Salisbury NHS Foundation Trust Quality Account 2009 / 2010 Quality Report Current view of Trust’s position and status of quality The Trust has continued to make significant progress over the last year around the key quality measures that impact on patients’, their families’ and visitors’ experiences through Striving for Excellence. This initiative, which started in 2008, has had a positive influence on the culture of the organisation and further emphasised the need to put quality at the centre of everything we do. This is reflected in a number of positive improvements over the year. These include: improvements to ward areas to help with privacy and dignity, reduced mortality rates, reduced length of stay for patients, low infection rates and high standards of cleanliness. The Trust is a national site for clinical dashboard development which is helping clinicians retrieve and use up-to-date clinical information to improve patient care. The Trust is also a national exemplar site for its work on risk assessment and prevention of venous thromboembolism (VTE). In the latest published performance ratings the Trust again complied with all the core standards and was given a rating of Good for its quality of services. Quality improvement capacity and capability Striving for Excellence has continued to focus attention on areas where the Trust could improve and this has driven changes across the Trust’s services. All quality improvements are linked to the way in which we plan our services and link to key themes around safety, service improvement, patient and public involvement, customer care and staff wellbeing. Quality remains at the heart of all planning and development and the way in which the Trust carries out its day-to-day work. This provides the quality assurances that are so important to the Trust, its patients and staff. For instance, quality of care is measured within directorates as part of their service reviews, as well as in mid and end of year reports. Provision of high quality care is a principle priority for the Trust and the Trust Board is committed to improving quality through a ‘whole organisation approach’. This can be viewed in directorate level plans and reporting processes. Quality is monitored regularly by the Board through a number of measures and indicators. This commitment will continue through a number of priorities for 2010/2011, which have been developed in accordance with views and comments from clinical staff, local people, commissioners and the Trust’s governors. These priorities will be addressed later in the Quality Account. Our staff continue to work hard to provide excellent standards of care and review and develop new ways of improving the experience of our patients. We cannot continue to make improvements without their commitment and professionalism and on behalf of the Board, I thank them for all their efforts so far and recognise the significant contribution that they will make in the future. To the best of my knowledge the information in this document is accurate. Matthew Kershaw Chief Executive 7 June 2010 The Trust also uses for example, clinical audit results, patient feedback, learning from complaints and safety reports. This information is used to show where improvement might be needed and objectives are then set in directorate and department service plans. Departments have also been fully involved in the development of the Trust’s long term vision and strategy, and planning in their own areas has had to take into account the need to maintain high standards of care within the current and future economic environment. The Trust has built on the success of its Executive led safety walk rounds which are now in their second year, by introducing a similar initiative during 2009, called quality walks. This enables staff to talk directly 2 Quality Narrative with Executive and Non Executive directors. The quality walk also enables each service to review its performance using information gained through several methods, including real time patient feedback, clinical audit results and key quality indicators. The Trust Board receive a quality indicator report every month and at every Clinical Governance Committee a patient story is heard. These stories may have come from complaints, incidents or from service improvement projects. The quality indicators and patients’ stories ensure the Trust keeps focused on the things that are important to our patients. The Trust acknowledges that staff wellbeing, capability and support are key to ensuring that quality remains a focus for the Trust and that staff are well equipped to take forward ideas and initiatives that benefit their patients. Better and more innovative use of technology to support education and training, appraisal systems and an ongoing review and introduction of new healthy lifestyle initiatives continue to be key features in the staff wellbeing strand of Striving for Excellence. Staff have also been recognised and rewarded for good customer care, service improvements, learning, mentoring, leadership and multidisciplinary team working, in the Trust’s annual Striving for Excellence awards ceremony. How we have prioritised our quality improvement initiatives We have used a wide range of methods to gather information and determine our priority areas. This includes results from national patient surveys, real time patient feedback from wards, and comments, compliments and concerns made through our Customer Care Department. We also used risk reports and issues raised by staff during the executive led safety and quality walk rounds. Priorities have also been discussed with clinical teams as part of the service planning process and the development of the Trust’s long term vision and strategy. Having identified a number of areas we have then gathered views from our Foundation Trust Governors and our staff and engaged with local people through a wide range of health fairs, before making our final choice. A number of their comments are included in this report. 3 The Trust Board has agreed that while good progress was made on last year’s priorities, further improvements can be made and additional work areas have been identified. A number of these work areas complement our CQUIN scheme (Commissioning for Quality and Innovation) and support the Care Quality Commission (CQC) regulations. The Board is, therefore, committed to achieving the following priorities. Although the priority areas remain the same as 2009/2010, the work to support them is different. The priority areas are of equal importance. Our selected priorities and proposed initiatives for 2010/2011 are: Priority 1 Continue to improve the in-hospital mortality rate to bring the Trust within the best performing hospitals in the country Priority 2 Ensure patients privacy and dignity is maintained during their stay, and improve responsiveness to their needs Priority 3 Reduce the average length of stay for all inpatients by 10% Priority 4 Increase the percentage of patients who rate the quality of care they received in the hospital as good or better Priority 5 Enforce zero tolerance for MRSA and Clostridium Difficile infection rates Progress in these priority areas will be monitored through the Trust’s clinical governance framework. The selected quality metrics will be reported through the quality indicator report, which is published every month for the Trust Board, Clinical Governance Committee and Clinical Management Board. Work is currently underway to ensure this report is published on the Trust’s website for our members and the public. Both the Medical Director and Director of Nursing lead in these priority areas. CONTINUE TO IMPROVE THE INHOSPITAL MORTALITY RATE TO BRING THE TRUST WITHIN THE BEST PERFORMING HOSPITALS IN THE COUNTRY Description of issue and rationale for prioritising HSMR (Hospital Standardised Mortality Ratio) is an indicator of healthcare quality and safety that measures whether the death rate at a hospital is higher or lower than you would expect. The average for all Trusts across the country is an HSMR of 100%. So an HSMR under 100% is better than average. Our current HSMR is 88.8% and is therefore good when compared to most other hospitals. Nationally the use of HSMR to measure mortality is being looked at. We will continue to monitor our deaths by HSMR and by actual number of deaths until the new national measure has been agreed. Meanwhile we will continue to put a number of initiatives in place which will reduce preventable deaths. What did we do last year to support this improvement? We continued to focus on the specific work within our Patient Safety Project. These were described in last years quality account: • Executive Safety Walk Rounds continued. An Executive Director visited a different department each week to discuss any safety issues with staff. By October 2009 all clinical departments had been visited and we are now repeating those visits and extending them to other departments such as housekeeping, catering, and portering. • We continued to carry out monthly reviews of notes to identify what was causing harm to patients whilst in hospital. We have used this information to identify new areas of focus such as nutrition and avoidance of pressure ulcers, as you will see further on in this year’s Quality Account. • We have implemented practices within the Intensive Care Unit to reduce infection rates further (care bundles). • As part of our work around the deteriorating patient, safety briefings have been introduced within a number of ward areas and we shall continue to increase these in 2010/11. • Within the theatres we have introduced the World Health Organisation Safe Surgery Checklist and STOP moment for each operation that takes place to improve safety and team working. The Trust was short listed for a national safety award for this work Progress on all these areas of work has been reported on a monthly basis to the Safety Steering Group. Current Status HSMR (3 year) National Trust Actual 105% 100% 95% 90% 85% 80% 2006-07 2007-08 2008-09 2009-10 Year HSMR per year from 2006-07 to 2009-10 What have our patients/ public told us? What will we do in 2010/2011? “Heard of DVT, never VTE – obviously good to prevent” “I think people need to know more about what to look for. I thought I had cramp – it was a DVT. I had no idea what it felt like” The Trust will continue to work hard at improving patient safety and improving the mortality rate further. • Venous thromboembolism (VTE) - The Trust is a national exemplar site for VTE and has a work programme in place to increase the number of patients undergoing a full assessment for risk of VTE to 95% from our current rate of 72% • We will continue with our Patient Safety project which has key areas of work aimed at improvement in: oLeadership for Safety oReducing Harm in Critical Care oReducing Harm in Perioperative Care (Theatres) oReducing Harm from Deterioration (Wards) oReducing Harm from High Risk Medicines (with particular focus on warfarin and insulin) Further details of these pieces of work can be found through the South West Strategic Health Authority website for the regional programme at www.southwest.nhs.uk or through the Institute for Health Improvement at http://www.ihi.org/ IHI/Programs/StrategicInitiatives/SaferPatientsNetwork.htm 4 PRIORITY ONE How will we report progress throughout the year? The Trust has a Safety Steering Group that will monitor the progress with this work on a monthly basis and report to the Clinical Governance Committee every three months PRIORITY TWO ENSURE PATIENTS PRIVACY AND DIGNITY IS MAINTAINED DURING THEIR STAY AND IMPROVE RESPONSIVENESS TO THE NEEDS OF PATIENTS Description of issue and rationale for prioritising Our patients expect to be treated with dignity and respect. They should also be able to expect services which are responsive to their needs. Dignity and respect mean different things to people but as you can see, further on, in the table of results from the recent national inpatient survey, our patients told us that they wanted to be involved more in decisions about their care and treatment, and felt that they needed more privacy when having their condition or treatment discussed. We acknowledge that we need to do more to achieve this for our patients. The NHS Constitution gives patients ‘the right to be treated with dignity and respect in accordance with human rights’. What did we do last year to support this improvement? Last year we focused on making structural changes to the sleeping areas and toilets on each of the wards. We also ran a successful campaign amongst staff and patients about same sex accommodation. Using the ‘real time feedback’ system in place in the Trust (asking patients who are currently in hospital to tell us about their experiences) we have monitored patients’ views and addressed issues as they arose. This year’s national inpatient survey showed that we have improved with 86% (81% last year) of patients not sharing accommodation with patients of the opposite sex. More still needs to be done and we aim to improve this. 5 We took part in the latest national audit on the end of life care using the Liverpool Care Pathway (LCP). The results showed that Salisbury had this pathway of care in place across 94% of the organisation, putting it in the top quartile in the country. Work will continue on this important aspect of care. The Trust also undertook the first ‘quality walk’ which enables Executive Directors and Non Executive Directors from the Clinical Governance Committee to visit wards to discuss and observe the quality of care and the compassion of staff. Patients are also invited to comment on what it is like to be a patient on the ward. What have our patients/public told us? “You have obviously done a lot of work since the last year on making sure patients don’t share rooms with members of the opposite sex” “I would recognise the nurse and doctor but do not know their name….” “…need to keep to keep people informed of what’s happening…there is a staff attitude with this in some areas” Current Status National Inpatient Surveys 2008/2009 and 2009/10 Were you involved as much as you wanted to be in decisions about your care and treatment? 2008 Mean score 74 2009 Mean score 69 During your stay in hospital , did you ever share a room or bay with patients of the opposite sex Were you given enough privacy when discussing your condition or treatment 81 86 85 81 Did you find someone on the hospital staff to talk to about your worries or fears Overall did you feel you were treated with respect and dignity while you were in hospital 57 89 56 88 Mean Scores for the 2008 compared to 2009 national inpatient survey results We will put a number of pieces of work in place that will help our staff deliver the quality of care they would want for themselves and their family. • We will continue the programme of ‘Quality Walks’ to include both Inpatient and Outpatient areas, and ensure action is taken to resolve any issues that arise. We will also share any good practice with wards and departments across the Trust. • End of Life Care – we will continue to improve the care for our dying patients, ensuring that they are treated as individuals, without pain and other symptoms. We will work with our primary care colleagues to ensure we are aware and follow the wishes of patients and their families about treatment decisions and choices. • Same Sex Accommodation – we will publish our delivery plan for 2010/11 on our web site and continue to make improvements so that no patient shares a room or bay with patients of the opposite sex. • The Kings Fund Point of Care programme - we will participate in this new national programme which aims to transform patients’ experience of care in hospital. The programme grew from the recognition that compassionate care in acute hospitals is not consistently experienced by patients and their families. How will we report progress throughout the year? The Clinical Management Board (CMB) will monitor the progress with this work monthly and report to the Clinical Governance Committee every three months PRIORITY THREE REDUCE THE AVERAGE LENGTH OF STAY FOR ALL INPATIENTS BY 10% Description of issue and rationale for prioritising By comparing our figures with other similar hospitals and listening to our patients and their families, the Trust knows there is room to reduce length of stay for patients so that they do not spend unnecessary days in hospital. Reducing hospital admissions and caring for people more appropriately outside of hospital is key to delivering an efficient high quality service. However, when hospital care is needed we should minimise that time whilst not undermining patient safety and quality of care – we can do this by improving the level of care so that patients recover more quickly and are ready to leave hospital sooner. We will continue to adoopt best practice in this area. What did we do last year to support this improvement? As part of our Right Treatment, Right Time, Right Place Programme a number of clinically led project teams have been improving the pathways of emergency patients through the hospital. This has involved pilot projects in our Emergency Department to reduce the time spent by patients in the Department as well as the development of an ambulatory assessment approach in our Medical Assessment Unit (MAU). This enables patients to be diagnosed and treated quickly, returning them to their own homes as quickly as possible where appropriate. The MAU have also worked with local GPs to improve the information we receive from them when patients are admitted to hospital to help to plan their ongoing care. 6 What will we do in 2010/2011? By working with GPs they have also been able to secure earlier referrals and admissions to the hospital so that patients don’t arrive, all together, very late in the day. Current Status Average Length of Stay 2008 - 09 2009 - 10 7.00 Our surgical and ward teams have been working on improving the discharge of patients by not delaying them unnecessarily due to, for example, waiting for medications. They have also been improving the use of our newly refurbished Discharge Centre to ensure that our beds are freed up early in the day for new admissions, whilst providing outgoing patients with a secure and comfortable environment whilst awaiting collection. Our ward teams have developed a ‘whiteboard’ system to help them to organise the treatment and discharge plans of every patient on their ward. This involves a multi-disciplinary team meeting daily around the board and ensures patient treatment and discharge happen in a timely manner. This also helps the ward to ensure patients are discharged earlier in the day. In addition to the work on our emergency care pathways we have recently started to roll out the ‘Enhanced Recovery Programme’ which has been successfully implemented in our Colorectal Surgery Service over the last few years. This programme uses up-to-date surgical and anaesthetic techniques as well as new approaches to preparing patients for their surgery, nursing and therapy post surgery, to reduce the recovery time from surgery. What have our patients/public told us? Why don’t you use the term ‘leaving hospital’ rather than discharge …” “I think there is not anywhere for people to go when they are not quite ready to be on their own at home. There is a big gap….” Average Length of Stay 6.00 5.00 4.00 3.00 2.00 1.00 0.00 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Average Length of Stay over time What will we do in 2010/2011? We will continue to work with patients and families to implement a number of changes, including • Leaving hospital safe, well and informed – we will further develop patient information with particular attention to medication messages, discharge advice and advice on promoting health. We will use the results from our clinical audits of discharge policy and GP/patient discharge summaries along with the feedback from our patient survey of discharge care to develop solutions to any problems. • We will ensure that as the most up to date evidence (NICE) is published we will implement it. • We will work with our primary and community care partners to explore alternative models and settings of care for some patients who don’t need to be in an acute hospital • We will continue to roll out the Enhanced Recovery programme in surgery and orthopaedics. How will we report progress throughout the year? Progress against length of stay as well as a number of other objectives such as time to surgery, is monitored through the Programme Steering Groups and the Joint Board of Directors meetings every three months. The Clinical Management Board will monitor the work on leaving hospital and on implementing ‘best practice’. 7 INCREASE THE PERCENTAGE OF PATIENTS WHO RATE THE QUALITYOF CARE THEY RECEIVED AS VERY GOOD OR BETTER Description of issue and rationale for prioritising It is important that the Trust does everything that it can to provide the best possible experience for each patient. If our patients are telling us that the quality of care is not as good as they would like, then we must identify those areas of concern and work to improve them. In the latest national inpatient survey only 75% of patients rated their care as excellent or very good. We have to improve this. What did we do last year to support this improvement? • We continued regular ‘real time’ feedback surveys in order to gather up to date views and comments from patients on our wards. • We continued to improve our meal time experience for patients through work undertaken by the Nutrition Steering Group and the catering department in improving menu choice and the food available. A flexi menu trial took place on two wards, the menus on these wards carried a choice of 79 dishes twice a day, and the aim was to identify food preferences and the times when patients prefer to eat. The trial resulted in 65 changes being made to our menus. • We completed a survey measuring patients’ expectations and perceptions of food within the hospital. As a result of the feedback from this we purchased temperature monitoring equipment as food temperature was an area patients were most unhappy with. • We introduced an ‘allergy aware’ scheme where new menus have been devised with a green tray system, in conjunction with the South West Coeliac Society. Our catering staff have also undergone training as part of this ‘allergy aware’ work. • We introduced trials of small appetite/nutritionally dense meals after identifying high levels of food waste in areas such as the Hospice and Elderly Care. The trial has proved to be very successful and from March 2010 has been offered on the standard menu across the Trust. • Our Patient Food Forum which has patient and public membership continues to meet and inform the Trust on meals available or proposed by our team of chefs. This has resulted in a range of signature dishes identified on the menu. • The Productive Ward – Releasing Time to Care programme continued throughout the year and all wards are now involved. This programme is designed to enable the nursing staff to review the way they work with the aim of helping them to have more time to spend on direct patient care. Improvements have been made through the implementation of bedside patient handovers at shift changes which makes the patient part of this communication process. We have undertaken a review of laundry delivery time and amount of linen delivered to fit better with the ward needs. We have also carried out work on some wards to improve the drug rounds process to ensure medicines are given on time and within safe procedures. • The development of an information centre where patients can access general information related to their health needs has been agreed in principle but requires building work to achieve. We are currently looking at how we can complete this and what alternatives there may be. However the Trust was the first general hospital in the country to achieve the ‘information standard’ for its patient information leaflets. What have our patients/public told us? “Don’t think much of the care ….. staff too busy doing other things” “Experienced very good care. No problem with quality of care and treatment” “With food there has been a drastic improvement” 8 PRIORITY FOUR Current Status through the CMB and on to the Clinical Governance Committee. Our commissioners will also receive reports as part of our contract with them. Overall, How would you rate the quality of care you received? (Q27) Excellent Very Good Good Fair Poor 100% 90% PRIORITY FIVE 80% 70% 60% ZERO TOLERANCE OF MRSA AND CLOSTRIDIUM DIFFICILE INFECTION RATES 50% 40% 30% 20% 10% 0% Sept & Oct 08 Nov & Dec 08 Jan & Feb 09 Sept & Oct 09 Nov & Dec 09 Jan & Feb 10 Real time feedback is a method used in the Trust where current inpatients are asked a number of questions about their experience in Salisbury District Hospital (an average of 100 patients are questioned each month) What will we do in 2010/2011? • Productive Ward: Continue the Productive Ward – Releasing Time to Care Programme to ensure that all wards have completed all modules. • Nutrition: Continue with our work on improving the nutrition and hydration of patients through improving the meal time experience and ensuring patients are assessed on admission for their nutritional status, and receive the help and support required to ensure that they receive a well balanced diet throughout their stay. • Implement our seasonal menus which will be reviewed on a quarterly basis (part of the Department of Health ‘Eat Seasonally’ campaign). We shall also continue to increase the percentage of food sourced locally. • Continue to gather patient feedback on the meal time experience. • Publish a Food and Nutrition policy with measurable standards which we can measure our performance against. • Pressure Ulcers: Reduce the number of patients developing serious (grade 3 and 4) pressure ulcers (sores) in hospital. This will be achieved through a focused piece of work encompassing how patients are assessed on admission for their risk of pressure sores, education for clinical staff including the links between ulcers and nutrition, and ensuring we carry out full investigations of any grade 3 or 4 pressure ulcers which do occur in hospital to ensure that we learn from these events to improve practice further. How will we report progress throughout the year? 9 Both nutrition and pressure ulcers are reported on the Trust quality indicator report which goes to the CMB every quarter. The work programmes will be reported Description of issue and rationale for prioritising Clostridium Difficile (C.Difficile) is a major cause of nosocomial diarrhoea with potentially fatal outcomes. Its incidence has increased significantly in recent years, partly with the emergence of more virulent strands. Rapid and accurate diagnosis of C.Difficile infection is essential for the management of patients and institution of adequate infection control practices. Methicillin-resistant Staphylococcus-aureus (MRSA) is a bacterium that can cause serious infections. It is resistant to numerous antibiotics of the beta-lactam family, including methicillin and penicillin. MRSA belongs to the large group of bacteria known as staphylococci, often referred to as staph. About 25-30% of all people have staph within the nose, but it normally does not cause an infection. In contrast only about 1% of the population have MRSA. Although the Trust has low infection rates for both MRSA and Clostridium Difficile, the prevention and control of infection is seen as a high priority for patients and a significant measure of quality of care. With infection rates coming down year on year, it is essential that the Trust continues to make further progress with specific attention to Clostridium Difficile. What did we do last year to support this improvement? The Trust has zero tolerance to poor infection control practices and sees this as everyone’s responsibility. • We continued the emphasis on hand washing through the Clean your Hands Campaign. • We established an ongoing monthly audit in all clinical areas of hand washing practice to ensure we continue to improve in this area. • We continued the three times a week infection prevention and control update meetings covering every aspect of cleanliness, practice (hand washing, uniform and work wear policy), and the management of infection across the whole site. Current Status MRSA Notifications 2008 - 09 2 1.5 1 0.5 0 What have our patients/public told us? 2009 - 10 2.5 Notifications • We monitored antibiotic prescribing practices across all specialities and have agreed a rolling audit programme to maintain appropriate practice. • We continued to monitor cleaning standards through the Credits for Cleaning audit programme. • We reviewed and developed detailed cleaning schedules with clear responsibilities for every clinical area, which is monitored through the monthly Matrons’ Monitoring meeting. • We continued to raise awareness with the public through our competition for a new design for gel dispensers in the hospital. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Number of MRSA Bacteraemia Notifications Clostridium Difficile Notifications per 1000 Bed Days 2008 - 09 5 “..I observed staff using hand wipes” 3 2.5 2 1.5 1 0.5 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Clostridium Difficile Rates What will we do in 2010/2011? We will work with staff, patients and visitors to • Sustain our improvement through the actions described above to achieve our targets of zero for both MRSA and C.Difficile. • Complete the dirty utility room (sluice) upgrade programme for every inpatient area. • Continue to reduce our infection rates from lines and interventions through the implementation of care bundles and the work in the Patient Safety Project (priority 1). How will we report progress throughout the year? Infection rates are reported to the Trust Board monthly. A bi-annual report from the Director of Nursing is also made to the Trust Board and the Trust will continue to comply with the Care Quality Commission (CQC) Hygiene code. 10 “…if it looks clean you feel much more confident …” 4 3.5 Notifications “Salisbury is quite good at infection control – seen it in the local paper and the league tables in the Telegraph.” 2009 - 10 4.5 Review of Services During 2009/2010 Salisbury NHS Foundation Trust provided and/or subcontracted forty four NHS services*. Salisbury NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these services. The income generated by the NHS Services reviewed in 2009/2010 represents 87% of the total income generated from the provision of NHS services by Salisbury NHS Foundation Trust for 2009/2010. *The services have been defined from ‘service line reporting’ Participation in Clinical Audits During 2009/2010, 34 national audits (of which 19 are ongoing datasets) and 7 national confidential enquiries covered NHS services that Salisbury NHS Foundation Trust provides. During 2009/10, Salisbury NHS Foundation Trust participated in 100% 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 Salisbury NHS Foundation Trust was eligible to participate in during 2009/2010 are listed in the table below. The national clinical audits and national confidential enquiries that Salisbury NHS Foundation Trust participated in during 2009/2010 are also listed in the table below. The national clinical audits and national confidential enquiries that Salisbury NHS Foundation Trust participated in, and for which data collection was completed during 2009/2010, 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. 11 % of cases submitted Audits Eligible Participation to each audit NCEPOD NCEPOD Deaths in acute hospitals Yes Yes 100 NCEPOD Acute kidney injury Yes Yes 100 NCEPOD Elective & emergency surgery Yes Yes 100 NCEPOD Parenteral nutrition Yes Yes 100 NCEPOD Paediatric surgery Yes Yes 100 NCEPOD Peri-operative care Yes Yes 100 CEMACH: perinatal mortality Yes Yes 100 NCEPOD Cosmetic surgery n/a n/a n/a National Audits National Kidney Care Audit (2 days) n/a n/a n/a National Sentinel Stroke Audit (n=40-60) Yes Yes 100 National Audit of Dementia: dementia care (n=40) Yes Yes 100 National Falls and Bone Health Audit (n=60) Yes Yes 100 POMH: prescribing topics in mental health services n/a n/a n/a National Comparative Audit of Blood Transfusion: Yes Yes 100 changing topics British Thoracic Society: respiratory diseases Yes Yes 100 College of Emergency Medicine: pain in children; Yes Yes 100 asthma; fractured neck of femur National Mastectomy and Breast Reconstruction Audit Yes Yes 100 National Oesophago-gastric Cancer Audit Yes Yes 100 RCP Continence Care Audit Yes Yes 100 Carotid endarterectomy Yes Yes 100 Use of blood in primary elective hip replacements Yes Yes 100 National comparative audit of blood collection Yes Yes 100 Adult asthma audit Yes Yes 100 Early Rheumatoid Arthritis (ERAN) Yes Yes 100 Health promotion in hospitals Yes Yes 100 % of cases submitted Audits Eligible Participation to each audit Continuous audits / datasets (no planned end date) NNAP: neonatal care Yes Yes 100 NDA: National Diabetes Audit Yes Yes 100 National Elective Surgery PROMs: four operations* Yes Yes Variable across 4 procedures NIAP: Adult cardiac interventions: coronary angioplasty n/a n/a n/a Congenital Heart Disease: Paediatric cardiac surgery n/a n/a n/a Adult cardiac surgery: CABG and valvular surgery n/a n/a n/a Renal Registry: renal replacement therapy n/a n/a n/a Pulmonary Hypertension Audit n/a n/a n/a NAPTAD: anxiety and depression n/a n/a n/a NHS Blood & Transplant: intra-thoracic; n/a n/a n/a liver; renal transplants ICNARC CMPD: adult critical care units Yes Yes 100*since Feb10 NJR: hip and knee replacements Yes Yes 100 NLCA: lung cancer Yes Yes 100 NBOCAP: bowel cancer Yes Yes 100 DAHNO: head and neck cancer Yes Yes 100 MINAP (inc ambulance care): AMI & other ACS Yes Yes 100 Heart Failure Audit Yes Yes 100 Heart Rhythm Management Yes Yes 100 NHFD: hip fracture Yes Yes 100 *since Dec 09 TARN: severe trauma Yes Yes 100 NHS Blood & Transplant: potential donor audit Yes Yes 100 Cardiac Rehabilitation Yes Yes 100 Use of Red Cells in Neonates and Children Yes Yes 100 National Vascular Database Yes Yes 100 Cancer registry audit of new urological cancers Yes Yes 100 Audit of complex urological operations Yes Yes 100 The reports of all published national clinical audits were reviewed by the provider in 2009/2010 and Salisbury NHS foundation Trust intends to take the following actions to improve the quality of healthcare provided. • Action plans have been developed for all national audits and confidential enquiries and these have been agreed by the Clinical Management Board. Monitoring of these actions will be through the 3:3 performance structure or through designated working groups, for example with the acute kidney injury (NCEPOD) the improvements are being undertaken by the ‘Reducing Harm from Deterioration (Wards)’ group The reports of 124 of 334 local clinical audits were reviewed by the provider in 2009/2010 and Salisbury NHS Foundation Trust intends to take the following actions to improve the quality of healthcare. • A report of all clinical audit results that indicate a risk to patients or the organisation are reported to the clinical risk group – examples of work undertaken to improve practice include fluid balance chart completion, better record keeping • All infection control audit reports were reviewed by the infection control group and changes to the commode cleaning process were made, as well as improvements to the cleaning hands signs for patients and visitors • Ward based audits based on ‘essence of care’ areas such as nutrition, communication, privacy and dignity were undertaken - these audit reports were reviewed by the nursing and midwifery forum and a number of changes have been made around call bells and meal time practice. 12 The Trust started collecting data for the heart rhythm management audit in October 2009, after being notified by the CQC that we were not participating. • 36 audits were undertaken by the maternity service to support the NHSLA (NHS Litigation Authority) standards • Other audit results / reports are reviewed by the Head of Clinical Governance and comments, suggestions for change are returned to the authors as well as a suggested re-audit timescale as appropriate Salisbury NHS Foundation Trust participates in a number of audits that are not on the national clinical audit advisory group list and these have been included in the table above. This activity is in line with the Trust’s annual clinical audit programme which aims to ensure that clinicians are actively engaged in all relevant national audits and confidential enquiries as well as undertaking baseline audits against all NICE guidelines. This enables the Trust to benchmark their performance against others nationally, to determine the focus of improvement programmes. Research The number of patients receiving NHS services provided by Salisbury NHS Foundation Trust in 2009/2010 that were recruited during that period to participate in research approved by a research ethics committee was 197. This compares to 114 last year. This increasing level of participation in clinical research demonstrates Salisbury’s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. Goals Agreed with Commissioners A proportion of Salisbury NHS Foundation Trust’s income in 2009/2010 was conditional upon achieving quality improvement and innovation goals agreed between Salisbury NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the commissioning for quality and innovation payment framework. The planned income for 2009/2010 was £703,554. The amount received was £124,340, which was less than the planned amount for reasons outside our control. Further detail of the agreed goals for 2009/2010 and for the following 12 month period are available on request from the Finance Department, Salisbury NHS Foundation Trust, Salisbury District Hospital, Odstock Road, Salisbury, SP2 8BJ. Care Quality Commission (CQC) Registration Salisbury NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is registered for the Hygiene Code. As of the 31st March 2010 Salisbury NHS Foundation Trust has no conditions on registration. Salisbury NHS Foundation Trust is not subject to periodic review by the Care Quality Commission. Salisbury NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period. A number of the special reviews for 2009/10 are not due data collection until April 2010 which is outside this reporting period. The Care Quality Commission has not taken enforcement action against Salisbury NHS Foundation Trust. Data Quality Salisbury NHS Foundation Trust submitted records during 2009/2010 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data which included the patient’s valid NHS number was: • 98.9% for admitted care (nationally 97%) • 98.9% for outpatient care (nationally 98.1%) • 95.8% for accident and emergency care (nationally 88.7%) Information Governance Toolkit attainment levels Salisbury NHS Foundation Trusts’ score for 2009/2010 for Information Quality Records Management assessed using the Information Governance Toolkit was 86% (81% previous v6 IGtoolkit 2008/09). 13 Clinical coding error rate error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were: Salisbury NHS Foundation Trust was subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission and the Salisbury NHS FT 2009 2010 Primary diagnosis incorrect Secondary diagnosis incorrect Primary procedures incorrect Secondary procedures incorrect 2.30% 4.70% 2.30% 4.80% 2009 National Average 4.4% 3.0% 4.7% 4.5% 13.1% 14.1% 11.2% 12.7% 2010 national audit results were not available at the time of writing. These results should not be extrapolated further that the actual sample audited. The following areas were audited: 2009: Trauma & Orthopaedics General Surgery Skin/breast/burns Complex elderly 2010: General medicine Plastics Endoscopies Neonatal Review of Quality Performance Performance of Trust against selected measures We have chosen to measure our performance against the following metrics. These areas have been chosen to cover the priority areas highlighted for improvement in this account as well as areas where our patients have told us, are important to them e.g. Cleanliness and infection control. These indicators are included in the monthly quality indicator report that is presented to the Board and CGC. Patient Safety Indicators National 2007/2008 2008/2009 2009/2010 Average What does this mean? 88.8 1. Mortality rate (HSMR – 3 Year) 101.70 100.60 100 (Estimated) Lower than 100 good Not 2. MRSA notifications 7 5 5 available Low number good 3. Patients with C. Difficile infection / 1,000 0.9 0.3 0.45 1.2 bed days Lower than 1.2 is good 4. Global Trigger / Adverse events Rates Not 44 42 Not Measured (Average) (Average) Measured 5. ‘Never Events’ that occur within the Trust. For instance, National Patient Safety Not Agency examples include operations that Measured take place on the wrong part of the body. 0 0 N/A Lower score better 0 is good 6. Patients having surgery within Higher 24 hours of admission with fracture 80% 52% 68% 61% number neck of femur (hip) better 7. % of patients who have a risk Higher Not Not assessment for VTE (venous 57% 72% number Measured Measured thrombo embolism) better 8. % patients who have a CT scan 68% 56% 89% 62% within 24 hours of admission with a stroke Higher number better 14 Clinical Effectiveness Indicators Clinical Effectiveness Indicators continued National 2007/2008 2008/2009 2009/2010 Average What does this mean? 9. Participation in national clinical audits Not 29/31 33/35 34/34 Measured 10. Compliance with NICE Technology Not 100% 83% 92% Appraisal Guidance(TAG) published in year Measured Higher number better Higher number better Patient Experience Indicators 10. Number of patients reported Not 35 45 58 with pressure ulcers (grade 3 &4) measured 11. % of patients stating the quality 78% 80% 75% 78 of care was very good or better 12. % of patients in mixed sex accommodation 25% 19% 14% 20 13. % of patients who stated they had 60% 60% 55% 72 enough help from staff to eat their meals 14. % of patients who thought 51% 61% 65% 85 the hospital was clean 15. % of patients who would recommend Not Not 82% 86% the hospital to a family or friend * Measured Measured Lower is better Higher number better Lower number better Higher number better Higher number better Higher number better Notes on recommended metrics: Please note that the figures are based on financial years – April to March 1. Based on the national definition through Dr Foster of Hospital Standardised Mortality Rate 3. National definition 4.5. Definition based on the Patient Safety First campaign 6.,7.,8. based on national definitions with data taken from hospital systems and National databases 9. Clinical audit activity is now in the body of the report so will not be reported here in future reports. 11-14, taken from national inpatient survey results and real time feedback system* Performance Against National Targets and Regulatory Requirements 15 2007/2008 2008/2009 2009/2010 2010/2011 Clostridium Difficile year on year reduction 147 73 79 tbc MRSA – maintaining the annual number of MRSA bloodstream infections at less than half of the 2003/2004 level 7 5 5 tbc 99.3% 99% 98.81% tbc 97% 96.1% 93.1% tbc For admitted patients, maximum time of 18 weeks from point of referral to treatment 87.99% 90.86% 95.2% tbc For non admitted patients, maximum time of 18 weeks from point of referral to treatment 97.2% 95.1% 98.5% tbc Maximum waiting time of four hours in A&E from arrival to admission, transfer or discharge 98.4% 98.2% 98.3% tbc Maximum waiting time of 31 days for subsequent treatments of all cancers Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers People suffering heart attack to receive thrombolysis within 60 minutes of call Maximum waiting time of two weeks from urgent GP referral to date first seen for all urgent suspect cancer referrals 2007/2008 46.87% 2008/2009 46.67% 2009/2010 55.26% 2010/2011 tbc 100% 100% 94.54% tbc Maximum waiting time of 31 days from diagnosis to treatment for all cancers 99% 99.3% 97.5% tbc Screening all elective inpatients for MRSA N/A N/A 100% tbc The Trust has fully met the national 24 core standards 24 24 N/A * People suffering heart attack to receive thrombolysis within 60 minutes of call achievement reliant on Ambulance Trusts performance ** C.diff includes community acquired numbers NHS Wiltshire as lead commissioner has reviewed the Quality Account produced by Salisbury Foundation Trust (SFT); 1. The quality account provides information covering the elements of quality as defined by Lord Darzi. These being patient safety, patient experience and clinical effectiveness (patient outcomes) 2. NHS Wiltshire is satisfied that the Quality Account incorporates all of the mandated elements of a Quality Account 3. There is evidence, within the Quality Account, that SFT has utilised both internal and external assurance mechanisms 4. NHS Wiltshire is satisfied with the accuracy of the data contained in the Quality Account The account identifies significant progress in relation to: l Privacy and Dignity and virtually eliminating same sex accommodation; l Infection control and reduction in MRSA and C.difficile. SFT have in their quality account identified a number of changes linked to the experience of patient’s e.g. length of stay. In addition to the items outlined in the Quality Account, SFT have also worked with commissioners during 09/10 through monthly performance and clinical quality review meetings. NHS Wiltshire would also note the positive steps taken by SFT to work with general practitioners to improve the quality of information in patient discharge summaries. Statement from Wiltshire Overview and Scrutiny Committee (coordinating OSC) Salisbury NHS Foundation Trust invited comments on their Quality Account from the Health Overview and Scrutiny Committees (OSCS) of Wiltshire, Hampshire and Dorset Councils. This is the first year that OSCs have been asked to perform this role and, on this occasion, all three have chosen not to make any comment. It should be noted that submitting comments is a voluntary requirement and that the decision of the OSCs is no reflection on the Trust Statement from Wiltshire Involvement Network (WIN) Salisbury NHS Foundation Trust has shared its Quality Accounts 2009/2010 with the Wiltshire Involvement Network (WIN) so that it has an opportunity to comment if it wished to do so. WIN has decided not to provide comment on this occasion. How to provide feedback All feedback is welcomed and the Trust listens to these concerns and steps are taken to address individual issues at the time. Comments are also used to improve services and directly influence projects and initiatives being put in place by the Trust. 16 Statements from NHS Wiltshire (coordinating PCT) Salisbury NHS Foundation Trust Quality Account 2009 / 2010 Designed and Printed by LGDavis Design and Print Solutions 0121 430 9000