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
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