply with CQUIN requirements
The commissioners asked us to provide information as part of a regional project
called PIP (Productivity Improvement Programme). We set up a plan to provide
information and analyse this in line with the project. This has helped us all to
understand the current services we provide, how we can improve efficiency and
to be clear about what we are doing to support people in Herefordshire. We were
able to reach each target at the appointed time.
Achievements against targets in the productivity improvement plan:
What we need to do/
Quarter 1 Quarter 2 Quarter 3
By when
Receipt of recommendations and action plans for
09/10
Submission by provider of input file for
benchmarking (BMT) (09/10)
Submission by provider of input file for Service
Line Economics (SLE) community model
Sign-up by all providers to generic quality
indicators to measure SLE tool
Submission of quality indicators for population of
SLE
Time to Care diary card exercise completed for
selected teams
Receipt of evidence based report to identify
measurable productivity improvement & service
improvement
Expected
Achieved
Expected
Achieved
Expected
Achieved
Quarter 4
Expected
Achieved
YES
YES
YES
YES
YES
YES
YES
5.7
Service Specifications Written and Quality and Performance
Indicators / Activity Performance Indicators Metric Agreed
All services have produced a document which describes the service which they
deliver, who delivers it, where, and when. It also describes the patient/ service
user group which it caters for.
Targets for activity etc were agreed with the Integrated Commissioning team
commissioners (people who pay for the service to be delivered) to decide if we
20
PART 3
were delivering the services to an appropriate standard. These targets have been
monitored throughout the year, and we have been able to show we have met
their targets.
5.8
Improve Data Quality
The type and detail of information we collect has been improved over the past
year, and staff training has addressed many of the issues we had. To do this we
have had support from Information Technology project managers who have
worked with us to tailor the data we collect and the systems we have in place. We
have more work to do to be able to have up to date accurate information which is
produced in a style which helps us to react more quickly to issues in services and
the needs for change, however we have made considerable improvements in
2009/10.
6
Patient Experience
During the last 12 months teams have asked patients/service users and carers
for their opinions of the services they are receiving. In Community Hospitals there
is a monthly survey of patient and carer opinions which is used to inform
managers and staff of the ways in which they could improve the services they are
delivering. Other services for instance Health Visitors, Podiatry and Podiatric
Surgery have undertaken patient satisfaction surveys, and we have used this
information to make changes to our services.
6.1
Mental Health Services
Mental Health Services have set up the Mental Health Reference Group, a group
of users and carers who work in partnership to lead change across services.
6.2
Sexual Health Services
Sexual Health Services undertook a Department of Health Survey of local young
people. This looked at many aspects of the service. Friendliness, Confidentiality,
Listening by staff, advice and treatment all received over 75% of positive answers
(service rated as GOOD or EXCELLENT). Areas where improvements can be
made were car parking, magazines available in waiting room, embarrassment
and waiting times. We have plans in place to
Success Story
redevelop the waiting room area at Gaol Street
to make it more comfortable for patients, and
NICE Guidance for Palliative
we are reviewing our Sexual Health services to
Care was assessed by our
see if we create additional appointments.
local specialist support team.
6.3
MacMillan Nurses
MacMillan Nurses took part in a national
survey (MORI poll). The survey showed that
the team explained their work well, that people
were happy with the support offered, the
information provided was informative and
Following this, the MacMillan
services were extended in
January 2010 to provide 24/7
expert advice and care all
day every day.
21
helped people and their families and that most people found the team easy to
speak to .
6.4
Recruiting Student Health Visitors and School Nurses
This year we invited local school pupils to take part in the selection of people to
take up places to train to become school nurses or Health Visitors. This proved
very successful. Three people were chosen to be supported to start their studies
in September.
6.5
Physiotherapy - Patient Reported Outcome Measures (PROMS)
A Physiotherapy lead service for people suffering from back pain problems has
introduced sufferers to Pilates as a way to manage their pain. Patients were
asked to record their pain levels at the start of the course and also after the 6
week course. The results of this show that people find this type of exercise
helpful and feel that it has decreased the level of pain they feel and improved
their mobility.
6.6
Parkinson’s Nurses
The team have supported the development of a pioneering project which has won
accolades for its innovation and patient satisfaction. The project was originally
conceived by local Parkinson’s patient Mike Canavan. The work has looked at
whether group singing can provide effective voice therapy for people with
Parkinson’s. The project has been declared a success by those who took part,
as well as being put forward for a national award.
7
Services Review
7.1
Service Review by Care Quality Commission
A recent review by the Care Quality Commission of the acute Mental Health
Services identified Good Practice observed:
The ‘Rights presentation’ was excellent in that it was regularly undertaken
and the recording made clear the extent of the patient’s understanding
and whether or not he had been provided with a rights information leaflet.
The Commission also noted that the leaflet includes information about the
Independent Mental Health Advocacy Service. There was evidence of
discussion about consent alongside a detailed assessment of capacity at
the beginning of the patient’s detention. The statutory consultees involved
due to the treatment plan of ECT for a patient lacking mental capacity had
provided extremely detailed accounts of their rationale for agreeing with
the treatment plan. The patient was prone to falling and the ward had
involved a physiotherapist to review his care, a falls diary had been
developed as well as a falls risk assessment and risk management plan.
22
PART 3
Success Story
The
new
Herefordshire
Intermediate
Care
Team
officially starts work on May 4th
2010 with a single point of
access and equitable service
for people across the whole
County. The service is to be
provided 24/7.
7.2 Delays in Discharge from Inpatient
Care
NHS Herefordshire Provider services have
been working with its partners to improve the
discharge of patients from Community
Hospitals and Mental Health Services.
Improvements have been made within the
year, and the overall delayed discharges
have reduced over 2009/10. However the
issue is a challenging one both nationally and
locally. Further work is underway to reduce the delays which result in people
staying in hospital longer than their medical needs indicate is necessary. The
development of a community based intermediate care team and work with our
partners in care will help us to continue to reduce delays across Herefordshire.
The data provided below provides an overall picture of delays within NHS
Herefordshire Provider Services including Community Hospitals, Intermediate
care and Mental Health, and those contracts for other In-Patient beds in the
community commissioned by NHS Herefordshire (excluding Hereford Hospitals
NHS Trust)
Number of bed days lost due to delay in discharge:
!
7.3
" #"# $" $
% & & "' $
"' (
Management of Complaints
During the year 52 letters of complaint were received by Herefordshire Provider
Services, of these 76% were sent an acknowledgement within 3 days.
We aim to acknowledge all letters within 3 days; however, complaint letters and
phone calls are received at various places in the organisation. The rural nature of
the area the organisation serves and therefore the distance between our staff
bases sometimes leads to delays in receipt of the letters at a point where an
acknowledgement can be sent and an investigation of the complaint can be
started.
23
Acknowledgement of complaints following receipt in service
9
8
7
6
5
4
3
2
1
0
Apr-09
May09
Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10
Responses within 3 days
Over 3 days
We are looking at the way we are managing the process as well as ensuring our
staff know what to do when they receive a complaint; giving due regard for
maintaining the confidentiality of an individual’s information when we pass on the
complaint to be dealt with. We are working closely with the NHS Herefordshire
and Herefordshire County Council Customer Insight Unit to ensure a coordinated approach to complaints management and response times.
8.
Service Improvements
8.1
Podiatric Surgery
The department has developed into a sub-regional “Centre of Excellence”. The
service undertakes 1000 operations and 5000 outpatient appointments per year.
Podiatric Surgery has out of county contracts with neighbouring counties which
account for about 50% of the department’s activity. Since the mid - 1990s
services have been provided by the Podiatric Surgeons of Herefordshire to
surrounding counties: Powys, Gloucestershire, Telford and Wrekin, South
Shropshire and Worcestershire. The team accept patients from across the
Country.
8.2
Community Hospitals and Intermediate Care
Across our community inpatient service (Ross Hospital, Leominster Hospital,
Bromyard Hospital and Hillside Intermediate Care) we have implemented the
NHS Institute “Releasing More Time to Care”. It is a part of a series of ways in
24
PART 3
which the NHS has been changing services according to the LEAN processing.
This is a Community Hospital improvement plan which looks at the way we
manage and communicate in our Community Hospitals and looks at way that
they can be simplified and streamlined.
This programme of work means that nurses have more time to spend with
patients and carers and the development of more systematised processes will
improve patient care. The programme has already resulted in release of 21%
trained nurse direct care time, (based on minute interval observations of an eight
hour shift,) and we have seen improvements in patients satisfaction with services
(see overleaf), which shows an increase in positive comments from patients
about their experiences during their stay with us.
8.3
MacMillan Nurses
Since January 2010, MacMillan Nurses are providing a 24/7 service in response
to the End of Life Strategy (DOH, 2008) and the Supportive and Palliative Care
Guidance for Adults with Cancer (NICE, 2004). Development of the service has
ensured that one of the most vulnerable client groups within Herefordshire Health
community and the health professional caring for them can now access specialist
support at week ends and bank holidays.
In the first twelve weeks of operation with one nurse on duty at week ends and
bank holidays, the service was accessed on 218 occasions by patients or carers
25
Success Story
Physiotherapists have been
supported by Practice Based
Commissioners to develop a
12 month pilot to provide
services at rural surgeries.
This will improve access for
those who find it difficult to
travel to the centres where
services are already provided.
8.4
and
129
occasions
by
healthcare
professionals. This new pattern of working by
the Macmillan Community Palliative Care
Service ensures support to health care
professionals in providing care, and ensures
that all patients in the palliative care phase of
an illness receive valuable support and
information at a time when they may be
feeling very vulnerable.
Community Intermediate Care
Since June last year work has been underway to amalgamate the existing
Community Intermediate Care teams from both Social Care and PCT into one
new countywide service. This will provide a more comprehensive and coordinated team, whose remit is to support people to remain in their own homes
via short term input from a multi-disciplinary team of staff. They work to both try
and avoid people being admitted into hospital/residential care unnecessarily and
to support a more timely discharge from inpatient facilities should someone be
admitted.
8.5
Physiotherapy
This year has seen the successful start of a new contract with the Rural GP
Practices to provide surgery based physiotherapy giving much improved access
to physiotherapy in rural areas.
Patients are now able to Self-refer to surgery based Physiotherapists, giving
better /quicker access to assessment and treatment plus a reduced need to take
up GP appointment time.
Choose and Book is now being offered for Physiotherapy services, enabling
better access to the service, across the county.
8.6
Occupational Therapy Services
The service has developed a new staff role of assistant therapist to support the
increased demand for services (18% more people asking for support over the last
3 years). The Falls Support Service is providing ‘Stay Steady’ Groups across the
county supporting improved independence for older people.
8.7
Intermediate Diabetes Service
The Diabetes Specialist Nurses is part of a shift of focus from hospital to
community care. In two years the service has improved access to specialist
services for patients, carers and staff working in the community and provided a
bridge between primary and secondary care providers, facilitating effective
26
PART 3
patient pathways and proven to be highly cost effective. In the first year referrals
to hospital specialist services were reduced by 50%.
8.8
Acute Mental Health Services
Refurbishment of Mortimer Ward, Jenny Lind Ward and ground floor public
access areas has been completed this year at the Stonebow Unit. Service Users
were consulted on aspects of the refurbishment and the work has made the
environment much more welcoming for patients, carers, visitors and staff.
Thanks go to NHS Herefordshire, the Strategic Health Authority and Charitable
Trust funds who have all contributed to the costs of the redevelopment.
8.9
Apprenticeships
Our services continue to support placements for local young people to gain
experience of working whilst gaining nationally recognised qualifications and
being paid an allowance for their studies. For many young people this offers a
realist way into work, and helps young people into work, and boosts the local
economy as well as providing well trained staff for local services.
8.10
Change Champions
Last year, 100 colleagues in Herefordshire PCT and Council took the challenge
through the Change Champions Transformation Programme 2009. Teams of
Change Champions were each tasked with helping services to drive improvement
in a key performance area.
One area where the champions have been working is on the ‘flow’ of patients
across services, helping to reduce the blockages in the system. They have
looked across the services from patients
arriving at the local acute hospital, through
Success Story
local Community Hospitals etc to the point
where they are in their own homes being Podiatric
Surgery
Service
supported by community services either recognised as a national
health or social care.
‘Centre of Excellence’ by the
Faculty of Surgery of The
College of Podiatrists (the
organisation which sets the
standards for training and
clinical practice for Podiatric
Surgery
in
the
United
Kingdom)
27
8.11 What Others Say About Us:
NHS Herefordshire’s (Commissioning Arm)
Commentary on Herefordshire PCT Provider Services Quality Accounts
High Quality Care for All, published in June 2008 set out the requirement for
all providers of NHS services to publish Quality Accounts annual reports to
the public on the quality of health care services they deliver. NHS
Herefordshire is pleased to endorse Herefordshire PCT provider services first
Quality account which provides information with regard to the quality of the
services it provides to the public.
Based on the knowledge NHS Herefordshire commissioners has of
Herefordshire PCT provider services, we believe that this report is a fair
reflection of the healthcare services provided. The report celebrates the
successes and improvements in quality but is balanced in that it recognises
those areas which require further development.
NHS Herefordshire commissioners monitor the quality performance of PCT
Provider services monthly through the Clinical Quality Review Forums.
Performance data in relation to quality is presented and verified, and action
plans supported to address areas of less than optimum performance.
NHS Herefordshire supports the overall broad priority areas for quality
improvements identified by PCT providers in these quality accounts and looks
forward to the detailed action plans, which will identify the desired outcomes
for patients, following these improvements in systems and processes
Nicky Willett
Associate Director of Nursing, Quality and Clinical Leadership
NHS Herefordshire
May 2010
28
PART 3
8.12 Herefordshire Council: Health Scrutiny Committee
Commentary on Herefordshire PCT provider Services Quality Accounts
29