Quality Accounts
April 2009 to March 2010
Page 1 of 38
Contents
Part 1: Statement on quality
3
Foreword
4
Part 2: Priorities for improvement and statements of assurance from the board
7
A: Priorities for improvement
7
Priority 1 – Improve patient safety
7
Priority 2 – Improve patient outcomes
11
Priority 3 – Improve patient experience
13
B: Statement of assurances from the Board
15
Part 3: Other information
24
Annex - statements from primary stakeholders
35
Glossary of Terms
38
Page 2 of 38
Part 1.
Statement on quality from the Chief Executive of the provider
Welcome to our quality accounts which set out our clinical priorities, what we have achieved and
what we are striving towards.
The Trust‟s Chief Nurse and our Medical Director explain these in more detail overleaf.
Our quality accounts give a real insight into our drive to continually improve patient care.
You will see that this document includes performance statistics which show progress against key
targets.
Overall, it was another year of steady success and good quality. We continued to strengthen our
work on patient safety and involved patients and their feedback on the use and redesign of our
services.
The Trust‟s reputation for effective infection control is well deserved, as our rates demonstrate.
Tightening up the management processes around surgery helped us meet the target for treating
patients within 18 weeks of a GP referral. It is worth remembering that in previous years national
waiting times for surgery were more likely to be 18 months than 18 weeks.
The four hour target in A&E has been with us for many years now and we continue to meet this
challenge, despite peak periods of activity. For example, when high number of fracture patients
were seen during the adverse weather in early 2010.
Our wards – being fairly old on the whole – can make it hard to segregate patients into same sex
bays and we had more incidences of mixed sex accommodation than we would like in 2009/10.
Despite this we were pleased to be awarded „excellent‟ in our privacy and dignity standards for
2009 in the annual Patient Environment Action Team (PEAT) assessment.
Achieving targets around single sex accommodation without moving patients is high on the priority
list for 2010/11.
You can read more about this and other targets in the following pages. The figures and information
you see are compiled from statistics which are validated by each division on a weekly or monthly
basis and are, to the best of my knowledge, accurate.
Chris Gordon, Chief Executive
Page 3 of 38
Foreword
We are delighted to present our first quality accounts for 2009/10. This provides an opportunity to
demonstrate to the public, our patients and staff how we have worked over the past year to
continually improve patient care and how this work will continue in 2010/11.
The Trust‟s strategic goal is to deliver the best quality of patient care in a safe environment by
improving patient safety, patient outcomes and patient experience.
Being active members of the South Central Patient Safety Federation has helped us stride forward
in this work, sharing our best practice and learning from others. We fully participate in the National
Patient Safety First Campaign and share the results of this and other local quality and safety
initiatives with the Trust Board.
Our drive for continuous improvement is also demonstrated by having Executive membership on
the programme Board of the Strategic Health Authority Advancing Quality initiative. This is a
detailed project which uses clinical data to identify areas for where we can affect outcomes for our
patients. This includes, for example, patient care pathways for acute myocardial infarction (heart
attack), hip or knee surgery. Examples of quality and safety improvements are presented in Part 3
of these accounts.
The Trust has a strong track record in using learning from national programmes to benefit patients.
In 2008/09, we took part in the NHS Institute of Innovation and Improvement‟s (NHS III) „Leading
Improvement in Patient Safety‟ programme. This led to our Safer Care Programme, which sets
ambitious goals based on small steps of change in clinical practice. Progress is monitored by our
Patient Safety and Quality Committee, of which the membership includes representation from the
local independent patient and public involvement forum and commissioning Primary Care Trust
(PCT), NHS Hampshire and a WEHCT non executive director. The programme consists of nine
interventions - five from the National Patient Safety Campaign and four local initiatives. They have
the shared aim of further reducing mortality within our hospital. Nursing quality and safety
indicators feed into this work and are monitored weekly to identify areas for improvement.
Our progress has led to national and international recognition providing further opportunity to share
our learning across the wider healthcare community. Key successes in 2009/10 were:
Reduction in hospital acquired infection
o 48% reduction in hospital acquired Clostridium difficile toxin positive cases (Cdiff)
o 40% reduction in hospital acquired Methicillin Resistant Staphylococcus Aureus MRSA
bacteraemia (bloodstream). Health Protection Agency data records three hospital acquired
and three community acquired cases of MRSA bacteraemia.
10% reduction in HSMR (hospital standardised mortality rates).
Page 4 of 38
20% reduction in a rate of adverse events per 1000 bed days as measured by the Global
Trigger Tool (see Priority Two).
26% reduction in hospital acquired pressure ulcers.
50% reduction in the time from patient diagnosis/admission with sepsis to administration of
antibiotics resulting in „highly commended‟ recognition at the national patient safety awards
2010 and invitation to present at the Patient Safety Congress.
Significant improvements in documentation and appropriate decision making regarding
deteriorating patients, particularly end of life care from regular patient note reviews (Priority
Two).
Selection and participation in national patient safety research projects
o The WISER Study – Warwick and Imperial Study to Examine Reliability in Healthcare
o Evaluating the World Health Organisation Surgical Safety Checklist – Imperial College and
Ipsos MORI
o Reducing central venous line related blood stream infections – National Patient Safety
Agency
Success in being granted places on the NIII programme - involving our Clinical Governance and
Patient Safety lead consultants visiting US healthcare organisations and developing a project to
enhance leadership performance and inpatient experience through the use of comment cards
and to reward staff for their work.
Implementation of the NIII Productive Ward initiative: „Releasing Time to Care‟ across the Trust.
Participation in the National Patient Safety Campaign leading to
o Certificate of progress and contribution to the campaign
o Recognition within a campaign „How to Guide‟ of our Trust Board‟s exemplary approach to
sharing and using patient stories to lead their agenda.
Selection by the Chief Nursing Officer for national roll out across the NHS for our work on
improving catheter care as an example of a „High Impact Action for Nursing and Midwifery‟.
A clean, safe environment enhances the provision of a quality care and service to our patients. The
Patient Environment Action Team (PEAT) programme assesses performance against cleanliness
and environments for NHS hospitals. We were delighted to achieve an excellent PEAT rating in
2010 and 2009 against the NPSA scoring framework at the Royal County Hampshire and Andover
War Memorial Hospital sites for environment, food and privacy and dignity – an improvement from
„Good‟ in 2008.
Page 5 of 38
We are committed to improving the quality of services based on the experiences reported by our
patients. The Trust participates in the annual Care Quality Commission (CQC) inpatient survey,
local surveys are carried out and we monitor feedback on our website and on NHS Choices
website.
In 2009/10 we opened a new outpatients facility at Andover War Memorial Hospital, a maternity
day assessment unit in our maternity wing and refurbished Kemp Welch ward. Working with the
NPSA has enhanced our knowledge and approach to redesigning clinical environments to promote
patient safety and improve efficiencies.
For the second year in succession we declared full compliance to the CQC‟s core Standards for
Better Health. As from April 2010, the CQC has introduced a registration process against new
Essential Quality and Safety Standards. The Trust‟s application to be fully registered to undertake
the regulated activities delivered at our hospital sites was accepted by the CQC. We take this
responsibility very seriously and are committed to maintain and continuously monitor our
performance against the standards.
Part 2 of the quality accounts outlines our priorities for quality and patient safety for 2010/11, which
includes statements of assurance from our Trust Board. Part 3 provides further information on the
quality of our services with statements from our commissioners and local stakeholders.
We would value your comments on our quality accounts and invite you to contact us via email on
WEHCT_Public.Relations@wehct.nhs.uk or by phone on 01962 824720.
Paula Shobbrook, Chief Nurse
Jeremy Hogg, Medical Director
Page 6 of 38
Part 2.
Priorities for improvement and statements of assurance from
the Board.
A. Priorities for Improvement 2010/11
Our priorities for the year ahead have been agreed by the Trust Board. They were developed by
our Chief Nurse and Medical Director with consideration of the themes arising from patient
feedback and following consultation with members of our Patient Safety & Quality and Risk
Management & Governance Committees.
Priority One - Improve Patient Safety
Rationale
Safety is a fundamental aspect of high quality, responsive and accessible patient care. Patient
safety is the top priority with a commitment to deliver high quality and value for money services for
our patients and commissioners. Continuous quality and safety improvement is reliant on fostering
a working culture where patient safety is central to all we do. Our aim is to create a „chronic
unease‟ whereby we anticipate where patient safety is compromised and further strengthen our
processes for responding to this.
How will we do this?
1.
Further Reduce Healthcare Acquired Infection (HCAI)
Reducing hospital acquired infections is integral to all elements of our safer care and clinical audit
programmes. In 2010/11 our aim is to continue our success in reducing patient harm through:Achieving or improving upon the Trust‟s nationally mandated targets for MRSA bacteraemia (no
more than three cases) and Cdiff (no more than 46).
Delivery of 100% MRSA screening.
Meeting the objectives of our infection control annual plan
o
Compliance with our isolation policy
o
Compliance with our Bare Below the Elbow policy
o
Compliance with our antibiotic policy
Page 7 of 38
How will progress be monitored?
Progress is monitored through a detailed programme of audits with results reviewed and actions
identified by the weekly Nursing Quality Group. This includes patient views collated from
inpatient surveys (comment cards and trackers), our Patient Advice and Liaison Service (PALS)
and complaints. If exceptions occur, the Chief Nurse who is the Director of Infection Prevention
and Control (DIPC) will intervene and direct the actions required to mitigate any risk exposed to
patients and instigate a full review.
Patient Safety Walkrounds (informal and formal) by executives, matrons and senior managers.
A full Root Cause Analysis investigation will be instigated if there is a MRSA bacteraemia case,
a death directly attributable to Cdiff or an outbreak (two or more cases in the same ward) of
Cdiff. All lessons will be reported to the Patient Safety and Quality Committee.
Progress will be monitored and compliance reviewed quarterly through our Infection Control
Committee.
To provide additional assurance, visits from our stakeholders such as our commissioners and
the Care Quality Commission will be undertaken.
2.
Meet the aims of the Trust’s Safer Care Programme for 2010/11
A Safer Care Programme (SCP) has been developed to help prioritise and coordinate
improvements in patient safety and clinical outcome. The SCP consists of the five national Patient
Safety First Campaign interventions and four additional local initiatives. It also incorporates aspects
of the quality contract with our main commissioning PCT, NHS Hampshire. The aims for 2010/11
are:
Leadership through safety:
To have completed executive patient safety walk rounds in all ward areas and implemented the
action plans by April 2011.
Reduce harm through deterioration:
Reduce number of adverse events from mortality reviews by a further 10% from 22 to 20. See
page 12 for details.
Reduce number of cardiac arrest calls by 20% - once the true baseline has been established for
2009/10.
Introduce a recognised communication tool (SBAR) to the Trust and evaluate impact.
Page 8 of 38
Reduce harm in critical care
To agree appropriate reduction from baseline with ICU and microbiology/ICT for 2010/11.
Reduce harm in peri-operative care
To monitor compliance against best practice for reducing surgical site infections and indentify
areas for improvement.
Reduce harm from high risk medications
Patients with significant blood clotting risks to be monitored via thrombosis committee.
75% patients to have completed medicines reconciliation tool by April 2011.
Reduce harm from sepsis
A further 50% reduction to no more than two hours from admission/diagnosis for antibiotic
administration.
Reduce harm from falls
75% falls assessments completed on day of admission by April 2011.
A phased three year trust strategy for the reduction in the severity of harm from falls will be
developed by July 2010.
Reduce harm from pressure ulcers
Further 25% reduction in grade 3 and 4 hospital acquired pressure ulcers from 2009/10 baseline.
Reduce harm from VTE
90% of patients admitted to have a VTE assessment form completed by April 2011.
How will progress be monitored?
Each intervention has a clinical champion with accountability for maintaining regular
measurement and focus.
Our Patient Safety Manager is responsible for co-ordinating activity, monitoring progress and
reporting exceptions to the Patient Safety and Quality Committee.
Patient, public and commissioner involvement is integral to each workstream. In addition, the
Independent Patient and Public Involvement Forum and Trust PCT commissioners are
members of the Patient Safety & Quality Committee which receive progress reports and provide
assurance to the Risk Management and Governance Committee.
The interventions are incorporated into the Board Assurance Framework, where exceptions are
escalated via the Risk Management and Governance Committee to the Trust Board.
Page 9 of 38
3.
To deliver the Patient Safety Strategy for 2010-11
The Patient Safety strategy 2009-2012 sets out the Trust‟s key aims and objectives for patient safety
over the next three years. It seeks to engage the hearts and minds of all staff through the delivery of
our Safer Care Programme. In addition, the Trust aspires to be recognised as being at the forefront of
patient safety both nationally and internationally. Implementation of this strategy will serve to enhance
the organisation‟s reputation and significantly reduce harm and costs incurred through error. A
sustainable future as a highly reliable organisation will then be maintained delivering on safety, cost,
performance and quality.
How will progress be monitored?
An annual review of progress against achievement of the aims and objectives will be undertaken
by the Patient Safety Committee. The following will inform this review:
Progress against the aims set for each intervention within the Safer Care Programme.
Progress reports reflecting WEHCT‟s participation in the National Patient Safety First
Campaign.
Performance and progress as measured by the Trusts participation in the South Central Patient
Safety Federation workstreams.
Compliance to the patient safety aspects of the quality contract schedule of with NHS
Hampshire.
Page 10 of 38
Priority Two – Improve Patient Outcomes
Rationale
A strategic goal for 2010/11 is to deliver high quality and value for money services for our patients
and commissioners. This goal underpins the Trust‟s work in relation to investing in safety and
quality in order to reduce harm to patients and reduce unnecessary costs. Monitoring patient
outcomes using a nationally recognised method will help provide assurance to our patients that our
clinical services at WEHCT are of a high quality. These measures will also help us demonstrate
our overall improvement and how we compare against other trusts. It is not enough to improve
against our own measures – we aspire to be leaders in patient safety and delivery of a quality
service.
How will we do this?
1.
Reduce our Hospital Standardised Mortality Rate (HSMR) by 10% from the 2009/10
baseline by April 2011
What is HSMR?
HSMR is an indicator of healthcare quality that measures whether the death rate at a hospital is
higher or lower than expected. HSMR is a statistical measurement which compares the expected
rate of death in a hospital with the actual rate of death. The company, Dr Foster, looks at those
patients with diagnoses that most commonly result in death for example, heart attacks, strokes or
broken hips. For each group of patients Dr Foster can work out how often, on average, across the
whole country, they survive their stay in hospital, and how often they die. Whilst, in itself, the
HMSR is not a single marker of the quality of care, it is a useful barometer by which a trust can
compare itself with others and can be useful in confirming that the safer care programme and other
service improvement schemes identified by the to improve patient safety are having the desired
effect. The baseline is 100 – lower indicates better than expected rate.
Page 11 of 38
Graph indicates
HSMR for WEHCT
between Jan 2009 –
Dec 2009
Safer Care Programme
Reducing Mortality
1
Leader
ship for
safety
2
Reducing
harm
from
deteriorat
ion
3
Reducing
harm in
critical
care
4
Reducing
harm in
periopera
tive care
5
Reducing
harm from
high risk
medicines
6
Reducing
harm from
Sepsis
7
Reducing
harm
from falls
8
Reducing
harm from
Pressure
ulcers
9
Reducing
harm
from VTE
Trust aimed to reduce mortality by 10% by end
December 2009 as measured by Dr Foster - achieved
Patient Safety Strategy outlines 15% reduction 2009/10;
10% reduction 2010/11; 5% reduction 2011/12
2.
Further reduce our adverse rate by 10% as measured by the Global Trigger Tool
(GTT) by April 2011
What is the GTT?
The GTT is an internationally recognised audit proforma designed to identify triggers and harm
events during a patients stay in hospital.
Traditional methods to detect adverse events during the delivery of care or treatment to patients
have focused on voluntary reporting and tracking of errors. However, only 10 to 20% of errors are
ever reported and of those 90 to 95% cause no harm to patients. A more effective way is needed
to identify events that cause harm to select and test changes to reduce harm. The use of triggers
to identify adverse events during a manual record review has been used extensively in several
countries to measure the overall level of harm in a healthcare organisation. The Institute of
Healthcare Improvement, based in the United States, developed the GTT to quantify all causes of
adverse events. This has been adapted for use in the UK. It has been extensively tested with
demonstrable reduction in adverse events by those healthcare organisations who have adopted its
use.
Page 12 of 38
The objective is to identify harm. In the context of the GTT, an adverse event is defined as any
physical harm to patients i.e. “would you be happy if the event in question happened to you?”
If the answer is no, then it is an adverse event.
At WEHCT, key themes are fed into the appropriate Safer Care Programme workstream and
clinical/service lead, raising clinical incidents where appropriate.
The WEHCT established process has been presented at a national Risk and Patient Safety
conference in November 2009. This also feeds into the regional Patient Safety Federation
workstream of „no needless harm‟.
How will progress be monitored?
In addition to the measures outlined in all three elements of priority one, our progress will be
monitored by the Patient Safety Committee through:
6 monthly mortality reviews of patients notes (using the GTT)
Monthly GTT reviews of 20 randomly selected patient records
Trust Board review of our monthly quality and safety scorecard
Priority Three – Improve Patient Experience
Rationale
Learning firsthand how it feels to be a patient at one of our hospitals or a user of our services in the
community is invaluable. Modern healthcare must be responsive which is why we need to listen to
our patients and act upon what they tell us. A positive experience of healthcare can contribute to
wellbeing and recovery. Our Patient Experience Strategy for 2010/11 reflects the following
objectives.
1.
Through implementation and quarterly monitoring of feedback from the Patient
Experience Tracker
A patient tracker is a hand held electronic device which allows us to gather instant feedback from
patients, carers and users. The trackers are currently used to monitor and analyse views on the
quality of care and service they receive. Examples include mixed sex accommodation, cleanliness,
stroke care and discharge processes.
In line with our Patient Experience Strategy, in 2010/11 a rolling programme will be developed to
provide focus and optimise use of the trackers.
Page 13 of 38
2.
Improvement in the CQC inpatient survey results
An annual national survey asks about the experiences of people who have been admitted to
hospital overnight or for longer. The questions in the survey cover the issues that patients consider
important in their care and what the CQC like to be included in national assessments. The survey
offers an insight into patient experiences and the information is used by the Trust to improve
services and by the CQC in their assessment of NHS trusts.
In 2010/11 WEHCT aims to build on the progress from previous years and improve on the areas
identified for improvement. These relate to the availability of verbal and written patient information
for inpatients.
3.
Further 20% reduction in ‘major’ complaints
Patient complaints provide an opportunity for us to learn and implement improvements from poor
patient experience. In 2010/11, we will continue to offer complainants a meeting with our CEO or in
his absence the designated deputy so we can apologise and share the learning from our review.
4.
No mixed accommodation unless clinically indicated
WEHCT is committed to maintaining single sex accommodation for patients during their stay in
hospital, in order to optimise their privacy and dignity. This reflects a national target for all
hospitals. Clinical justifications have been agreed to ensure patient safety remains paramount in
deciding bed allocation.
How will progress be monitored?
All recommendations and subsequent action plans from information gathered from patient
surveys, focus groups and comment cards will be reported by divisions and approved at the
Patient Safety & Quality Committee. The committee will monitor the implementation of action
plans across the Trust and report a summary of progress to the Board in its quarterly patient
experience reports.
Single sex accommodation will be monitored on our quality and safety scorecard and reviewed
weekly by the Executive Management Team.
Page 14 of 38
B
Statements of assurance from the Board
Review of Services
During 2009/10 Winchester and Eastleigh Healthcare NHS Trust provided and/or
sub-contracted 50 NHS services.
Winchester and Eastleigh Healthcare NHS Trust manages two hospitals (Andover War Memorial
Hospital and the Royal Hampshire County Hospital, Winchester) and provides a wide range of
general hospital services, including accident and emergency, maternity and diagnostics, as well as
some services in the community.
We have around 2200 staff and approximately 400 beds.
Our clinical services are managed through four divisions; medicine & elderly care; family services;
diagnostics and surgery & anaesthetics.
The population we serve is around 350,000 locally.
The health authority which covers the area we work in is NHS South Central and the primary care
trust which commissions the majority of our services is NHS Hampshire.
WEHCT has reviewed all the data available to them on the quality of care in all 50 of these NHS
services.
We monitor our services performance through weekly and monthly scorecards, which include
quality and safety. A copy of the 2009/10 performance begins on page 27.
Income
In
2009/10
the
operating
income
of
the
Trust
totalled
just
over
£143
million.
The income generated by the NHS services reviewed in 2009/10 represents 90.4% of the total
income generated from the provision of services.
Participation in clinical audits and national confidential enquiries
During 2009/10, 23 national clinical audits and eight national confidential enquires covered NHS
services that WEHCT provides.
During that period WEHCT participated in 83% national clinical audits and 88% national
confidential enquires of the national confidential enquires which it was eligible to participate in.
The national clinical audits and national confidential enquires that WEHCT was eligible to
participate in during 2009/10 are as follows:
Page 15 of 38
Topic
Topic
NNAP: neonatal care
National mastectomy & breast reconstruction
NDA: National Diabetes Audit
National Oesophago-gastric cancer audit
ICNARC: adult critical care
National audit for inpatients with diabetes
PROMS: national elective surgery
CEMACH: perinatal mortality
NJR: hip & knee replacements
CEMACE: Obesity in pregnancy
NBOCAP: bowel cancer
NCEPOD: Acute kidney
NLCA: lung cancer
NCEPOD: Caring to the end
MINAP
NCEPOD: Parenteral Nutrition
National Sentinel Stroke Audit
NCEPOD: Elective & emergency admissions
National Audit of Dementia
NCEPOD: surgery in children
National Falls & Bone Health audit
Did not participate in 2009/10
National Audit of Blood transfusion
Heart Failure
National Sentinel Stroke Audit
Pulmonary Hypertension
British Thoracic Society; Respiratory diseases
TARN- severe trauma (Severe trauma patients are
treated at Southampton General Hospital)
College of emergency medicine: pain in children
RCP Continence Care (Not a priority audit for WEHCT
in 2009/10)
College of emergency medicine:asthma
NCEPOD: Peri operative care (Data collection over
one week period. NCEPOD unable to allow deferment of
WEHCT data to following week)
College of emergency medicine: fractured neck
of femur
The national clinical audits and national confidential enquires that Winchester and Eastleigh
Healthcare NHS Trust participated in during 2009/10 are as follows:
Topic
Topic
NNAP: neonatal care
British Thoracic Society; Respiratory diseases
NDA: National Diabetes Audit
College of emergency medicine
ICNARC: adult critical care
pain in children
PROMS: national elective surgery
asthma
fractured neck of femur
NJR: hip & knee replacements
National mastectomy & breast reconstruction
NBOCAP: bowel cancer
National oesophago-gastric cancer audit
Page 16 of 38
NLCA: lung cancer
CEMACH: Perinatal mortality
MINAP
CEMACE: Obesity in pregnancy
National Sentinel Stroke Audit
NCEPOD: Acute kidney
National Audit of Dementia
NCEPOD: Caring to the end
National Falls & Bone Health Audit
NCEPOD: Parenteral nutrition
National audit of Blood transfusion
NCEPOD: Elective & emergency admissions
National audit for inpatients with diabetes
NCEPOD: surgery in children
The national clinical audits and national confidential enquires that WEHCT participated in, and for
which data collection was completed during 2009/10, are listed 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 audit or enquiry.
%
Title
%
Title
submitted
submitted
British Thoracic Society;
NNAP: neonatal care
100%
NDA: National Diabetes Audit
100%
College of emergency medicine:
pain in children
100%
ICNARC: adult critical care
100%
College of emergency medicine:
asthma
100%
PROMS: national elective surgery
80%
College of emergency medicine:
fractured neck of femur
100%
CEMACH: perinatal mortality
100%
National mastectomy & breast
reconstruction
100%
NJR: hip & knee
100%
National Oesophago-gastric cancer
audit
100%
NLCA: lung cancer
47%
National audit for inpatients with
diabetes
100%
NBOCAP: bowel cancer
100%
CEMACE- Obesity in pregnancy
100%
INAP
98%
NCEPOD: Acute kidney
50%
National Sentinel Stroke Audit
100%
NCEPOD : Caring to the end
100%
National Audit of Dementia
100%
NCEPOD: Parenteral nutrition
Awaiting
confirmation
from NCEPOD
National Falls & Bone Health audit
100%
NCEPOD: Elective & emergency
admissions
Awaiting
confirmation
from NCEPOD
National audit of Blood transfusion
100%
NCEPOD: surgery in children
100%
Respiratory diseases
Page 17 of 38
100%
The reports of 14 national clinical audits were reviewed by WEHCT in 2009/10 and WEHCT
intends to take the following actions to improve the quality of healthcare provided.
(For another 9 of the national audits we are awaiting publication of the report & one is currently under review by the lead consultant)
Actions required/outcome
Title
NNAP: neonatal care
Reviewed by paediatricans, reported to patient safety
committee. Results have shown marked improvement.
Achieving 100% in most areas and compare very favourably to
similar units nationally.
NDA: National diabetes audit
Publication date of executive report is June 2010.
ICNARC: adult critical care
Results are benchmarked and are continually better than the
national average in both case adjusted ICU and hospital
mortality rates.
PROMS: national elective surgery
Awaiting national report.
CEMACH: perinatal mortality
Results regularly reviewed at Divisional Governance
Committee, and presented to Chief Executive. All areas remain
th
in the 95 centile, well below the national average.
NJR: hip & knee
Awaiting update.
NLCA: lung cancer
Improve timeliness and completeness of data collection
(redesigning multidisciplinary proforma and include the data for
patients who some of their treatment is undertaken at another
trust).
NBOCAP: bowel cancer
Report reviewed by consultants both at national and regional
meetings. Any concerns with local data are being peer
reviewed.
MINAP
Quarterly reports are reviewed by consultants and last report
showed achieving 80% against the suggested 75%
compliance.
National Sentinel stroke audit
The results for 2009 ranked the Trust in the top 25% in the
country; this is an extensive audit of stroke services including
all aspects of patient care. Plans are in place to further improve
the service in 2010.
National Audit of dementia
Data collection still in progress.
National falls & bone health audit
Report recently released and with leads to review actions from
this will then form part of the overall trustwide strategy to
reduce harm from falls.
National audit of blood transfusion
Reported to Patient Safety Committee and results showed
overall good compliance with the national standards. Results
are used at induction training and teaching within the teams.
British Thoracic Society;
Awaiting final report from college.
Respiratory diseases
College of emergency medicine:
Awaiting final report from college.
- pain in children
- asthma
- fractured neck of femur
National mastectomy & breast
reconstruction
Report recently released and with lead reviewing actions.
National Oesophago-gastric cancer audit
Contribute to this audits but our data is not benchmarked
against others.
National audit for inpatients with diabetes
Good results which have been presented to Clinical Audit
Committee.
CEMACE- Obesity in pregnancy
Results of audit presented at Divisional Governance
Page 18 of 38
Committee, national guidelines due to be released shortly from
Royal College of Obstetricians and Gynaecologists (RCOG)
and Centre for Maternal and Child Enquiries (CMACE).
NCEPOD: Acute kidney
Nominated lead agreed at Patient Safety & Quality Committee
and reviewing actions.
NCEPOD : Caring to the end
Nominated lead agreed at Patient Safety & Quality Committee
and reviewing actions.
NCEPOD: Parenteral nutrition
Publication due June 2010.
NCEPOD: Elective & emergency
admissions
Publication date to be confirmed.
NCEPOD: surgery in children
Publication date to be confirmed.
The reports of 47 local clinical audits were reviewed by WEHCT in 2009/10 and Winchester &
Eastleigh Healthcare NHS Trust intends to take the following actions to improve the quality of
healthcare provided.
Title
Chest drains (adults) NPSA alert
Outcome/ Actions required
This was a re-audit and showed improvements in aspects of
documentation of consent and the procedure itself. The
consideration and use of image guidance for pleural
effusions has increased significantly compared to 2008.
Action: A further round of training for junior medical staff is
planned for this year.
Chest drains (children)
This audit for children also demonstrated that safe practice
was being followed in line with the national guidance.
Re-audit care bundle to prevent surgical
site infection
There is very good compliance with this care bundle which
has shown marked improvement from the previous year.
Documentation audits
Overall these audits demonstrated a basic general standard
of documentation with over 300 notes being audited from all
specialties, action in place regarding timing of entries and
re-audit planned for 2010.
Outcomes of hip & knee replacements
The results demonstrate an improvement in all measured
parameters. These results are comparable to those from
arthroplasty centres in the UK and reflect favourably upon
the RHCH.
Postnatal readmission result of Serious
Untoward Incident
This showed compliance with re-admission guidelines.
Pain assessment audit - Northbrook Ward
This showed 100% of parents satisfied with child's pain
control.
Hep B screening
This audit led to alignment with national practice saved 1000
tests per annum.
Cystoscopy audit
The results demonstrated patients felt they were provided
with enough information about their procedure and informed
of the result.
Page 19 of 38
Perioperative antibiotic prescribing
The action plan from this audit included the education of
surgical and anaesthetic teams; ensuring copies of
guidelines are available in all theatres; colleagues are
challenged if not adhering to guidelines; post op antibiotics
are administered when specifically indicated.
Point prevalence antibiotic re-audit
Results show that compliance in the latest audit in
November 2009 was 94% with > 70% of patients on oral
antibiotics. This is a substantial improvement on the last set
of results.
Blood culture observation audit
The results of the last audit showed that the contamination
rate was around 3.3% which is better than the national
average of 5%. The aim will be to continue or improve this
rate further.
Gentamicin monitoring audit
This audit was conducted in 2008 and as a result new
guidelines for gentamicin dosing in adults were introduced.
This was re audited in Dec 2009 and results show
improvement. There will be further education for junior
doctors and a further audit will be carried out later this year.
Documentation audit, neonates and paeds
Regular audits have demonstrated progressive
improvement. The latest result showed improvements and
directed further staff education. A re-audit is planned.
Inter-ward transfer of patients with an
infection control issue
Action in place to review the patient transfer form and relaunch. The content of verbal handovers to be recorded in
the patients nursing records – paper or electronic by
transferring ward. Medical staff admitting new patients to
check patients‟ MRSA status.
Compliance with MRSA protocols
Action in place to: ensure all wards must carry out an MRSA
screen on admission of an emergency patient. Ensure
topical treatment started on time. Ensure staff use the
MRSA care plan for all patients.
Care bundle to prevent surgical site
infection
The Trust documentation on peri-operative care has been
changed to include the WHO recommendations and Saving
Lives care bundle recommendations.
Acting on radiological imaging reports
Action implemented to provide a simple sticker system to
tick when images have been requested, performed, read
and understood and a line to include actions taken.
The Use of clinical probability and D-dimer
in the context of suspected pulmonary
embolism
Action regarding education – clinical probability should
determine tests done and this must be documented.
Audit of safeguarding liaison forms
Improvement from previous levels. Is presently being
reaudited.
Morphine dispensing audit
Action is that every morphine dose dispensed is audited –
100% compliant with guidelines to date.
Page 20 of 38
Weekly quality nursing audits includes:
Hand hygiene, Infection control
assessment, pressure ulcer assessment,
nutrition assessment, VIP scores & Medical
Early Warning System (MEWS)
Results are reviewed at weekly meeting and actions agreed
which are addressed by each ward. Revised weekly audits
in place for 2010/11 audit other areas of concern.
Audit of anaesthetic charts
This is a re-audit and results better than previous audit with
100% completion of some of the standards.
Actions are to make changes to electronic prescribing to
prevent accidental administration errors.
Audit of paracetamol prescribing and
administration
Care Bundle for ventilated patients
HepB vaccination follow up
Procacitonin audit
Action agreed to improve the documentation of oral
hygiene.
This had previously been identified as an area of concern
the audit has now demonstrate marked improvement.
This has shown that using PCT, has improved antibiotic
prescription, and use has now been extended. This audit
was presented as a poster both locally and at The
Federation of Infection Societies Annual Conference.
Pneumococcal audit
The action from this audit was to ensure we advise GPs to
vaccinate individuals after recovery against pneumococci.
Re – audit children‟s National Service
Framework
This is a re-audit of a 2007 Regional benchmarking showing
considerable improvement in ALL aspects of the children‟s
NSF, with multiple evidence of good practice. Action plan
developed following this which is reviewed at paediatric
governance.
NICE CG, Acutely ill patients
Action Plan to be agreed at Patient Safety Committee.
Sepsis Audit
Actions from this audit were to: Devise a proforma that can
act as both a guideline and an audit tool.
Provide multi-disciplinary education on the recognition and
management of sepsis.
Develop a sepsis box with all the equipment required to
initially diagnose and treat a patient with suspicion of sepsis.
Pregnancy status in radiology
Actions following this audit were to provide further training
for radiographers.
Re- Audit should subsequently be extended to Fluoroscopy,
CT and theatre imaging & re-audit.
Audit of adequacy of cervical spine
radiography in trauma cases
Actions for this audit were: Education of radiographers and
A&E doctors.
Encouragement of A&E doctors and radiologists to consider
CT C spine as primary imaging in unconscious pts and
those who are undergoing CT Head for trauma.
Improved report turnaround (<48 working hours).
Encourage better communication between A&E and medical
imaging staff for all cases but particularly C spine trauma.
An Audit of daily medical assessment on
the Intensive Care Unit
Actions are to provide teaching/mentoring of new junior staff
Provide feedback on completed daily medical reviews
Publicising the results of ongoing audit into the quality of
medical reviews.
Paediatric emergency care
Action is to develop a paediatric clerking proforma.
Page 21 of 38
Urinary Catheter Audit
Local recurrence rates following breast
conserving surgery for breast cancer
Group and save practice in elective surgery
Improving the effectiveness of Medical
Management of Miscarriage
Antimicrobial audit – Northbrook ward
Actions for this audit is to, Review of the quality and
frequency of training for all levels of staff. Provision of
training and/ or updates where attendance is monitored and
recorded.
A self-assessment form of competency to identify gaps in
knowledge and practice and prompt the need for further
update and training.
Review of Trust policy on urinary catheterization.
Results show that we are well below the national accepted
level for recurrence.
All patients are now given request form at the time of
booking, with the result sent back to surgical preassessment clinic.
Re-education of colorectal F1s to ensure a G+S is taken
prior to surgery.
This completed audit cycle demonstrates the development
of the EPAU and changes in protocol resulted in the service
surpassing the RCOG standard, making medical
management a suitable alternative to surgery, thereby
improving patient choice.
Actions are to adhere to antibiotic policy and guidelines. To
encourage doctors from other specialties to consult with
paediatric team and microbiology team for prudent
prescribing of antimicrobial drugs.
Pressure Ulcers
Divisional action plans and monthly tissue viability steering
committee who will monitor progress.
South Central breast screening
programmes
The Trust has a good performance overall – no specific
issues to address here.
Standard precautions and PPE Audit
Ward sisters and Charge Nurses were made aware of the
audit findings at the weekly Quality audits meeting and were
asked to check their own areas and raise awareness for
improved practice in those areas. Each ward involved in the
snapshot audit was given a detailed action plan for their
area.
Audit of side room usage
Actions are to include Liverpool Care Pathway patients as
amber and reduce them being removed from side rooms
before other patients.
It is recognised that staff education on management of
patients with Cdiff as per Trust policy is required. It is
recommended that this is done through ward-based
teaching through Infection Control Link Practitioners with
support from the Infection Control Team.
Audit on Staff Awareness of Clostridium
Difficile Policy
Isolation precautions audit
Overall the Trust scored highly with 7 wards achieving 100%
compliance, 9 wards achieving. 95% compliance and 3
wards achieving 91% compliance.
Page 22 of 38
Participation in research
The number of patients receiving NHS services provided or subcontracted by WEHCT that were
recruited during that period to participate in research approved by a research ethics committee was
399 patients in National Institute of Health Research (NIHR) adopted studies and 172 patients in
non NIHR adopted studies (independent research organisations).
Use of the CQUIN payment framework
WEHCT‟s income in 2009/10 was not conditional on achieving quality improvement and innovation
goals through the Commissioning for Quality and Innovation payment framework because the
Trust came to a local agreement with its main commissioner which recognised WEHCT‟s
improvements in quality.
Statement on CQC registration and inspection
WEHCT is required to register with the Care Quality Commission and its current registration status
is registered to carry out the following regulated activities with no conditions on registration:
Treatment of disease, disorder or injury
Diagnostic and screening procedures
Surgical procedures
Termination of pregnancies
Family Services
Maternity and midwifery services
Assessment or medical treatment for persons detained under the Mental Health Act 1983
The CQC has taken enforcement action against WEHCT during 2009/10.
An unannounced CQC inspection on 10 February 2010 found Winchester and Eastleigh
Healthcare NHS Trust to be compliant with 9 of the 10 measures inspected. The Trust breached
the regulation to protect patients, workers and others from the risks of acquiring a healthcare
associated infection. This resulted in a Care Quality Commission requirement to improve. On 16
March 2010, the Care Quality Commission carried out an unannounced follow-up visit to the Trust
to gain assurance that it had implemented this requirement. The Trust provided assurance it had
addressed the area for improvement.
WEHCT is not subject to periodic review by the Care Quality Commission.
WEHCT has not participated in any special reviews or investigations by the CQC during the
reporting period.
Page 23 of 38
Data Quality
WEHCT 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 was:
97.45% for admitted patient care
98.87% for outpatient care; and
92.64% for accident and emergency care
- which included the patient‟s valid General Practitioner Registration Code was:
98.1% for admitted patient care;
98.29% for outpatient care; and
93.16% for accident and emergency care
Our score for 2009/10 for Information Quality and Records Management, assessed using the
Information Governance Toolkit was 73%.
WEHCT 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
diagnosis and treatment coding (clinical coding) were
Primary Diagnosis
14.7%
Secondary Diagnosis
12.5%
Primary Procedural
10.9%
Secondary Procedure
7.9%
These figures, together with results from other audits carried out at WEHCT, are publicly available
on the Audit Commission website (www.audit-commission.gov.uk).
Part 3.
Other information
The section is set out to mirror our three priorities; patient safety, patient outcomes and patient
experience. Safety is the foundation stone of the high quality services we all have a right to expect.
Patient safety is the expected „norm‟ at WEHCT with the aim to exceed expectations by providing
care that gives the best results possible and is complimented by friendly, informative
communication and good facilities.
Page 24 of 38
PATIENT SAFETY
Sepsis
„Reducing Harm from Sepsis‟ is one of our Safer Care Programme initiatives. Comprehensive
training using high-tech simulation dummies has revolutionised how we raise awareness and treat
this potentially fatal condition. This work has been “highly commended” in the 2009 National
Patient Safety awards, was accepted as a poster presentation at the International Quality and
Safety Conference in April 2010 and conference presentation at the Patient Safety Congress in
Birmingham in May 2010.
For every hour there is a delay in managing severe sepsis, there is an 8% increased risk of dying.
There are over 18 million cases of severe sepsis worldwide each year and it kills 1,400 people
worldwide every day.
Before the training started the Trust was in line with the national average of treating sepsis within
7.5 hours. An audit revealed that the time from identifying severe sepsis to receiving antibiotics has
halved and in many cases is within two hours. Length of stay has reduced by 2-3 days on average
and the mortality rate has also significantly reduced from 26% to 16.2%.
Infection Control
WEHCT has made significant inroads into reducing the risk of infection (as outlined in parts 1 and
2 of these accounts). The figures below demonstrate the progress made:CDifficile infections (>2 years hospital acquired) by year and month
16
14
12
Infections
10
2008/09
2009/10
8
6
4
2
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Month
MRSA (hospital and community acquired) by month from Apr-07
with trendline
5
4
Infections
3
2
1
Month
Page 25 of 38
Mar-10
Jan-10
Feb-10
Dec-09
Oct-09
Nov-09
Sep-09
Jul-09
Jun-09
Aug-09
Apr-09
May-09
Jan-09
Mar-09
Feb-09
Oct-08
Nov-08
Dec-08
Jul-08
Sep-08
Aug-08
Apr-08
Jun-08
May-08
Jan-08
Mar-08
Feb-08
Oct-07
Nov-07
Dec-07
Jul-07
Sep-07
Aug-07
Apr-07
Jun-07
May-07
0
PATIENT OUTCOMES
The Trust monitors a wide range of patient outcomes to give assurance that it is treating patients in
a timely manner and as well as meeting a wide range of national performance targets.
The table below outlines our performance against national and local quality and safety indicators:Area
Clinical
Outcomes
Patient
Experience
Patient
Safety
Performance
Indicator
2008/9
Actual
2009/10
Actual
2009/10
Target
Rating
Hospital Standardised Mortality Rates (HSMR)
91.4
85.3
100
Green
Readmissions within 7 days (exclude paed/ NNU)
2.9%
2.8%
5.0%
Green
Returns to theatre (unplanned within same inpatient
admission)
-
14
Cancelled operations (as proportion of elective
activity)
0.7%
0.8%
0.8%
Green
Breaches of 28 day standard following cancelled
operation
1.9%
1.7%
Less than
5%
Green
Complaints
257
232
264
Amber
Unnecessary bed moves
882
1581
600
Red
Mixed sex accommodation (number of incidents)
-
350
0
Red
Incidents of MRSA (hospital and community
acquired
5
6
8
Green
Incidents of Clostridium Difficile (C-Diff) hospital
acquired only
63
32
111
Green
Number of pressure ulcers (grade 3 and 4 hospital
acquired)
27
20
18
Amber
18 week RTT target – Admitted Patients (Total
Trust)
Over 90%
Over 90%
90%
Green
18 week RTT target – Non-admitted Patients (Total
Trust)
Over 95%
Over 95%
95%
Green
18 week RTT target – Specialty Achievement
-
84.7%
unknown
unknown
4 hour A&E target
98.4%
98%
98.19%
Green
Patients referred to RAPC are seen within 2 weeks
100%
99.4%
98%
Green
Total Attendances Offered a Genito Urinary
Medicine within 48hrs
100%
100%
100%
Green
Delayed Transfer of Care
1.7%
2.6%
3.5%
Green
Page 26 of 38
Further detail on performance
Activity summary
GP referral rates in 2009/10 followed the same trends as 2008/9, including the spike in referrals in
March and overall were 3% higher. First outpatient attendances were 2.3% higher than last year
mirroring the increase in referrals. Whilst follow-up attendances are 2% below last year, the new to
follow-up ratios have increased. A&E attendances were 2.4% higher this year than last year.
Cancelled Operations
A robust management framework was implemented in 2009/10 to minimise the number of
operations the hospital cancelled for non-clinical reasons. This has significantly reduced the
volume of cancellations and has ensured that the Trust achieved this target.
18 Weeks
The Trust has achieved both the 18 week targets, Admitted Patient Care (90%) and Non Admitted
Patient Care (95%). However, a new target has been added from January 2010 for the last quarter
of 2009/10 to monitor our achievement of 18 weeks at specialty level rather than the Trust‟s overall
position. This new target presents the Trust with a significant challenge. We have been able to
deliver this target across specialties but have had difficulty in achieving 18 weeks in several key
areas.
A&E
The Trust achieved the 4 hour A&E target for the year. Increased scrutiny of procedures and
improving the patients flow meant that the Trust achieved 98.19% at year end and was 98th out of
156 Trusts.
Cancer
From January 2009 new cancer targets were introduced via the Department of Health‟s (DH)
cancer reform strategy which continues the work of the cancer plan published in 2000. In order to
monitor performance against the new cancer wait times standards the process for collecting cancer
waits was aligned with the process for 18 weeks. The DH has not yet confirmed the operational
standards. The most significant changes are that the new targets apply to all patients with cancer
(not just first primary cancers as per the old rules) and that patient choice (ie, opting not to attend
an appointment) can no longer be counted as a pause in the patient pathway.
Pressure ulcers
It is estimated that nationally up to 30% of patients in hospital may suffer from a pressure ulcer.
Reducing harm from pressure ulcers was one of the local priorities for our Safer Care Programme
in 2009/10. This aimed to improve the monitoring and treatment of pressure ulcers and to reduce
the numbers of avoidable grade 3 and 4 (more serious) pressure ulcers.
Page 27 of 38
The outcome of the work has been an improved culture of reporting, early identification of pressure
ulcers on admission and a 26% reduction in grade 3 and 4 pressure ulcers. We thoroughly
investigate all grade 3 and 4 pressure ulcers using Root Cause Analysis and these are reported to
Social Services and as Serious Untoward Incidents. To date no hospital acquired pressure ulcers
have raised any safeguarding concerns.
Complaints
We set ourselves a challenging target to reduce complaints by 20% in 2009/10 to match the
reduction achieved in the previous year. We received 235 complaints which, when mapped against
the activity levels for the Trust, showed a 10% decrease.
The following charts show a comparison of the number of complaints received against the volume
of activity. The rise and fall in activity levels correlate with the rise and fall in complaints. For
example the lowest levels of activity are in August and January which corresponds to the lowest
number of complaints.
Graph shows admitted patient activity
4200
4000
Spells
3800
3600
3400
3200
3000
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Month
Bed moves
We had significant challenges with capacity due to extreme weather conditions in the winter and
community outbreak of norovirus. This, plus the requirement to care for patients in same sex
accommodation, meant that we moved patients more than is ideal. We have introduced a new bed
management system and aim to reduce this.
Page 28 of 38
Serious Untoward Incidents (SUIs)
WEHCT follows the national guidance to report Serious Untoward Incidents and has robust
processes for reviewing incidents and sharing learning. A sub group of the Patient Safety &
Quality Committee – led by the Medical Director – reviewed all SUIs and red clinical incidents
during 2009/10. The group‟s findings were presented to the Patient Safety & Quality Committee
where incidents are then „closed‟ once there is agreement that actions have been implemented to
prevent a recurrence. A robust Root Cause Analysis approach is used to ensure that the
organisation learns from incidents.
Enhanced recovery
We are a national pilot site for enhanced surgical recovery which is a new anaesthetic technique
which is being used to improve patient recovery past surgery and has almost halved our length of
stay for hip replacements in less than 12 months. We have expanded this approach across many
surgical specialties and now have many surgical teams from other Trusts visiting to be trained in
the technique.
Page 29 of 38
Patient Story –
Keeping fit is second nature to an Andover man who is back on the treadmill just weeks after
having a hip replacement.
Terry Lofts’ surgery was performed under the Enhanced Recovery Programme (ERP) which is
designed not only to prepare patients for surgery, but also to reduce its impact and speed
recovery.
Early mobility is a key part of the process as it not only gives the patient confidence but also helps
cut the risk of blood clots and chest infections, as well as restoring fitness and reducing muscle
wastage.
Being a very sprightly 61 made Terry, from Andover, a perfect candidate for the new model of care.
Patients on the ERP have morphine-free anaesthetics and minimally invasive surgery. In addition,
every aspect of rehabilitation is pre-planned, including medication and any equipment that is
required as well as follow-up appointments (home visits and outpatient clinics).
All of these factors, especially the new anaesthetic and surgery techniques, enable patients to start
the recovery process much sooner with the added benefit of shortening their time in hospital by
around six days.
However hard staff work to make a hospital stay as pleasant as possible, going home is where the
real recovery and getting back to normal begins.
Within hours of his operation at the RHCH, Terry was up and walking with the aid of crutches. He
said: “The physios were great and gave me good advice as well as confidence. The staff I came
across were cheerful too and this made the whole experience more pleasant than I expected.
“Everything about my treatment was thorough, meeting the consultant, the pre-assessment
session and follow-up phonecalls. I felt very well looked after and I liked having appointments with
the consultant at my local hospital.”
The ERP is not just restricted to hips – patients requiring knee and colorectal surgery will also
benefit from the new approach.
Page 30 of 38
Patient experience
The Trust carries out its own inhouse surveys in a variety of ways such as patient trackers,
comment cards, focus groups and questionnaires.
We also participates in national surveys.
Feedback from patients provides an invaluable insight on how it feels to be treated at one of our
hospitals or to use the services we provide in the community.
WEHCT also uses patient feedback on service changes, such as the transfer of vascular surgery
to Southampton or the redesign of the new outpatients department at Andover.
Here are some comments from surveys instigated by WEHCT together with our response:Service/ward/
Feedback
Response
96% of patients said they were either
„satisfied‟ or „extremely satisfied‟.
There were concerns about the
continuity of breastfeeding support
and advice. This service was
previously provided by the NCT but
from March 2010 the expertise will be
developed inhouse, providing greater
continuity. There were some negative
comments about the cleanliness of
the bathrooms and toilets.
There has been communication at public
meetings and via the media outlining the new
breastfeeding support service.
The results showed marked
improvements to 2008.
Teambuilding and reinforcing of roles and
responsibilities – especially for reception staff
have been addressed by the A&E matron.
department
Maternity Survey
(rolling survey every
three months)
A&E survey from
Spring 2009 (based on
the 2008 national A&E
survey)
Issues which remain relate to staff
manner and attitude.
Some patients did not understand the
signage at the front door.
Lack of space for wheelchairs.
Treatment Centre
Survey 2009
Cleaning rotas have been altered to give
these areas more attention.
Improved signage now in place on the door to
access the unit.
All wheelchairs are now placed in the main
corridor area adjacent to the waiting area.
Children‟s area locked.
Children‟s area – it is now the responsibility of
the nurse in charge to ensure that the room is
unlocked at the beginning of the shift.
Many respondents (98%) gave the
highest ratings possible.
A new map will be generated for the leaflet
(people felt the current one was unclear) and
the staff will use centrally funded and
professionally printed literature instead of
photocopied material.
The few calls for improvements were
limited to the quality of the printed
information.
Here are some comments from our latest national survey (the inpatient survey 2009) together with
our response. The ratio of positive/negative comments received is not reflected in the table below,
the comments were overwhelmingly positive across all areas.
Service/ward/
Feedback
Response
“Everyone was kind, considerate and very
professional. My hand was held when needed
and I felt really cared for. Thank you.”
A discharge leaflet will be
produced in 2010/11.
department
Gynaecology
“From consultant to cleaners, everyone was
pleasant, always had time to talk to you, nothing
was too much bother.”
“A discharge pamphlet should be issued to all
patients on leaving the hospital.”
Page 31 of 38
The Trust has signed up to a
carbon reduction programme, of
which low energy lighting is a key
part.
“Low energy light bulbs being used does not give
enough light for private reading.”
General surgery
“I requested to have my op and any treatment at
this hospital despite living in London.”
“I am appalled by the possibility of the
outpatients department being moved away from
hospital.”
“There was a genuine love/care towards my
welfare”
“Understaffed nurses”
“A couple of nurses did not speak great English”
The Trust is currently considering
moving the RHCH outpatients
department to another location on
the site AND NOT to a location
elsewhere.
An Audit Commission review of
staffing levels found that nurse
staffing levels were in line with
other hospitals nationally. Our
policy on safe staffing levels
requires that there are at least two
trained nursing staff on each ward.
The Trust provides a free
language course for all staff whose
first language is not English. Their
attendance can be requested by
their line manager.
Trauma and
orthopaedics
“Excellent sympathetic attitude of staff addressed
my fear of staying in hospital”
“Food is ridiculously poor – this should really be
a healing environment – how can feeding
patients this trash in any way improve health?”
WEHCT regularly enjoys positive
feedback about its food service.
This comment is one of two
negative comments about the food
– there were seven comments
praising the quality, range and
temperature of the food.
The Trust sources an increasing
amount of its produce from local
suppliers.
Cardiology
“The whole experience was as pleasant as can
be…nursing and medical staff were kind and well
trained. Excellent.”
“Cost of hospital car parks extortionate.”
“Mixed wards need to be abolished.”
The car parking charges are lower
or in line with local authority
charges. It costs the Trust to
maintain the car parks and we
would rather pay for them from
parking revenue than from money
that could be used to fund patient
care.
The Trust is working hard to
eliminate mixed sex
accommodation (see part 2,
patient experience objectives).
Medicine and elderly
care
Gastroenterology
“All staff were helpful and polite. No complaints.”
“I was in hospital for 3 days and during this time
2 patients that were unable to feed themselves,
food was placed in front of them and left.”
“Fantastic care and treatment”
“The porter was also very good.”
“Less noise during silent hours by hospital staff.”
General medicine
“The care and attention I received from doctors
and nurses was outstandingly good.”
“Discharge delays”
Page 32 of 38
A patient feeding project is
underway to identify which patients
need extra help at mealtimes.
Trained volunteers are supporting
this work.
The issue of noise is being
addressed by the Nursing Quality
Group.
Working groups have been
established (with representation
from the Independent Patient and
Public Involvement Forum) to
address this issue. We achieved
our target to reduce delayed
discharge to less than 3.5% in
2009/10.
Consultation with Employees
Feedback from our staff is equally important and the Trust places a great deal of emphasis on
informing and involving staff in key decisions.
The Joint Consultative Negotiation Committee, comprising Trade Union representatives and
senior managers meets regularly to discuss issues affecting staff.
The Trust holds a monthly staff briefing called Talking Point led by the Chief Executive to give
the latest news and get feedback. There is a system in place for cascading information to all
staff via their managers. There is also a briefing sheet from the meeting posted on the Trust
intranet, available to all staff.
At the March 2010 meeting and via the intranet – a survey posed a range of questions. When
asked if they felt proud of the service the Trust provides, 91% said yes. Having heard about the
problems at Mid Staffordshire NHS Foundation Trust, the majority of staff said they thought the
same thing could not happen at WEHCT.
They also responded to a question asking how they felt about working in closer partnership with
other NHS trusts. The vast majority (80%) of staff thought that collaboration would improve patient
care and, given the choice of how they felt about this, 75% found the prospect of greater flexibility
exciting, rather than daunting.
An even higher percentage (97.2) were in favour of changes to the patient pathway and saw these
as positive compared to just 2.2% who thought they could be disruptive.
Staff involved in new projects, such as Productive Ward are surveyed at the beginning of the work
to establish satisfaction levels and uncover any issues. Repeat surveys are then carried out to
monitor improvement.
The overall percentage for absence for the Trust in 2009/10 was 3.3% and compared favourably
to 2008/09 when the figure was 4.3%. The Trust continues to work to improve the health and
wellbeing of staff. Free eye examinations and access to free health and weight monitoring
equipment have been provided on 2009/10 and 2010/11 as part of a comprehensive staff
wellbeing strategy.
The staff survey of 2009 revealed that there have been nine key findings where the Trust has
improved, one where there has been deterioration and 26 have remained the same.
In general, staff felt more appreciated in 2009 by management and work colleagues and felt that
their ability to perform their job efficiently had improved.
However, the feeling of stress and
pressure had risen. To address this, there has now been added focus on recruitment of
substantive staff in funded posts to alleviate pressure, predominantly within the nursing workforce.
Page 33 of 38
The survey also highlighted the fact that in 2009, staff felt much more part of a team environment
then they had done the previous year.
Work-related injuries had decreased which shows an improvement in health and safety.
Staff displayed their frustrations however, feeling that there had been a lack of training compared
to the previous year and that their job roles were not as well understood. The number of staff who
had been appraised by their manager was also below the national average. To improve this, online
information to support managers and staff have been put into place as well as providing training in
different ways, such as simulation and emergency scenario sessions on the wards rather than in
the classroom.
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Annex - statements from stakeholders.
Statement from the Independent Patient and Public Involvement Forum
The Forum would like to congratulate the Trust on the effort it has made in improving the priorities
of Patient Safety, Patient Outcomes and Patient Experience.
In practical terms the Forum has provided personal observations and direct patient feedback on
the day to day running of the Trust. The Forum conducted a major survey, over 200 attendees to
the A & E Department, and has been encouraged by the actions taken from the report provided.
Members have also worked with operational staff and managers of the Fracture Clinic to improve
the waiting times by the medical and nursing staff being prepared to experiment with changes to
the appointment system. The suggestions for change have been implemented across the clinic
sessions. Improvements are ongoing as the changing situation provides further opportunities.
The Forum has provided patient feedback over the year, some positive and some negative and the
Trust has been very quick in establishing whether improvements are required and are possible.
The Forum is represented on the following committees: Patient Safety, Transport, Sustainable
Development (Andover and Winchester), Releasing Time to Care, Mixed Bed Bays, Patient Flow,
Patient Environment Action Teams (PEAT), Andover Project Group and Locality Groups at both
Andover and Romsey.
Apart from visiting wards to talk to patients and staff over the past year, five Forum members have
been inpatients at the RHCH, and have been in a position to talk to patients and feed back both
their own concerns and those of others. Three of these patients were admitted via A & E, so giving
firsthand comments.
In summary the Forum feels that the Trust has enhanced its service in the areas of Patient Safety
and Patient Experience.
Jean Pushman
Chairman of IPPIF
14.6.2010
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Statement from NHS Hampshire
NHS Hampshire has reviewed the Quality Account produced by Winchester and Eastleigh Healthcare
NHS Trust. The review concluded that:
1. The Quality Account provides information covering the elements of quality as defined by
Lord Darzi. These are patient safety, patient experience and clinical effectiveness (patient
outcomes).
2. NHS Hampshire is satisfied that the Quality Account incorporates the mandated elements
required.
3. There is evidence, within the Quality Account, that Winchester and Eastleigh Healthcare
NHS Trust has utilised both internal and external assurance mechanisms.
4. Based upon the data sources available, NHS Hampshire is satisfied with the accuracy of the
data contained in the Quality Account.
Patient Safety
The Quality Account identifies significant progress in relation to the nine elements of the Safer Care
Programme. All elements have clear, specific and measurable aims. For 2010/11 Winchester and
Eastleigh Healthcare NHS Trust has set patient safety targets to continue to reduce pressure ulcers,
reduce the effects a fall has on a patient and the continued improvement in the treatment of patients
with sepsis symptoms.
Patient Outcomes (Clinical Effectiveness)
Winchester and Eastleigh Healthcare NHS Trust has identified that a further reduction of the Hospital
Standardised Mortality Rate and adverse event rate, evident in utilisation of the Global Trigger Tool, are
key priorities. In addition, the Trust will need to continue with maximising Stroke care as set out in the
Stroke Strategy.
Patient Experience
In 2009, Winchester and Eastleigh Healthcare NHS Trust, has continued to develop the monitoring of
patient experience. The Trust has used this feedback and identified a number of changes linked to the
experience of patients for 2010/11. These priorities have been partly driven from the outcomes of the
National In-patient survey and will run alongside achieving the virtual elimination of mixed sex
accommodation in 2010/11. The Trust has integrated these objectives with those associated with
minimising patient moves and achievement of performance targets.
D. M. Fleming (Mrs)
Chief Executive
NHS Hampshire
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Statement about the position of Hampshire County Council’s Health Overview and Scrutiny
Committee
Hampshire County Council’s Health Overview and Scrutiny Committee (HOSC) has been
invited to submit its view of our Quality Accounts to us and for this statement to form part of our
final document.
The HOSC is not contributing to the Quality Accounts of any of the providers it works with. It is not
obliged to do so and its members are satisfied that they have direct methods of raising concerns
and discussing issues with WEHCT.
The Trust enjoys and values its excellent working relationship with the HOSC and shares
information freely with its members, either through the sending of papers, by presentations to the
committee or through briefing sessions and phone calls.
Statement about the position of Hampshire LINK
The Trust quality accounts were sent to Hampshire LINK (local involvement network) and this was
raised at their management Board meeting. There were no additional comments to incorporate
from Hampshire LINK for the 2009/10 quality accounts.
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Glossary of Terms
AWMH
Andover War Memorial Hospital
Cdiff
Clostridium difficile
CEO
Chief Executive Officer
CMACE
Centre for maternal and child enquiries
CQC
Care Quality Commission
CQUIN
Commissioning for quality and innovation
EPAU
Early pregnancy assessment unit
GTT
Global Trigger Tool
HSMR
Hospital standardised mortality rates
ICT
Infection control team
ICU
Intensive care unit
MEWS
Medical emergency warning system
MRSA
Methicillin Resistant Staphylococcus Aureus
NIII
NHS Institute for Innovation and Improvement
PCT
Primary Care Trust
PEAT
Patient Environment Action Team
RHCH
Royal Hampshire County Hospital
ROGC
Royal College of Obstetrics & Gynaecology
SHA
Strategic Health Authority
VIP
Visual infusion phlebitis score
VTE
Venus Thrombo Embolism
WEHCT
Winchester and Eastleigh Healthcare NHS Trust
WHO
World Health Organisation
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