Quality Account 2009/10
2
Quality Account 2009/10
At The Royal Marsden, we deal
with cancer every day – so we
understand how valuable life is.
And when people entrust their
lives to us, they have the right to
demand the very best. That’s why
the pursuit of excellence lies at the
heart of everything we do.
We continually strive towards
improving the quality of
patient care as well as the
overall patient experience as
both are vital in achieving
better outcomes. Our quality
report summarises our
performance over the last year
and sets out our targets for
2010/11 and beyond.
4 Who we are
6 Statement on quality from
the Chief Executive
8 Priorities for improvement
20 Statements of assurance
from the Board
38 Performance against key metrics
40 Annex
42 Glossary
Quality Account 2009/10
3
Contents
Quality Account 2009/10
4
Who we are
The Royal Marsden NHS Foundation Trust is
a world leader in cancer research, science and
education.
We have two hospitals: one in Chelsea,
London, and a health and science campus
in Sutton, Surrey. We also have a Medical
Daycare Unit which we run in partnership with
Kingston Hospital.
We work closely with The Institute of Cancer Research
(ICR) and together we are the only National Institute
of Health Research (NIHR) Biomedical Research
Centre specialising in cancer in the UK. We work in
partnership to undertake groundbreaking research
into new cancer drug therapies and treatments. The
partnership makes us the largest comprehensive
cancer centre in Europe with a combined staff of 3,500.
The Royal Marsden and the ICR recently announced
a new academic partnership with Mount Vernon
Cancer Centre which, through translational
research linked to clinical trials, will make a major
contribution to improvements in personalised
medicine and patient care.
This year, the Trust celebrated six years as an NHS
foundation trust. We were one of the first hospitals
to be awarded this status in April 2004.
Quality Account 2009/10
5
6
Quality Account 2009/10
Statement on quality
from the Chief Executive
The quality of patient and family care
is at the centre of everything we do at
The Royal Marsden NHS Foundation
Trust. The Royal Marsden is the largest
comprehensive cancer centre in Europe and,
together with our partner, The Institute of
Cancer Research, we are responsible for the
UK’s largest research programme in cancer.
Minimising the risk of healthcare-associated
infections is one of our highest priorities and we
were pleased to receive a very positive report from
the CQC with full compliance on all aspects of the
Hygiene Code. The Trust saw a further reduction
in the number of healthcare-associated infections,
meeting all targets, and continues to have one of the
lowest rates for an acute trust in the country.
Having a single specialty focus and such a large
programme means that we are able to attract the
leading cancer doctors, scientists, nurses and
rehabilitation professionals internationally to work
in an integrated way to ensure the highest quality of
cancer care, research and education.
This year, the Trust has seen the completion of
several phases of the large capital programme which
is ensuring that patients and their families experience
care in the most appropriate, modern and technically
sophisticated environment. In January 2010, four
new operating theatres in the Wolfson Surgical Suite
at our Chelsea site became fully operational. We are
also nearing completion on an improved critical care
complex and a new Ambulatory Care Centre, housing
a purpose-built Medical Day Unit and a new Clinical
Assessment Unit.
In 2009/10, we were rated by our regulator Monitor
and the Care Quality Commission (CQC) as
‘excellent’ both for the quality of care and quality of
financial management. We are the only foundation
trust in the country to achieve this four years in a
row. We were also placed in the top percentile of all
trusts for the quality and experience of patient care
in the annual patient survey.
At Sutton, work has commenced on the new
Children’s and Young Persons’ Centre, built in
conjunction with the Teenage Cancer Trust. The
Centre will be the largest of its kind in Europe
and will house the world’s first drug development
The Trust has, for over ten years, published its
quality and performance data quarterly and annually programme for children and teenagers. Together
in the integrated governance reports. To ensure even with the ICR, we are also building a Centre for
more accountability from ‘ward to Board’, since April Molecular Pathology which will allow us to develop
new approaches in personalised medicine and
2009, the Board has received a monthly Quality
achieve the best results for patients. Increasingly, we
Account monitoring key areas of patient safety,
are able to personalise the delivery of therapeutics
effective care and the experience of care.
by identifying which tumours respond to specific
In 2009, the Trust was the first to achieve the Customer drugs and other modalities of treatment. The Centre
for Molecular Pathology will enhance and extend the
Service Excellence standard not only for the quality of
work we already undertake in molecular diagnostics
its patient care at both Chelsea and Sutton but also for
and drug development to make a real difference to
our satellite chemotherapy service at Kingston.
patients wordwide.
A major focus for The Royal Marsden is patient
To the best of my knowledge the information in this
safety and we were therefore delighted this year to
document is accurate.
be awarded NHSLA level 2 which is a significant
milestone in ensuring that we achieve the safest
environment for our patients, their families and the
staff working in the Trust.
7
Quality Account 2009/10
The Critical Care Unit at The Royal Marsden.
Date: 4 June 2010
Cally Palmer CBE
Chief Executive
8
Quality Account 2009/10
Priorities for improvement
The Royal Marsden has a track record of
innovation and improvement in the quality of
service provided to patients and their families.
In 2009/10, two examples of this work are:
Real time feedback from patients: monitoring
and guiding improvement to services
For the first time in 2009, the Trust was also able
to monitor patients’ experience of care in real
time using the Picker frequent feedback approach.
Patients in the Trust’s Medical Day Units have
responded to questionnaires using an electronic
handheld device. The patients’ comments are then
immediately uploaded and form a monthly feedback
report which goes directly to clinical front line staff
and to the Board in their monthly Quality Account.
In response to these reports, staff design action
plans to improve their service. Patients’ comments
have been used by clinical teams to monitor and
improve their practice and the patients’ accounts
have reflected this improvement.
In a further initiative to improve the quality of these
services, a cohort of the Membership Council
(patients and carers) have been working with the
Chief Nurse and matrons to further roll out the
frequent feedback survey and to design new patientfocused questionnaires for outpatients departments
and inpatient wards.
Matrons’ weekly ward rounds to ensure clean
and fit-for-purpose environments
The second initiative was to ensure that the
patient environment is clean and fit-for-purpose.
A matrons’ checklist for the quality of the patient
environment was developed using key items from
the Hygiene Code. Weekly inspections have then
been undertaken by matrons inspecting each other’s
wards. Together with the hand hygiene audits,
these weekly matrons’ audits are uploaded onto
the new Trust-wide Synbiotix monitoring system.
All members of the Trust, staff from the bedside to
the Board, can view these audits as they appear
weekly on the Trust intranet. As part of these audits,
patients and families are asked their views on the
cleanliness and preparedness of the ward / unit
environment.
Priorities for improvement 2010/11
Category
No.
Priority
Safe care
1.
Reduction of healthcareassociated infections
2.
Reduction in falls
3.
Reduction in medication
incidents
4.
Effective assessment,
monitoring, treatment of
venous thromboembolism
1.
Reduced length of stay
2.
Reduction in the hospital
standardised mortality ratio
3.
Reduction in the incidence of
pressure ulcers
1.
To be in the top 20% of trusts
for key areas of the National
Inpatient Survey
2.
To be in the top 20% of trusts
for key areas of the National
Outpatient Survey
3.
Roll out of the real time patient
feedback survey throughout
the Trust
Effective care
Patient
experience
In 2009/10, the Trust consulted with patients and
carers from the Membership Council, members of
the Board and representatives from clinical staff and
decided on nine quality priorities for improvement
over 2010/11. Three priorities were each chosen to
monitor safe care, effectiveness of care and finally
the experience of patient care. In setting these
priorities, the Trust aims to reflect national and
international priorities that are a proxy of quality of
patient care and have endeavoured throughout to set
stretching targets.
9
6
Number of MRSA bacteraemias
5
Counts
4
3
2
1
Mar 2010
Feb 2010
Jan 2010
Dec 2009
Nov 2009
Oct 2009
Sep 2009
Aug 2009
Jul 2009
Jun 2009
May 2009
Apr 2009
Mar 2009
Feb 2009
Jan 2009
Dec 2008
Nov 2008
Oct 2008
Sep 2008
Aug 2008
Jul 2008
Jun 2008
May 2008
Apr 2008
Mar 2008
Feb 2008
Jan 2008
Dec 2007
Nov 2007
Oct 2007
Sep 2007
Aug 2007
Jul 2007
Jun 2007
May 2007
Apr 2007
Mar 2007
Feb 2007
Jan 2007
Dec 2006
Nov 2006
Oct 2006
Sep 2006
Aug 2006
Jul 2006
Jun 2006
May 2006
Apr 2006
Mar 2006
Feb 2006
Jan 2006
Dec 2005
Nov 2005
Oct 2005
0
Safe care
Priority 1: To continuously reduce healthcare
associated infections (HCAI)
In 2000, the Public Accounts Committee estimated
that there were at least 100,000 cases of hospitalacquired infections annually. The National Audit Office
(2009) stated that this remains the best estimation of
incidence available (CNO, 2010). Patients with cancer
are more vulnerable to infection and, having sustained
an infection, are more likely to develop serious
complications from it. The Royal Marsden therefore
sees reducing the incidence of HCAIs as an essential
safety and quality priority. To this end, the Trust took
the following actions in 2009/10 to reduce HCAIs:
1.Increased membership of the Trust
Infection Prevention and Control Team.
2.Improvements to the built environment
including an increase in isolation rooms.
3.The introduction of the weekly
matrons’ cleanliness audits.
4.Increased teaching for all clinical staff,
including doctors, nurses and rehabilitation
therapists, on the importance of optimal
infection prevention and control practices.
5.Clinical link nurses for infection prevention
and control on every ward and unit
acting as clinical champions.
6.Matrons’ weekly audits, hand hygiene audits
and high impact intervention 7 on every ward/
unit with weekly performance indicators
reflected on the Synbiotix database.
The Health Protection Agency (HPA) graphs shown
above and on the next page demonstrate that the
Trust has succeeded in reducing HCAIs against
its target.
2010/11 target: Maintain a very low incidence of
MRSA, reduce the incidence of Clostridium difficile
further and introduce new technology to increase the
decontamination of wards and units.
Quality Account 2009/10
Monthly MRSA bacteraemia count since October 2005 (HPA, March 2010)
National
Trust
2.5
2.0
1.5
1.0
Rate per 10,000 days
Regional
3.0
Apr-Jun 2010
Jan-Mar 2010
Jan-Mar 10
Oct-Dec 09
July-Sept 09
April-June 09
Jan-Mar 09
Oct-Dec 08
July-Sept 08
April-June 08
Jan-Mar 08
Oct-Dec 07
July-Sept 07
April-June 07
Jan-Mar 07
Oct-Dec 06
July-Sept 06
April-June 06
Jan-Mar 06
Oct-Dec 05
July-Sept 05
April-June 05
Jan-Mar 05
Oct-Dec 04
July-Sept 04
April-June 04
An incidence rate for the 2-64 years age group will be calculated once the denominator for this age group is available.
Oct-Dec 2009
Jul-Sep 2009
Apr-Jun 2009
Jan-Mar 2009
Oct-Dec 2008
Jul-Sep 2008
Apr-Jun 2008
Jan-Mar 2008
Oct-Dec 2007
Jul-Sep 2007
Apr-Jun 2007
Jan-Mar 2007
Oct-Dec 2006
Jul-Sep 2006
Apr-Jun 2006
C.difficile incidence rate* (65 years and over)
3
Jan-Mar 2006
Oct-Dec 2005
Jul-Sep 2005
Apr-Jun 2005
Jan-Mar 2005
Oct-Dec 2004
Jul-Sep 2004
Apr-Jun 2004
Jan-Mar 2004
Oct-Dec 2003
Jul-Sep 2003
Apr-Jun 2003
Jan-Mar 2003
Oct-Dec 2002
Jul-Sep 2002
Apr-Jun 2002
Jan-Mar 2002
Oct-Dec 2001
Jan-Mar 04
0
Jul-Sep 2001
0.0
Apr-Jun 2001
C.difficile incidence rate* (2-64 years)
2
1
Incidence per 100 bed days*
4.0
Comparison
with national and regional trends for MRSA bacteraemia rate
3.5
Quality Account 2009/10
10
Priorities for improvement
0.5
5
Clostridium difficile (CDI) incidence Jan 2004-March 2010 (HPA)
4
Year and quarter of report
*The denominator represents the total number of nights spent in hospital by patients aged 65 years and over per quarter and is
calculated from Hospital Episode Statistics. Denominators for 2005 - 2007 are based on the estimate for 2004.
11
The Chief Nursing Officer (England) included the
prevention of falls as one of the most important
national high impact actions for patient safety. The
National Patient Safety Agency (NPSA) found that in
an average 800 bed acute hospital trust, there will be
around 24 falls every week and over 1,260 falls every
year, representing the highest volume patient safety
incident reported in hospital trusts in England (NPSA;
2007). Although the rate of falls at The Royal Marsden
is low compared with the average for acute trusts
(national average: 4.8 per 1,000 hospital days,
The Royal Marsden average is 3.15 per 1,000 hospital
days) the prevention of falls is a key priority for the
Trust. Patients with cancer are vulnerable to the
spread of cancer into their bones and therefore a fall
can result in a broken bone.
As can be seen from the table below, although the
incidence of falls seems to have risen in 2009/10, in
fact it is the near misses or very low severity falls
that have risen as the result of increased awareness
of the requirements for reporting. All other types
Number of falls per 1,000 bed days, 2008/09 and
2009/10
2.0
2008/09
1.8
2009/10
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
Very Low
Low
Moderate
Severity
High
of falls from low through to high have significantly
reduced.
The Trust aims to reduce falls even further and,
to this end, conducted a retrospective audit into
causative themes. The environment especially in
bathrooms and toilets was identified as a theme
and, following this, the Head of Rehabilitation has
been working with a team of clinical and estates
personnel on an action plan to introduce new
environmental aids and also raise awareness and
education regarding falls.
2010/11 target: To reduce falls further by improving
the built environment and using the new Patient
Safety First Campaign ‘How to’ Guide for reducing
harm from falls (PSF 2010).
Quality Account 2009/10
Priority 2: Reducing patient harm from falls
Quality Account 2009/10
12
Priorities for improvement
Number of medication incidents per 1,000 bed days
2008/09 and 2009/10
Number of medication near misses per 1,000 bed
days 2008/09 and 2009/10
4.0
1.2
2008/09
2008/09
3.5
2009/10
2009/10
1.0
3.0
0.8
2.5
0.6
2.0
1.5
0.4
1.0
0.2
0.5
0.0
Very Low
Low
Moderate
Severity
High
Priority 3: Reduction of medication incidents
Among the most common adverse events that
affect patients in hospitals are medication errors.
In cancer care, a major part of treatment is based
on medications and therefore safety in this area is
very important. The Trust Board recognised the
importance of senior leadership in this area and,
as a response, in 2009 the Executive Medications
Incident Review Group was formed. This group
meets monthly and is chaired by the Chief Nurse.
During 2009, the following initiatives have been
rolled out to reduce the incidence and severity of
medication incidents:
1.A new mandatory computer simulation training
system was purchased to test the critical
reasoning of all nurses in their preparation
and administration of medications.
2.Increased mandatory training for junior
doctors on safe prescribing of medicines.
0.0
Very Low
Low
Moderate
Severity
High
3.Nurse consultant-led awareness raising on all
wards/units about reporting near misses to
be able to identify patient safety themes.
4.The development of a mandatory template
for the prescribing of high-risk medications
for patients leaving hospital.
5.Increased employment of Specialist Pharmacists
working with doctors and nurses on the
wards/units to increase safe prescribing.
6.Enrolment of the Trust in the Patient
Safety First and Institute for Healthcare
Improvement’s programme of reducing
errors in high-risk medications.
7.The employment of an Anaesthetic Specialist
Registrar as the Patient Safety Fellow.
As can be seen from the graphs above, 2009/10 has
seen an increase in the reporting of near miss and
low-risk incidents and a sharp reduction in more
serious moderate and high-risk errors.
13
Priority 4: Prevention, assessment, monitoring
and treatment of VTE
Venous thromboembolism (VTE) is a significant
cause of mortality, long-term disability and chronic
ill health. The goal of the established National VTE
Prevention Programme is to reduce avoidable death
and long term disability from VTE. It is thought that
there are around 25,000 deaths from VTE each year
in hospitals in England. There is strong evidence
that many of these deaths are avoidable if a patient
is assessed for risk of VTE on admission to hospital,
with appropriate prophylaxis then provided based
on national guidelines. The prevention of VTE is a
national target and is a national Commissioning for
Quality and Innovation (CQUIN) goal.
The Royal Marsden in 2009 developed a cancer
specific assessment tool (based on the national
tool but with cancer specific information added)
and policy. During 2010/11, all inpatients will
be assessed using this specific tool and their
prophylaxis monitored and documented.
2010/11 target: All inpatients will have a cancer
specific VTE assessment made and documented
using the Trust adapted national tool. All inpatients
will be monitored and their prophylaxis for VTE in
line with National Institute for Health and Clinical
Excellence (NICE) guidance documented. A root
cause analysis will be undertaken on all confirmed
inpatient cases of pulmonary embolism (PE) or deep
vein thrombosis (DVT).
Quality Account 2009/10
2010/11 target: To see an increase in the reporting of
near misses to improve prevention and a decrease in
incidents that cause actual patient harm.
Elective length of stay, 1 April 2006 – 31 March 2010
6.0
5.5
Average length of stay (days)
Quality Account 2009/10
14
Priorities for improvement
5.0
4.5
4.0
3.5
3.0
2.5
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
Apr-09
Mar-09
Feb-09
Jan-09
Dec-08
Nov-08
Oct-08
Sep-08
Aug-08
Jul-08
Jun-08
May-08
Apr-08
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
2.0
Effective care
Priority 1: Reducing elective length of stay (LoS)
and increasing same day admission for surgery
People with cancer often have to face a lengthy
and complex treatment pathway. It is therefore
very important to reduce time spent in the hospital
environment. There is also international evidence to
show that planned protocolised care pathways, for
example, using the enhanced recovery programme
methods, increase the quality of care and reduce the
length of time spent unnecessarily in hospital. Over
the last few years, the Trust has increased the size
and number of Day Units for both chemotherapy
and surgery to minimise the need for overnight
admissions to hospital.
In 2009, the Trust has implemented several initiatives
to further reduce the elective length of stay:
1.An enhanced recovery programme has
commenced in upper gastrointestinal surgery
and will be implemented in four other
surgical specialties throughout 2010.
2.Specialist pharmacists accompany the discharge
co-ordinator and site specialist nurse on a
discharge ward round each day to ensure
discharge medications can be co-ordinated.
3.The haemato-oncology team are exploring new
ways of reducing the LoS for transplant patients.
4.Each surgical specialty is challenging itself
to admit patients on the day of surgery
unless there is a clinical reason not to.
5.Accommodation close to both sites of
the Trust has been identified for patients
who need to travel long distances to
the Trust for same day admission.
The same day admission rates have improved across
both sites.
2010/11 target: Reduction in elective LoS to an
average of 3.5 days and the same day admissions at
Chelsea to 80% and Sutton to 95% with no increase
in emergency readmissions within 14 days.
15
treat effectively so that the burden for patients and
families is reduced.
The HSMR provides a comparison of a trust’s actual
number of deaths with their expected number of
deaths. If the HSMR is 100, then the actual number
of deaths exactly matches the expected number of
deaths. If the number is higher than this, there may
be a need to investigate the cause. The figure for the
Trust in 2009 is 75.4 which means that the Trust
has had fewer deaths than expected for the patient
group it has treated. This figure is therefore good
and means that the Trust is within the group of
acute trusts with the lowest HSMR in London.
From 2009, all data is collected at ward level and
centrally analysed in quality assurance. To add more
rigour to this process, from March 2010, the wards
now have direct access to the Synbiotix database
and can directly input minimising any loss of data.
Incidence of pressure ulcers
Total number
2009/10
Pressure ulcers
250
Pressure ulcers / 1,000 bed days
3.84
Trust HSMR
Calendar Year*
2008
2009
The Royal Marsden
83.1
75.4
*full financial year data is not available for 2009/10 at time of
publication. Source: Dr. Foster Intelligence.
2010/11 target: To maintain or further reduce the
Trust’s HSMR by concentrating on reductions in
HCAIs, falls and incidents, and further roll out of the
Hospital2Home programme.
Priority 3: Reduction in the incidence of pressure
ulcers
Pressure ulcers represent a major burden of sickness
and reduced quality of life for patients and create
significant difficulties for them, their carers and
families. New pressure ulcers are estimated to occur
in 4–10% of patients admitted to acute hospitals
in the UK, with one study putting this as high as
20% (Clark M, Bours G, Defloor T; 2004). Some
people with cancer are at higher risk of developing
pressure ulcers through immobility, reduced diet
and some medications. An essential aspect of the
Trust’s patient assessment, monitoring and care is
to be aware of the risks of pressure ulcers and to do
everything to prevent, diagnose early, monitor and
2010/11 target: To reduce the incidence of all
hospital acquired pressure ulcers.
Quality Account 2009/10
Priority 2: Reduction in hospital standardised
mortality ratio (HSMR)
Quality Account 2009/10
16
Priorities for improvement
National Inpatient Survey results
2008%
2009%
National
avg. %
A16 Planned admission: should have been admitted sooner
15
12
22
Question (lower scores are better)
A22 Admission: had to wait long time to get to bed on ward
20
15
30
B12+ Hospital: toilets not very or not at all clean
4
3
7
D6 Nurses: did not always wash or clean hands between touching
patients
9
8
15
E10+ Care: did not always get help in getting to the bathroom when
needed
27
20
32
G6+ Discharge: not fully told purpose of medications
11
9
20
G12 Discharge: not told who to contact if worried
9
7
22
G13 Discharge: did not receive copies of letters
sent between hospital doctors and GP
24
20
42
H2 Overall: doctors and nurses working together fair or poor
2
1
7
H4 Overall: worried about security of personal information held by the
hospital
4
3
7
H7 Overall: no posters/leaflets seen explaining how to complain about
care
30
21
41
J4+ Religious Beliefs: not always respected by hospital staff
8
4
10
Patient experience
Priority 1: Improvement in patient satisfaction
reflected in the Frequent Feedback survey
In 2009/10, the Picker Frequent Feedback survey
was introduced onto the five Medical Day Units at
The Royal Marsden. Over 1,150 patients completed
the questionnaire on the handheld electronic device.
The questionnaire contains 27 questions, a sample
of which, reflecting improvements over time, are
included below:
1.Over 75% of patients felt they were completely
informed of what would happen in terms of
any tests and treatment they may receive.
2.The proportion of patients that said staff
‘always’ address them by the name they
wish to be called has improved from 84%
in Quarter 1 to 95% in January 2010.
3.Patients who needed written or printed information
has shown gradual improvement over time
from 94% in Quarter 1 to 99% in Quarter 3.
4.The majority (82%) of patients report
consistency in information received
from different staff members.
5.The level of dignity and respect has remained
high across the year, with 94% of patients
recording that doctors treated them with
respect and 95% that nurses did so too.
2010/11 target: To roll out the use of the Picker
Frequent Feedback survey to all inpatient and
outpatient areas of the Trust and to be able to
demonstrate improvements in experience over 2010/11.
17
Quality Account 2009/10
Priority 2: To remain in the top percentile of
trusts in the annual National Inpatient Survey
The National Inpatient Survey is conducted annually
and again in 2009, 459 patients rated the Trust in
the top 20% of hospitals in the country for their
experience of inpatient care. In the table opposite
are 12 examples of care where the lowest score is
the best and on the right of the table is the national
average from all hospitals surveyed.
2010/11 target: For patients to continue to rate
The Royal Marsden in the top 20% of hospitals in
the country.
Quality Account 2009/10
18
Priorities for improvement
National Outpatient Survey results
2004/05
2009
Highest
score
nationally,
2009
Q1 From the time you were first told you needed an
appointment, how long did you wait?
89
92
92
Q2 Were you given a choice of appointment times?
88
90
90
34
36
50
Q10 In your opinion, how clean was the Outpatients Department?
92
93
95
Q11 How clean were the toilets at the Outpatients Department?
88
90
94
Q13 Did you have enough time to discuss your health
or medical problem with the doctor?
90
92
95
Q15 Did the doctor explain the reasons for any treatment
or action in a way that you could understand?
92
93
94
Q16 Did the doctor listen to what you had to say?
93
95
96
Q17 If you had important questions to ask the doctor, did
you get answers that you could understand?
87
90
92
Q18 Did you have confidence and trust in the
doctor examining and treating you?
91
94
96
Q19 Did the doctor seem aware of your medical history?
92
95
95
91
93
95
Q32 Did a member of staff explain why you needed
these test(s) in a way you could understand?
86
89
91
Q33 Did a member of staff tell you how you would
find out the results of your test(s)?
77
83
92
Q34 Did a member of staff explain the results of the
tests in a way you could understand?
80
86
88
Q36 Before the treatment did a member of staff
explain what would happen?
93
96
97
Q37 Before the treatment did a member of staff explain any
risks and/or benefits in a way you could understand?
88
91
94
Question (higher scores are better)
Before the appointment
Waiting
Q8 Were you told how long you would have to wait?
Hospital environment and facilities
Seeing a doctor
Overall about the appointment
Q25 How much information about your condition
or treatment was given to you?
Tests and treatment
19
The National Outpatient Survey was conducted in
2009/10 and previously in 2004/05. In 2009, 512
patients responded and continue to rate the Trust
in the top 20% of trusts for their experience of
outpatient care. In the table to the left are a few
examples of the questions answered by patients
with 100 being the highest possible score.
2010/11 target: To use the Picker Frequent Feedback
real time monitoring to achieve an improvement over
the year in patients’ day-to-day experience in the
Outpatient Department.
Quality Account 2009/10
Priority 3: To remain in the top percentile of
trusts in the National Outpatient Survey.
20
Quality Account 2009/10
Statements of
assurance from the Board
During 2009/10, The Royal Marsden provided and/or During 2009/10, The Royal Marsden participated in
subcontracted comprehensive cancer NHS services. 95% of the national clinical audits and 100% of the
The Royal Marsden has reviewed all the data available national confidential enquiries which it was eligible
to participate in.
to it on the quality of care in all of these services.
The income generated by the NHS services
reviewed in 2009/10 represents all of the income
generated from the provision of NHS services by
The Royal Marsden for 2009/10.
Participation in clinical audits and national
confidential enquiries
During 2009/10, 21 national clinical audits and
three national confidential enquiries covered NHS
services that The Royal Marsden provides.
The national clinical audits and national confidential
enquiries that The Royal Marsden was eligible to
participate in – and those in which it did participate
during 2009/10 – are shown opposite.
The national clinical audits and national confidential
enquiries that The Royal Marsden participated
in, and for which data collection was completed
during 2009/10, are listed below alongside the
number of cases submitted to each audit or enquiry
as a percentage of the number of registered cases
required by the terms of that audit or enquiry.
Number of cases submitted to
each audit or enquiry
Number of cases
submitted as % of
registered cases
required
NLCA: lung cancer
Completion date 26 June 2010
ongoing
NBOCAP: bowel cancer
26
100
National clinical audit title
DAHNO: head and neck cancer
19
100
National Falls and Bone Health Audit
n/a organisational
100
National Comparative Audit of Blood Transfusion
<10
100
National Mastectomy and Breast Reconstruction Audit
353
100
National Oesophago-gastric Cancer Audit
11
100
National Health Promotion Hospitals
100
100
BAPEN: British Artificial Nutrition Survey
<50
100
RCR National Audit of Head and Neck Pathway 2010
5
100
RCR National Audit of Pre-Operative Staging for Rectal
Cancer 2009
Collection in progress. Final
submission date 29 May 2010
ongoing
National clinical audits of the Occupational Health
management of lower back pain and depression
40
100
National audit of depression screening and management of staff 40
on long-term sickness absence by OHS in the NHS: round 2
100
National audit: ABS at BASO report: an audit of screen
detected breast cancers for the year of screening
60
100
National audit: BCCOM Project
>362
100
4th National Audit Project of the Royal College of
Anaesthetists (NAP4)
0
100
21
National clinical audit title
Participated
Continuous; all patients
1
ICNARC CMPD: adult critical care units
No
2
National Lung Cancer Audit (NLCA): lung cancer
Yes
3
National Bowel Cancer Audit Programme (NBOCAP): bowel cancer
Yes
4
Data for Head and Neck Oncology (DAHNO): head and neck cancer
Yes
5
National Falls and Bone Health Audit
Yes
6
National Comparative Audit of Blood Transfusion
Yes
One-off; all patients
7
National Mastectomy and Breast Reconstruction Audit
Yes
8
National Oesophago-gastric Cancer Audit
Yes
Intermittent samples of patients
9
National Care of the Dying Audit – Hospitals (NCDAH)
Yes
10
National Health Promotion Hospitals
Yes
11
British Association for Parenteral and Enteral Nutrition (BAPEN)
Yes
12
Royal College of Radiologists (RCR) National Audit of Head and Neck Pathway 2010
Yes
13
RCR National Audit of Pre-Operative Staging for Rectal Cancer 2009
Yes
14
RCR National Audit of the Use of Radiotherapy for Malignant Spinal Cord Compression 2008
Yes
15
RCR Single Fraction Radiotherapy for Bone Metastases 2008
Yes
16
RCR National Audit of Late Effects of Chemoradiotherapy for Carcinoma of the Cervix 2008
Yes
17
National clinical audits of the occupational health management of lower back pain and
depression
Yes
18
National audit of depression screening and management of staff on long-term sickness
absence by occupational health and safety (OHS) in the NHS: round 2
Yes
19
National audit: Association of Breast Surgery (ABS) at British Association of Surgical
Oncology (BASO) report: an audit of screen detected breast cancers for the year of screening
Yes
20
National audit: Breast Cancer Clinical Outcome Measures (BCCOM) Project
Yes
21
4th National Audit Project of the Royal College of Anaesthetists (NAP4)
Yes
National confidential enquiry title
Participated
One-off; all patients
1
Surgery in children study
Yes
2
Parenteral nutrition study
Yes
3
Emergency and elective surgery in the elderly
Yes
Quality Account 2009/10
Eligible national clinical audits and national confidential enquiries
Quality Account 2009/10
22
Statements of assurance from the Board
The reports of seven national clinical audits were
reviewed in 2009/10 and the Trust intends to take
National audit
Date
published
the following actions to improve the quality of
healthcare provided.
Reviewed by
Committee(s)
Description of actions (local)
1
NLCA: lung cancer
2009
Tumour Working
Group Dec 2009
Lung Tumor Working Group felt these
numbers were not accurate so we are
checking these.
2
NBOCAP: bowel cancer
2009
Tumour Working
Group
Due to be analysed and discussed.
Annual report
3
DAHNO: head and neck
cancer
2009
Surgical Audit
Group for
information
Excellent compliance. No change in practice.
4
National Falls and Bone
Health Audit
March
2009
Clinical Audit
Committee
The Trust Lead for Reduction in Falls will use
data from this audit to help in Trust action
plans.
National Audit of the
Organisation of Services
for Falls and Bone Health
of Older People
Nurse consultant (rehabilitation) will liaise
with the Medical Director to determine Trust
action relating to assessment of inpatients for
osteoporosis and fracture risk.
Note: prospective surgical patients already
have this assessment as part of their preoperative workup.
5
National Comparative
Audit of Blood
Transfusion
1) Report on the use of
Fresh Frozen Plasma
(FFP)
2009
2) Report on the Blood
Collection Audit
2009
Hospital
Transfusion
Committee
No significant changes to practice.
3) Bedside Transfusion
Re-Audit
2009
Hospital
Transfusion
Committee
No significant changes to practice.
Hospital
Transfusion
Committee
No significant changes to practice.
The Trust is acting to reduce the use of the
product.
Hospital Blood Transfusion Team reviewed
operational issues and procedures.
All blood transfusion related policies
reviewed and updated annually.
The development of the role of transfusion
practitioner to enable change and adoption
of good practice in the transfusion pathway.
Practice is monitored through regular audits.
23
6
National Mastectomy and
Breast Reconstruction
Audit
Date
published
Reviewed by
Committee(s)
National audit shows breast cancer
patients have increased access to
immediate reconstructive surgery but
highlights the need for more improvement.
To ensure improvement in documentation of
decision making and counselling.
16 October Tumour Working
2009
Group
Compliant with recommendations made in
report. No significant changes to practice
needed.
2nd annual report of the
National Mastectomy and
Breast Reconstruction
(MBR) Audit
7
National Oesophagogastric Cancer Audit
Description of actions (local)
September Surgical Audit
2009
Group, Breast
Audit and Research
Meeting
Second annual report.
Quality Account 2009/10
National audit
Quality Account 2009/10
24
Statements of assurance from the Board
The reports of 74 local clinical audits were
reviewed in 2009/10 and The Trust intends to take
the following actions to improve the quality of
healthcare provided:
Audit title (Audit ID)
Action plan
Date to be completed by
National Patient Safety Agency (NPSA)
Patient Safety Alert 20 – Improving
safer use of injectable medicines (Nar
187)
All related policies and procedures to
be updated annually.
November 2008
Continue to review high risk practices
with specific areas.
Ongoing
Retrospective review of
The Royal Marsden practice in
inflammatory breast cancer (IBC)
(Br79)
Results fed back to Breast Research
and Audit Meeting.
June 2009
Submitted for publication: Cancer, IBC
supplement.
June 2009
Accrual of new renal and melanoma
patients to clinical trials comparison
between 2007 and 2008 (Sk4)
To improve further the accrual rate. To
continue to improve documentation in
notes about consideration of patient to
trial.
April 2009
Repeat audit planned.
March 2010
No change to guidelines.
N/A
April 2009
1
2
3
4
The incidence and prognostic
significance of carcinoembryonic
antigen (CEA) flare in patients with
advanced colorectal cancer receiving
first-line chemotherapy (GI101)
5
New immobilization system in patients A new procedure when setting couch
treated with radical radiotherapy for
height has been implemented.
prostate cancer (URT065)
March 2009
May 2009
6
Body temperature of post operative
patients (Anaes53)
Purchase of theatre tympanic probes,
increased use of warming devices and
patient temperature control for surgical
wards.
October 2009
7
Advanced Herceptin (Br87)
Further discussion of results at the
Breast Audit and Research Meeting.
May 2009
Audit extended: continuation of
trastuzumab in HER2 positive
metastatic breast cancer following
either adjuvant trastuzumab or
progression of disease on trastuzumab
(BR102).
May 2009
8
Blood transfusion in oesophageal
No change to unit guidelines.
cancer patients during radiotherapy (GI
097)
N/A
25
Action plan
Date to be completed by
9
A. Information sharing
April 2009
B. End of life care
December 2010
C. Outreach visits
April 2010
D. GP meetings
December 2009
E. Symptom support and advice
April 2010
F. 24/7 advice
Ongoing
Professional users’ survey of the
paediatric palliative care outreach
service (PAE 072)
G. Symptom boxes
December 2010
H. Allied health professionals
June 2010
I. Education and training
Ongoing
10
Effectiveness of pegfilgrastim in
reducing inpatient bed stay and
antibiotic usage following autologous
stem cell transplant (HAEM054)
Haemato-oncology Unit guidelines to
be updated to include administration
of pegfilgrastim to all adult autologous
transplant patients.
June 2009
11
Use of the Patient Symptom
Assessment in Lung Cancer (PSALC)
Quality of Life (QOL) Questionnaire
in the assessment of lung cancer
patients receiving chemotherapy,
and comparison with previous
European Organisation for Research
in the Treatment of Cancer (EORTC)
QLQ C30 + LC13 and Functional
Assessment of Cancer Therapy
(FACT-L) QOL questionnaire audits
(LUN070)
A 3-arm study protocol is to be written December 2009
(using EORTC QLQ – the most
consistent and comprehensive of all 3
questionnaires). This study will aim to
assess the difference in pick-up rate of
symptoms/problems between each arm.
Assess patient satisfaction.
June 2009
12
Occupational therapy documentation
(REHAB1)
Findings of audit and record keeping
guidelines to be presented and
discussed at team meeting.
May 2009
Additions to be made to the current
guidelines to ensure all identified gaps
in practice are clearly standardised.
May 2009
Ensure that all new staff are aware
of the record keeping standards that
have been developed at a local level
in accordance with the College of
Occupational Therapy’s guidelines.
May 2009
Results to be fed back to the Clinical
Practice Forum.
May 2009
Review the audit tool. Re-audit planned. February 2010
13
Surgical management of primary
retroperitoneal sarcomas (SAG13)
Results fed back to Surgical Audit
Group, 15 May 2009.
May 2009
Quality Account 2009/10
Audit title (Audit ID)
Quality Account 2009/10
26
Statements of assurance from the Board
Audit title (Audit ID)
Action plan
Date to be completed by
14
Now standard preoperative tool
for assessment of DIEP flaps at
The Royal Marsden since April 2008.
Ongoing
CT Angiogram imaging in Deep
Inferior Epigastric Perforator (DIEP)
flap breast reconstruction (SAG14)
Results fed back to surgical audit
group, 15 May 2009.
To continue to develop abdominal-free
flap techniques.
15
Prescribing errors before and after the
introduction of a new pre-printed drug
chart on CCU (ANAES42)
Results fed back to surgical audit
group, 15 May 2009.
16
The value of day 8 blood count in
treatment decisions when using oral
vinorelbine (LUN 075)
In patients receiving oral vinorelbine
September 2009
with cisplatin or carboplatin it is
planned to omit the day 8 visit to the
hospital for a blood count. Day 8 drugs
will be dispensed on day 1 and a
member of staff (to be confirmed which
discipline) will contact the patient by
phone and confirm their wellbeing and
tell them to take their day 8 medication.
17
Chimerism Monitoring Post
Allogeneic Haematopoietic Stem Cell
Transplantation (HAEM 038)
Myeloablative unrelated donors will no
longer be monitored (local guidelines
will be updated).
May 2009
June 2009
The transplant protocol on the EPR will June 2009
include a new tick box to indicate who
should be monitored. This protocol
should be sent to David Gonzalez
de Castro in the Institute of Cancer
Research (ICR).
18
Genetics referrals from the GI Unit for
Information about requirements for
patients with colorectal cancer (GI 103) genetic testing is now included in
the GI Unit guidelines. As a result,
patients for genetics referral are now
being identified during the initial MDT
discussion and all genetics referrals
will be documented on the Electronic
Patient Record (EPR).
March 2009
19
Neutropaenia in patients with small
cell lung carcinoma (SCLC) undergoing
platinum-based chemotherapy (LUN
072)
July 2009
Lung Unit guidelines to be updated
: All SCLC patients receiving
chemotherapy will receive G-CSF
(pegfilgrastim) with at least the first
cycle of treatment.
A prospective audit will be initiated
December 2010
which will aim to collect practice and
outcome data after the change in policy.
27
Action plan
Date to be completed by
Results fed back internally within the
Trust.
July 2009
Update EPR records in line with drug
charts on admission.
July 2009
Document indication for antimicrobial
prescription on the drug chart.
July 2009
Document review date/duration.
July 2009
Audit surgical prophylaxis.
April 2009
July 2009
20
Snapshot audit of antimicrobial point
prevalence study (PHR112)
Promote antimicrobial guidelines.
Ongoing
Results fed back internally.
July 2009
Review of the Trust antibiotic
guidelines for surgical prophylaxis.
September 2009
Review data relating to our implants
and infection rates and a month’s data
of breast/plastic surgery antibiotic
usage across the Trust at biweekly
oncoplastic MDT planned.
September 2009
22 Annual infection report to the surgical
audit group on 14 July 2009: MRSA,
Clostridium Difficile, diarrhoea,
bacteraemia, gram-negative resistance,
wounds (SAGAR9)
Powerpoint presentation available for
further dissemination to unit level and
next feedback date planned.
May 2010
23
Experience of surgical management of
oesophago-gastric junctional cancer in
bariatric patients (SAG 16)
Abstract submitted to external meeting: June 2009
8th International Gastric Cancer
Congress (IGCC), June 10-13, 2009,
Krakow, Poland.
24
First report on deaths in the 30 days
following completion of radical
radiotherapy or chemo-radiation
between March and August 2007
(deaths at The Royal Marsden and
deaths reported to The Royal Marsden)
(RT011)
Results fed back to Radiotherapy Audit June 2009
Group.
21
Surgical antibiotic prophylaxis in
Critical Care Unit (CCU), (Anaes 63)
25 Assessing the best use of CT/MRI
resources in acute adult brain imaging
(RA 041)
Rolling programme.
All cases needing urgent MRI or CT
brain need to be discussed before
scheduling brain imaging.
April 2009
MRI is usually the first brain imaging
test unless contra-indicated or patient
not well enough to tolerate MRI or for
specific clinical reason in which CT
should be first test.
April 2009
Consider reviewing fast brain MRI
protocol between Sutton and Chelsea.
December 2009
Quality Account 2009/10
Audit title (Audit ID)
Quality Account 2009/10
28
Statements of assurance from the Board
Audit title (Audit ID)
Action plan
Date to be completed by
26 Compliance with the Human Tissue
Authority (HTA) requirements for
consenting of donors for harvesting
of bone marrow, peripheral blood
haematopoietic progenitor cells and
donor lymphocytes adult bone marrow
and Peripheral Blood Stem Cell (PBSC)
donor consent (HAEM 047)
Future training sessions will
encompass all current / changed
documentation / SOPs for clinicians.
This will include information about
updated HTA Codes of Practice,
guidance and publications where
applicable.
January 2009 and
ongoing
The requirement for legibility of
signatures etc will be highlighted in
training.
January 2009 and
ongoing
August 2009
27
Repeat patients’ survey of occupational
therapy relaxation programme within
The Royal Marsden – February 2009
(NAR209)
Updating of the compact discs (CDs)
of the programme, improving the
marketing of the service and providing
a follow-up session for patients.
April 2009
28
Intensive care units in London; are we
prepared for a fire? (Anaes 55)
Results fed back to Surgical and
Anaesthetic Audit Groups.
September 2009
29
Neuropathic pain in Acute
Lymphoblastic Leukaemia (ALL) (PAE
073)
A proforma document for assessment
and documentation of neuropathy and
neuropathic pain will be developed.
October 2009
A guideline will be developed with
a clear guide to medical and other
therapeutic intervention.
October 2009
A care pathway will be developed
to ensure that all children with
neuropathy and pain are referred to the
appropriate services.
October 2009
30
Histology classification as predictor
No change in practice required.
of clinical outcomes in advanced Non
Small Cell Lung Cancer (NSCLC) (LUN
077)
N/A
31
Prognostic significance of blood
transfusions in oesophageal cancer
patients treated with combined
chemoradiotherapy (GI097)
N/A
No change in practice required.
29
Action plan
Date to be completed by
Results fed back at the Multiprofessional Clinical Practice Forum,
Nursing, Rehabilitation, Radiography
Advisory Committee (NRRAC),
Rehabilitation Heads of Service
meeting, Rehabilitation Open Forum
and Nurses Open Meeting.
August 2009
Following discussion with an
independent advisor (nurse consultant
IV therapy) the audit questions will
be amended slightly to accommodate
changes to practice.
June 2011
The Rehabilitation Outreach Team will
act on the findings and a re-audit will
be carried out in one years time after
which the proposed research project
will be underway.
June 2010
33 Outcome of oncoplastic procedures:
our experience (BR91)
Presentation submitted to The
International Meeting of Oncoplastic
and Reconstructive Breast Surgery
(ORBS), 28th / 29th September 2009,
East Midlands Conference Centre,
Nottingham, UK
October 2009
34 CT request forms (RA053)
Implementation of new Radiology
Information System (RIS) with
electronic requesting.
December 2010
35
Lung TWG: Access times to care audit
(LUN081)
It will be important therefore that
the Lung TWG focuses its efforts
on preventative work, and further
engagement and partnership working
with primary care practitioners. The
audit findings will be considered in
terms of the group’s work plan and
three year service delivery plan.
August 2009 and
ongoing
36
Patient compliance re. completion of
EORTC QoL forms (LUN090)
The EORTC form will be copied and
distributed in a single-sided format.
31 July 2009
The pain question (Q9) should
be moved to the top of a page if
practicable.
31 July 2009
Issues to be addressed in mandatory
training sessions.
Ongoing
Continued development of procedurespecific consent forms.
Ongoing
Implementation of new Trust consent
policy.
October 2009
September 2009
32
Findings for combined repeat audits
examining patients’ and nurse’s views
regarding rehabilitation nursing within
The Royal Marsden (NAR207b, NAR
208b)
October 2009
37 Consent for elective surgery (Anaes66)
Quality Account 2009/10
Audit title (Audit ID)
Quality Account 2009/10
30
Statements of assurance from the Board
Audit title (Audit ID)
Action plan
Date to be completed by
38 Weekly paclitaxel in the treatment
of relapsed ovarian and primary
peritoneal cancer – Royal Marsden
Hospital experience (2003-2008)
(GYN027)
Poster presentation at European Cancer September 2009
Organisation (ECCO) September 2009.
39 What you can expect from
The Royal Marsden – patient
experience (NAR 216)
Quality officer working with different
Committees to ensure unmet needs
identified addressed.
June 2010
Care that supports the physical,
June 2010
emotional, spiritual and cultural needs.
As much information as wanted is
offered.
Ongoing
40 Access to Case Note Editor (CGE13)
An action plan to facilitate best
practice in the access of confidential
information is in place.
October 2009
41 Annual snap-shot re-audit of timeliness
of diagnosis notification to General
Practitioners (GPs) – (Measure Topic
2B-110), Manual of Cancer Services
Standards
To continue to monitor the Chelsea site September 2009
and report to Breast MDT until system
is embedded.
42 Annual snap-shot audit of on
timeliness of diagnosis notification to
General Practitioners (GPs) – Measure
topic 08-2E-109 (Gynaecology MDT),
Manual of Cancer Services Standards
There were no cases that require
March 2010
serious diagnosis notification to GPs in
the period audited. Re-audit planned.
Operational audits:
Re-audit planned 2009.
November 2009
43
Patient survey of wig provision at
the Sir William Rous Unit (SWRU),
(REHAB 6)
The service will continue to use the
existing supplier and range of wigs
as this appears to meet the needs and
requirements of patients.
October 2009
44
Comparison of prescribed radioiodine
activity with administered activity for
benign thyroid disease (HAN011)
To continue to monitor the variation
in measured I-131 capsule activities
against nominal activity purchased.
Ongoing
45
Use of Methylnaltrexone in
The Royal Marsden NHS Foundation
Trust (PCU068)
Creation of The Royal Marsden
guidelines for the use of
methylnaltrexone.
October 2009
46
Outcome after re-treatment with ECX
or EOX in patients with oesophagogastric cancer, (GI 111)
No change to existing GI Unit
guidelines. Good practice confirmed.
N/A
(In line with European Society for
Medical Oncology (ESMO) guidelines
which made this recommendation in
May 2009.)
31
47
Action plan
Date to be completed by
Re-audit of chronic obstructive
To encourage spirometry for all new
pulmonary disease (COPD) in the Lung referrals if not already indicated as
Oncology Clinic (LUN 071)
having been done, i.e. from the referral
letter.
December 2009
To consider which scoring method
for dyspneoa is most appropriate to
introduce, e.g. MRC dyspnoea score or
CAT questionnaire.
December 2009
To confirm criteria for patients
requiring COPD screening, e.g. current
smokers, those short of breath, but
excluding those already on maximum
therapeutic inhaler dose.
December 2009
To arrange that the scoring tool be reDecember 2009
presented after treatment for COPD, e.g.
after six weeks.
To consider with Radiology colleagues
whether COPD can be detected from
CT scans.
December 2009
To improve documentation,
Performance Status (PS) has
been added to the chemotherapy
prescription template, and plans are
being made to include PS on the EPR .
December 2009
48
Lung Unit: Mortality within 30 days of
anti-cancer therapy, October 2008 to
March 2009 (POMCGM13a)
49
South West London Cancer Network:
None. Good practice confirmed.
Lymph node diagnostic pathway audit ,
1 January – 31 March 2009 (LYM 040)
N/A
Quality Account 2009/10
Audit title (Audit ID)
Quality Account 2009/10
32
Statements of assurance from the Board
Audit title (Audit ID)
Action plan
Date to be completed by
50 Annual audit of ‘Tissues for Research
Consent’ Implementation (NAR 004)
It is recommended that measures are
again taken to highlight completion of
Tissue Consent forms, particularly in
the following areas:
January 2010
-New adult Private Patients at Sutton
-New NHS Paediatric outpatients
-Follow-up NHS Paediatric outpatients
-New NHS patients at Kingston (SWRU)
-Follow-up NHS patients at Kingston
(SWRU)
Specification and / or review of the
required processes and procedures for
Tissue Consent should be considered,
and details of processes / procedures
included in relevant Standard
Operating Procedures (SOPs).
January 2010
Consideration should be given to setting October 2010
internal targets for Tissue Consent form
completion at first outpatient attendance
and for ensuring recording of the form
details on the EPR.
Further annual review of quarterly data Ongoing
from EPR, with action as appropriate to
ensure ongoing form completion, data
collection and EPR data recording.
December 2009
51 Medical Device Training records
(NAR229)
Highlight to all staff that although
some of the training is recorded
centrally by attendance at mandatory
training, it is still required that a
training log is kept at ward level in the
medical device folder.
November 2009
Review training programmes for oral
November 2009
syringes, microclave age etc and
where possible incorporate into current
sessions within mandatory training/
induction.
Discuss with consultant dietician the
training for pH indicator strips and
training records.
November 2009
Organise representatives to visit wards
to update training where required.
November 2009
Repeat audit.
June 2010
33
Action plan
Date to be completed by
52
Staff attend action-planning day
organised by SWLCN Patient Survey
Group.
January 2010
South-West London Cancer Network
(SWLCN) – patient survey 2009:
The Royal Marsden NHS Foundation
Trust (SWLCNRMH1)
Implement action-plan.
May 2010
53 Irinotecan and docetaxel as second
line chemotherapy for advanced
oesophagogastric cancer (GI 124)
Performance status should be recorded
on the EPR annotation at every patient
attendance (not just at each treatment
commencement).
December 2009
54 Patient and family member experience
of the Lung Cancer Support Group,
2009 (LUN 079)
Review methods of advertising the
March 2010
Lung Cancer Support Group to relevant
patients and families.
Ongoing review of location of the group Ongoing
(suitable venues are acknowledged to
be scarce).
55 Patient and family member experience
of the Mesothelioma Support Group,
2009 (LUN 080)
Schedule separate time during group
for patients and family members if
possible (and requested by current
patient / family members).
March 2010
Ongoing review of location of the group Ongoing
(suitable venues are acknowledged to
be scarce).
January 2010
56 Annual Snap-shot audit of the
documentation of patients’ preferred
name (NAR238)
No change in policy – re-audit
planned to ensure improvement in
documentation.
October 2010
57 Outcomes for patients with rectal
cancer from the South-West London
Cancer Network who have achieved
pathological complete response after
neoadjuvant chemoradiotherapy (GI
113)
Confirmed good practice. No actions
required.
N/A
58 Use of Zometa in NSCLC (LUN086)
The Lung Unit guidelines have been
updated to recommend that every
newly referred patient requires a bone
scan (or PET scan) assessment.
January 2010
The survival analysis should be
repeated to stratify patient groups
into single versus double-agent
chemotherapy, by age group and by
sex.
January 2010
For lung patients receiving platinumbased chemotherapy, EDTA testing
to be limited to patients where CG is
under 50 or over 120.
December 2009
59 Cockcroft –Gault calculation (CG)
and EDTA clearance for estimation of
GFR in lung cancer patients receiving
platinum-based chemotherapy (LUN
082)
Quality Account 2009/10
Audit title (Audit ID)
Quality Account 2009/10
34
Statements of assurance from the Board
Audit title (Audit ID)
Action plan
Date to be completed by
February 2010
60
Nutrition Screening and Weight
Audit January 2010 (NAR205 a-c) for
dissemination of results to wards.
Meeting with Chief Nurse, matrons and January 2010
divisional nurse directors.
61
Spiritual assessment (EDC1, EDC2a,
EDC2b)
Results fed back to the Equality and
Diversity Committee.
Repeat results confirmed improvement.
April 2010
A comprehensive action plan will be
monitored by the NRRAC Committee.
62
Reducing systematic and random
errors for cranial radiotherapy using
ExacTrac (RT21)
63 Are we following NICE guidelines on
Laboratory monitoring of Head and
Neck Cancer patients at risk of refeeding syndrome (HAN13)
64
Further research to be done into
intrafraction motion.
2011
Form introduced.
April 2010
Re-audit planned.
April 2010
Lymph node yield in neck dissections – Results fed back to head and neck
is there a difference between consultant team.
surgeons and specialist registrars?
(HAN14)
March 2010
March 2010
65 Correct administration of thyroxine
(HAN12)
Results fed back to the Radiotherapy
Audit Meeting.
November 2009
66
Results fed back to local team.
January 2010
Good practice confirmed. Reminder
to MDT about availability of receptor
information at the time of treatment
planning for all patients.
March 2010
Metastatic Breast Cancer patients
referred to the Drug Development Unit,
Royal Marsden Hospital (BR94)
67 What proportion of women are tested
for HER2 prior to commencement
of drug treatment (if undergoing
resectional surgery and receiving
adjuvant or neo-adjuvant
chemotherapy)? (BRCLE1)
68
Frequency of complications associated Good practice confirmed.
with tumour biopsies on patients
undergoing Phase I clinical trials (DDU
036)
69 Opiate use on the Paediatric Ward (PAE Opiates can contribute to nausea and
074)
vomiting and may require further antiemetics especially at the introduction
(first 3 days) of opiates.
Recognition of risk of opiate
withdrawal after 10 days of opiates.
Recommendations have been
given as part of Picture Archiving
Communication System (PACS)
programme.
N/A
October 2009
October 2009
35
Action plan
Date to be completed by
70
Diagnostic Imaging (PACS) staff will
continue to work with advocates
for overseas patients to verify
demographic data. Note: This risk
should be removed or minimised once
the planned radiology information
system (RIS) is installed at
The Royal Marsden.
November 2009 and
ongoing
Incorrect patient demographics on
PACS (RA 054)
‘Private patient’ stickers have been
February 2010
introduced for attachment to the
imaging CD cases. These will note the
currently known name of the patient so
that the translator/advocate can check
that all patient identity details are
correct when the advocate meets the
patient.
The audit results have been discussed
with The Royal Marsden data quality
manager who will lead investigations
into the source(s) of any incorrect
patient registration (identity) details.
February 2010
71 Audit of infiltration of IV contrast in CT Rewrite infiltration sheet to be easier to March 2010
(RA 056)
understand and complete.
72
Radiotherapy cannulation in MRI (RA
057)
Radiology cannulation and infiltration
audits are on going.
April 2010
73 Trust-wide re-audit of falls incidents
In the incident reporting form add a
recorded for older patients greater than ‘not applicable’ box in the ‘Recording
55 years of age (QM022c )
Neurological Assessment’ section.
April 2010
In the incident reporting form add a
tick box to specify whether a referral
has been made and who to in the
‘Recording referral to Physiotherapist’
section.
April 2010
Continue manual handling training
encouraging staff to raise awareness
for cause of falls, prevention of falls,
referral processes and documentation
completion.
Ongoing
Ensuring staff complete all parts of the
Accident and Incident Report Form.
Ongoing
Disseminate report to Falls Group
(quarterly meeting) to discuss results.
Ongoing
Good practice confirmed.
January 2011
74
Inter-operator variety in length of total
prostate biopsy cores in the active
surveillance programme (URT071)
Quality Account 2009/10
Audit title (Audit ID)
Quality Account 2009/10
36
Statements of assurance from the Board
Patients recruited to participate in research
The number of patients receiving NHS services
provided or subcontracted by The Royal Marsden
in 2009/10 that were recruited during that period to
participate in research approved by a research ethics
committee was 4,113.
Number of Number of
trials
patients
Randomised control trial
(RCT)/National Cancer
Research Network (NCRN)
80
519
Non-RCT (NCRN)
40
611
Total number of drug trials
307
1,378
Total number of non-drug
trials
150
2,735
Total active trials
457
4,113
Registration with the Care Quality
Commission (CQC)
The Royal Marsden is required to register with the
CQC and its current registration status is registered.
There are no conditions for registration.
The CQC has not taken enforcement action against
The Royal Marsden during 2009/10.
The Royal Marsden is not subject to periodic review
by the CQC.
The Royal Marsden has not participated in any
special reviews or investigations by the CQC during
the reporting period.
Information on the quality of data
Commissioning for Quality and Innovation
A proportion of The Royal Marsden income in
2009/10 was conditional upon achieving quality
improvement and innovation goals agreed between
The Royal Marsden and Sutton and Merton Primary
Care Trust through the Commissioning for Quality
and Innovation (CQUIN) payment framework.
Further details of the agreed goals for 2009/10 and
for the following 12 month period are available on
request from the Chief Nurses’ office.
In 2009/10, the amount of income conditional upon
achieving quality improvement and innovation goals
was £539,247 of which the Trust earned £522,879 in
2009/10.
The Trust received full funding for two CQUINs.
On the third, the Trust achieved 63% of discharge
summaries dispatched within 48 hours against a
target of 100%.
The Royal Marsden submitted records during 2009/10
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 is shown in the table below.
Data quality (% completeness)
NHS number
GP practice
2008/09
2009/10
2008/09
2009/10
Inpatient and
daycases
97.8%
97.6%
97.8%
97.9%
Outpatients
98.1%
98.1%
97.9%
98.0%
Both NHS number and GP practice completeness
has been shown only for patients from England and
Wales. This is because the Trust has an unusually
high proportion of patients from overseas who will
therefore not have an NHS number or UK registered
GP practice.
The Royal Marsden score for 2009/10 for Information
Quality and Records Management assessed using
the Information Governance Toolkit was 86%.
37
Clinical coding
Coding errors
2008/09
2009/10*
HRG errors
28.5%
8.0%
Primary diagnosis errors
37.5%
5.0%
Primary procedure code
errors
32.7%
35.7%
Secondary diagnosis errors
74.3%
7.2%
Second procedure code
errors
39.7%
12.8%
*Draft figures as of 21 June 2010 pending approval of Audit
Commission. The results above were based on a focused audit of
just 200 patient episodes. It is important, therefore,
that these results are not extrapolated beyond the
audit sample. The areas audited in each year are as
follows.
2008/09
Breast surgery
Childhood diseases
Malignant prostate disorders
2009/10
General surgery (mostly specialist
sarcoma)
Mouth, head, neck and ears procedures
and disorders
Respiratory neoplasms without
complications
Quality Account 2009/10
The Trust was subject to the Payment by Results
clinical coding audit during the reporting period by
the Audit Commission and the error rates reported
in the latest published audit for that period for
diagnoses and treatment (clinical coding) were as in
the table below.
38
Quality Account 2009/10
Performance
against key metrics
Overview of performance against quality of care indicators selected by the Board
Measure reported
2009/10
2008/09
Safe care
1.
Patients with MRSA septicaemia
1
1
2.
Patients with C.difficile infection
35
38
3.
Moderate to serious falls
0.1/1,000 bed days
0.5/1,000 bed days
4.
Moderate to serious medication errors
0.3/1,000 bed days
1.4/1,000 bed days
Effective care
5.
Elective length of stay (full year average)
3.97 days
3.69 days
6.
Hospital standardised mortality ratio (HSMR)
75.4
83.1
7.
Reduction in all hospital acquired pressure sores
3.84/1,000 bed days
Change in data capture
therefore unable to
compare years
Patient experience
8.
Picker Frequent Feedback survey
>1,151 patients
participated; scores
of patient satisfaction
improved over the
year from 75% to 95%
Commenced in May
2009
9.
National Inpatient Survey
Top 20% in England
Top 20% in England
10.
National Outpatient Survey
Top 20% in England
Top 20% in England*
*Represents score from 2004 National Outpatient Survey, year last conducted prior to 2009/10.
39
2009/10
target
2009/10
2008/09
Patients waiting less than 13 weeks at month end for first
outpatient appointment
99.97%
100.00%
100.00%
Patients waiting less than 26 weeks at month end for inpatient admission
99.97%
100.00%
100.00%
Access targets
Operations cancelled by the Trust at the last minute
0.8%
0.6%
0.6%
Last minute cancelled operations not subsequently performed within
one month
5.0%
0.0%
0.0%
Patients requiring admission who waited <18 weeks from referral
to treatment
90.0%
95.3%
94.4%
Patients not requiring admission who waited <18 weeks from referral
to treatment
95.0%
98.4%
98.0%
NHS 18 week targets
Cancer waiting times targets
All urgent GP referrals seen within 14 days
93.0%
98.9%
95.2%
All referrals for breast symptoms seen within 14 days**
93.0%
98.1%
n/a
Treatment within 31 days of decision to treat for first treatment
96.0%
99.7%
99.3%
Subsequent surgical treatment started within 31 days of decision
to treat*
94.0%
98.9%
94.2%
Subsequent drug treatment started within 31 days of decision to treat*
98.0%
99.8%
99.8%
Treatment started within 62 days of urgent GP referrals
85.0%
87.6%
95.0%
Treatment started within 62 days of recall date for urgent screening centre
referrals*
90.0%
95.9%
100.0%
Commentary: *Only a national target since January 2009. **Only a national target since January 2010. The Trust met all key
performance targets in 2009/10. This includes the new target for Breast Symptomatic referrals to be seen with 14 days.
Response to regulators
The Royal Marsden scored in the top percentile
for staff experience with staff reflecting a positive
experience in working for the Trust.
The Royal Marsden declaration to the Care Quality
Commission (CQC) indicated the Trust’s compliance
The Trust’s radiotherapy and chemotherapy
with all of the core standards and, in March 2010,
services are accredited to the ISO 9001 standard. All
the Trust was registered with the CQC with no
laboratories are CPA accredited.
conditions. In October 2009, the Trust received a
rating of excellent for quality of clinical care.
The Royal Marsden also achieved international
accreditation for its blood and marrow transplant
In October 2009, The Royal Marsden also received
programme (JACIE), the Customer Service
excellent for the management of resources from
Excellence standard for patient experience and
the NHS foundation trust regulator Monitor.
The Royal Marsden is therefore the only trust to have recognition under the Department of Health’s
received double excellent for four consecutive years. Information Accreditation Scheme for the quality of
patient information.
Quality Account 2009/10
National targets and regulatory requirements
40
Quality Account 2009/10
Annex
Responses from the Local Involvement
Networks
Kensington and Chelsea LINk
Kensington and Chelsea LINk appreciate that this
is the first year of publishing a Quality Accounts for
the Royal Marsden NHS Foundation Trust and that
the process has been a steep learning curve for us
all. The LINk would like to thank Trust staff for their
support over 2009/10 and look forward to working
with them more closely in the coming year.
Sutton LINk
Sutton LINk has worked with The Royal Marsden
to encourage patients to be both aware of the LINk
and how involvement can improve local heath and
social care services. The Royal Marsden promotes
the Sutton LINk by displaying a wide range of
information on the LINk in the PALS office. Meetings
have taken place between the Trust and LINk staff,
including a conference call arranged between the
two Trust sites, patient groups and a member of
staff from the Sutton LINk team.
Response from Primary Care Trust
Sutton and Merton PCT
NHS Sutton and Merton Primary Care Trust, as
lead commissioner for The Royal Marsden NHS
Foundation Trust, believes the Quality Accounts
provide an accurate reflection of the quality work
being undertaken by the Trust and the PCT is fully
supportive of the Trust’s approach to quality and its
areas identified for improvement in 2010/11.
We are particularly pleased with the Trust’s
impressive results for MRSA and the high level
of patient experience evidenced by the 2009/10
national in- and out-patient surveys. NHS Sutton
and Merton are satisfied that the Quality Account
2009/10 has provided assurance on the performance
of The Royal Marsden Foundation Trust and that
the accuracy of data is being validated through the
external audit process.
Sutton and Merton LINk have identified priority
areas based on what the community has identified
Bill Gillespie
as needing improvement – the discharge process
Chief Executive
at St Helier hospital is one of these priority areas.
Consultation has been carried out across both
boroughs and a Sutton and Merton LINk working
group has been set up to monitor and oversee
the work. LINk members also attend an ESTH
Discharge Information group to monitor progress
with the St Helier targets and this particular group
Dr Martyn Wake
arranged a visit to The Royal Marsden who has a
Joint Medical Director
high achievement of targets around discharge. The
intent was to explore good practice and look at
where the discharge process could be improved at St
Helier.
Quality Account 2009/10
41
42
Quality Account 2009/10
Glossary
Adjuvant chemotherapy
Cancer chemotherapy used after the main tumour
has been removed by some other method.
Clinical champion
An expert nurse, doctor or therapist who is
responsible for promoting an area of health care.
Antibiotic
Medicines used to treat bacterial infections.
Cohort
A group of subjects who have shared a particular
experience during a particular time span.
Antimicrobial
A substance that kills or inhibits the growth of
microorganisms such as bacteria and fungi.
Bacteraemia
The presence of bacteria in the blood.
Bariatric
When a person weighs in excess of 121 kg (19
stone).
Commissioning for Quality and Innovation
(CQUIN)
National programme to reward hospitals who
provide care that is of a high quality in certain
assessed areas.
Contraindication
A factor that increases the risks involved in using a
particular drug, carrying out a medical procedure or
engaging in a particular activity.
Biopsy
The removal of a sample of tissue from the body for
examination.
CPA
Clinical Pathology Accreditation.
Blood count
A test that measures the number of red cells, white
cells and platelets in blood.
Cranial radiotherapy
The use of high-energy rays to destroy or control
cancer cells in the head.
Care Quality Commission (CQC)
CQC regulates all health and adult social care
services in England, including those provided by
the NHS, local authorities, private companies or
voluntary organisations. It also protects the interests
of people detained under the Mental Health Act.
CT
Computed tomography (CT) is a medical imaging
method.
CCU
A Critical Care Unit is a specialised department in a
hospitals that provides intensive care medicine.
Customer Service Excellence (CSE) standard
The Government’s customer service standard. This
scheme replaces the Charter Mark.
Dyspneoa
Shortness of breath.
EDTA
Chemoradiotherapy
The combination of simultaneous chemotherapy and A test to measure how kidneys are working.
radiotherapy.
Elective surgery
Surgery that is not urgently required.
Chemotherapy
Treatment with anti cancer drugs to destroy or
control cancer cells.
43
EPR
The Electronic Patient Record is the computerised
system of patients’ medical records.
GFR
Glomerular Filtration Rate. A test to measure how
kidneys are working.
GI
The gastrointestinal (GI) tract is the digestive system
of the body.
Haematopoietic progenitor cells
Cells found in bone marrow that give rise to all the
blood cell types.
Health Protection Agency (HPA)
Helps protect UK public health by giving support
and advice to the NHS, local authorities, emergency
services, the Department of Health and any other
organisations that play a part in protecting health.
Healthcare-associated infections
An infection acquired during the course of
healthcare.
HER2
A gene associated with a type of breast cancer.
High impact intervention
A healthcare activity that carries a high risk of
associated infection, such as inserting a catheter.
Histology
The study of the microscopic anatomy of cells and
tissues of plants and animals. It is performed by
examining a thin slice of tissue under a microscope.
Hopsital2Home programme
Support for those close to death in choosing their
preferred place to die away from hospital. For
example at home or in a hospice. The patient’s care
is co-ordinated by a senior nurse or doctor from the
hospital working together with the patient’s family,
family doctor and community healthcare team.
HRG
Healthcare Resource Group is a list of healthcare
procedures used for financial coding purposes.
HSMR
Hospital Standardised Mortality Ratio. An indicator
of healthcare quality that measures whether the
death rate at a hospital is higher or lower than
expected.
Hygiene Code
The Health and Social Care Act 2008 Code of
Practice for health and adult social care on the
prevention and control of infection.
ICNARC CMPD
Intensive Care National Audit and Research Centre:
Case Mix Programme Data.
Information governance
Ensures that organisations achieve good practice
with data protection and confidentiality.
Integrated care pathway
A multidisciplinary outline of anticipated care,
placed in an appropriate timeframe, to help a patient
with a specific condition or set of symptoms move
progressively through a clinical experience to
positive outcomes.
Integrated governance
Systems and processes by which trusts lead, direct
and control their functions in order to achieve
organisational objectives, safety and quality of
service.
Quality Account 2009/10
Enhanced Recovery Programme
A national scheme that places the patient at the
centre of a multi-professional team to plan for greater
partnership in care, improved quality of care and
shorter lengths of stay in hospital.
Quality Account 2009/10
44
Glossary
Intravenous contrast
Fluid used in CT [computerised tomography] to help
highlight blood vessels and organs to improve the
quality of the image. The contrast fluid is injected
into a vein.
ISO 9001
A system used to measure the quality of a service.
IV therapy
Intravenous therapy or IV therapy is the giving of
liquid substances directly into a vein.
JACIE
Joint Accreditation Committee of ISCT (International
Society for Cellular Therapy) and EBMT (European
group for Blood and Bone Marrow Transplantation).
This body sets the quality standards for hospitals
wanting to carry out bone marrow and stem cell
transplantation.
LoS
Length of stay.
Lymph node
Part of the immune system.
MDT
Multi-Disciplinary Team is a group of healthcare
professionals from different disciplines who work
together.
Membership Council
A council consisting of elected and nominated
representatives who assist in governing The Royal
Marsden NHS Foundation Trust.
Meticillin-resistant Staphylococcus aureus
(MRSA) and Clostridium difficile (C. difficile)
Bacteria that are a significant cause of hospitalacquired infections.
Monitor
The independent regulator of NHS foundation trusts.
MRI
Magnetic resonance imaging (MRI) is a medical
imaging technique used in radiology to visualize
detailed internal structure and limited function of the
body.
National Audit Office
Audits central government departments, government
agencies and non-departmental public bodies.
National Patient Safety Agency (NPSA)
Shares learning from patient safety incidents
occurring in the NHS.
Neoadjuvant chemotherapy
Chemotherapy given before an operation.
Neoplasm
An abnormal mass of tissue that serves no purpose.
Neuropathic pain
Pain that comes from problems with signals from
the nerves.
Neuropathy
Disease or malfunction of the nerves.
Mesothelioma
A rare form of cancer that is usually caused by
exposure to asbestos.
Neutropaenia
A blood disorder characterized by an abnormally
low number of a type of white blood cell. Patients
with neutropenia are more susceptible to bacterial
infections.
Metastatic
A cancer that has spread to other organs from the
original tumour site.
NHS Litigation Authority (NHSLA)
The NHSLA works to improve risk management
practices in the NHS.
45
Prophylaxis
A measure taken to prevent a disease or condition.
Prospective audit
An audit based on real-time collection of data which
reflects current rather than past practice.
NRRAC
Nursing, Radiography and Rehabilitation Advisory
Committee .
Pulmonary Embolism (PE)
A blockage of a blood vessel in the lung.
Oesophagogastric cancer
Cancer of the oesophagus (gullet) and stomach.
Radical radiotherapy
Treatment given with the aim of curing the cancer.
Oncoplastic surgery
The use of plastic and reconstructive surgical
techniques combined with surgery to remove a
cancer.
Radiotherapy
Is the use of high energy rays to destroy cancer cells.
It may be used to cure some cancers, to reduce the
chance of recurrence or for symptom control.
Opiate
A narcotic drug that contains opium or an opium
derivative.
Resection surgery
Surgery performed to remove tissue in an organ or
structure.
Percentile
A comparison score.
Second line chemotherapy
Chemotherapy given when cancer has failed to
respond to an initial treatment of chemotherapy.
Performance status
An attempt to measure cancer patients’ general wellbeing.
Spirometry
A test that can help diagnose lung conditions.
PET scan
SWLCN
Positron Emission Tomography is a medical imaging South West London Cancer Network.
technique.
Synbiotix
Picker Institute Europe
A computer system that collects clinical data about
An organisation that administers patient surveys
patient safety and quality of care.
including the frequent feedback surveys which
gathers data from patients in real time using
Tumour
handheld devices.
An abnormal growth of cells.
Platinum-based chemotherapy
This chemotherapy can be used for cancer patients
who have a high chance of recurrence of disease.
Pressure ulcers
Bed sores or pressure sores.
TWG
Tumour Working Group.
Venous Thromboembolism (VTE).
Blood clot typically occurring in leg but which can
form in any blood vessel.
Quality Account 2009/10
NICE
National Institute for Health and Clinical Excellence
which reviews medicines, treatments and tests.
It makes clinical guidelines and public health
recommendations.
The Royal Marsden NHS Foundation Trust
Chelsea
Fulham Road
London SW3 6JJ T 020 7352 8171
Sutton
Downs Road
Sutton
Surrey SM2 5PT T 020 8642 6011
Kingston
Galsworthy Road
Kingston upon Thames
Surrey KT2 7QB
T 020 8973 5030
www.royalmarsden.nhs.uk
Patron: Her Majesty The Queen
President: HRH Prince William of Wales
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Communications with photography by Michael Heffernan