United Lincolnshire Hospitals
NHS Trust
Quality Account 2010/11
Further information about us can be found at:
www.ulh.nhs.uk
Contents
Part 1
Statement on quality from the Chief Executive
3
Part 2
Description of areas for improvement in 2011/12
• Priority 1 – Continuing to improve the timeliness in response to complaints
• Priority 2 – Ensuring patients have had a venous thrombo-embolism (VTE)
risk assessment on admission to hospital
• Priority 3 – Reducing healthcare associated infections
• Priority 4 – Delivering the same sex accommodation requirements
• Priority 5 – Meeting nutritional needs
4
5
6
Statements of assurance
• Review of services
• Participation in clinical audits
• Participation in clinical research
• Commissioning for Quality and Innovation (CQUIN)
• Care Quality Commission (CQC) statements
• Data quality
• NHS Number and General Medical Practice Code validity
• Clinical coding error rate
• Information Governance toolkit attainment levels
10
10
10
16
17
18
19
20
20
20
7
8
9
Part 3
Review of quality performance
22
Organisational arrangements and initiatives to embed quality
22
2010/11 improvement priorities
• Priority 1 – Reducing our hospital standardised mortality ratio (HSMR)
• Priority 2 – Reducing health care associated infections
• Priority 3 – Improving the handling of complaints
• Priority 4 – Ensuring patients have had a venous thrombo-embolism (VTE)
risk assessment on admission to hospital
• Priority 5 – Delivering same sex accommodation requirements
29
30
32
35
37
Feedback
40
External regulation and assurance
41
Quality overview
• Performance of ULHT against selected measures
• National targets at a glance
44
44
45
Stakeholder comments
46
39
Part 1
A statement on quality from the Chief Executive
Welcome to United Lincolnshire Hospitals NHS Trust’s second Quality Account. This
account provides an annual report to the public about the quality of services we
provide. It includes a review of priorities over the last year and our plans for the
future.
Our vision for quality is still to deliver the safest, most effective health care that is
recognised by all to be world class.
We will continue to review the quality of services that we provide and build on the
improvements that have been made this last year and review our priorities for quality
improvement in partnership with our patients, staff and other organisations
Andrew North
Chief Executive
The content of this draft Quality Account has been approved by the Trust Board on
31 May 2011 and to the best of our knowledge the information in this document is
accurate.
3
Part 2
Description of areas for improvement in 2011/12
For 2011/12 we have chosen to focus on five priorities for improvement which reflect
the three domains of quality and form part of our two year Quality Plan. Some of the
areas for improvement are a continuation of the priorities that we identified for
2010/11 in recognition of their importance to our patients, staff and the overall quality
of care that we provide. The five areas of improvement for the coming year are:
Continuing to improve the timeliness in response to complaints
Ensuring patients have had a venous thrombo-embolism (VTE) risk assessment
on admission to hospital
Infection prevention – (MRSA/C difficile + new mandatory reporting requirements)
Delivering the same sex accommodation requirements
Meeting nutritional needs
Although the following area is still an important issue for the Trust, it will not be
identified as a key improvement priority for 11/12 because of the progress achieved
in 10/11:
Reducing our hospital standardised mortality ratio (HSMR)
In addition to the four areas that formed part of our priorities for 2010/11, one new
priority has been identified.
Meeting the nutritional needs of patients
During a planned review of our services by the Care Quality Commission (CQC) in
February 2011, the CQC identified major concerns at one of our locations regarding
regulation 14 (meeting nutritional needs) and the Trust has therefore identified
nutrition as an improvement priority for 2011/12.
What will we be measuring and reporting in 2011/12?
A description of our aims and goals and our monitoring arrangements for each of the
five priorities for 2011/12 is detailed below:
4
Priority 1
Continuing to improve the timeliness in response to complaints.
Description of the issue and the rationale for prioritising
In the last year we have changed the way in which we manage issues raised by
users of our services. This has enabled us to resolve concerns raised with us closer
to the point of occurrence and at an earlier stage. The impact of the new service has
been a significant reduction in the number of formal complaints received by the
Trust.
Although our actions have reduced the number of formal complaints, there is still
significant progress for the Trust to make in terms of ensuring that complainants
receive a timely response to their concerns. We will be revisiting our staff training to
ensure all those involved in leading and supporting complaint investigations have the
appropriate knowledge and skills.
In order to ensure the Trust learns from complaints, a system will be developed to
ensure departments use the data collated to improve the services they deliver.
Aim/goal for 2011/2012
Over the coming year we will aim to increase the number of complaints that are
responded to within the agreed timescale to over 80%. We will also aim to ensure
complaint investigation and response training is provided across all sites to improve
the quality of investigations.
A satisfaction questionnaire will be used to obtain feedback from those who have
raised concerns and complaints to enable us to continuously improve the delivery of
the service.
In order to do this we will:
•
Undertake a project to determine the root cause for complaints not being
investigated within the timescales and make improvements based on this
•
Circulate questionnaires to those who raise complaints/concerns
•
Revise training for complaints investigation and response and deliver this
•
Retain a database of all individuals who have received the appropriate training to
act as a lead investigator and supporting investigator
•
Provide training to departmental heads on dissatisfaction data and how to report
this and use within their teams
Monitoring and reporting of complaints performance
Complaints performance is recorded on the electronic Datix Risk Management
system. Performance against our complaints standards is reported as part of the
quality dashboard that is considered at each clinical directorate performance
management review meeting. Performance will be reported to the Quality and Safety
Committee.
5
Priority 2
Ensuring patients have had a venous thrombo-embolism (VTE) risk assessment on
admission to hospital.
Description of the issue and the rationale for prioritising
VTE is a significant patient safety issue; measuring of VTE risk assessment sets an
effective foundation for appropriate prophylaxis. This gives the potential to save
lives. This was identified as one of our key quality goals for 2009-2011.
VTE was one of the national CQUINs for 2010/11. The aim of the scheme was to
introduce risk assessments on admission to hospital for inpatients. This helped us
plan for effective prophylaxis (prevention) strategies and improve outcomes for our
patients.
Aim/goal for 2011/12
There is an increasing body of evidence and information that suggests that
implementation of comprehensive programmes for VTE prevention saves lives. We
have identified VTE prevention as one of our key quality goals for 2009–2011.
During 2010/11, the national CQUIN goal on VTE risk assessment has already made
a significant difference to the priority trusts place on VTE prevention. Including a
national goal on VTE prevention for a second year will help ensure that the national
best practice resources on VTE are effectively used for the benefit of patients at a
local level. This will build on the good work that has been done during 2010/11.
To build on our Trust developments in 2010/11which will fully embed VTE risk
assessment. Our aim is that at least 90% of all of our adult inpatients will have a VTE
risk assessment on admission to hospital using the national tool and that we sustain
compliance.
Monitoring and reporting of VTE
The number of adult inpatient admissions reported as having had a VTE risk
assessment on admission to hospital using the national tool will be entered into the
national Unify system on a monthly basis
A report on VTE will be included in the performance report for reporting bi-monthly to
the Trust Board
Our performance will also be reported as a CQUIN and monitored at the Quarterly
Quality Review meeting with the commissioners.
6
Priority 3
Reducing healthcare associated infections.
Description of the issue and the rationale for prioritising
Over the last few years, much of the focus for reducing healthcare associated
infections has focussed around reducing MRSA bacteraemia and Clostridium
difficile. The Trust has performed well in terms of delivering reductions for both of
these organisms.
Since January 2011, NHS health care providers have been required to extend their
mandatory reporting of infections to include all cases of sensitive strains of
staphylococcus aureus (MSSA). It is anticipated that mandatory reporting will be
extended even further to include other organisms during 2011/12.
Aim/goal for 2011/2012
It is important that over the coming year we continue to work closely with our
community colleagues to make sure that we maximise the opportunity to prevent
healthcare associated infections. As well as delivering further reductions in MRSA
bacteraemia (maximum of nine cases full year) and C difficile (maximum of 92 cases
full year), we will aim to reduce our MSSA bacteraemias by at least 10% from 26 to
23.
We will continue to review our infection prevention control strategy in relation to risk
to include policies, guidelines and procedures, staff training, audit of the environment
and staff practice as detailed in the Health and Social Care Act (2008). Root cause
analysis will continue to be undertaken to identify areas for change, with findings
shared with the appropriate teams including colleagues in the community. Our
infection action plan and audit programme will be reviewed and updated throughout
the year with prompt feedback of audit findings.
In addition to our programmes of work to manage risks associated with intravenous
cannulae, antibiotic prescribing and environmental cleanliness, we will continue our
work programme, which started in 2010/11, to reduce the incidence of urinary
catheter insertion and the associated risk of infection.
Monitoring and reporting
The Trust will continue to report cases of MRSA bacteraemia, MSSA bacteraemia
and C difficile via the national mandatory reporting system and will comply with any
additional in-year reporting requirements. Monthly data for a range of infections will
continue to be monitored and reported from individual ward up to the Trust Board.
We will continue to display our infection rates publicly to ensure that our patients and
staff are aware of the progress that we are making.
7
Priority 4
Delivering the same sex accommodation requirements.
Description of the issue and the rationale for prioritising
During 2010, the Department of Health issued revised guidance for eliminating
mixed sex accommodation which included a requirement to eliminate breaches
within areas where patients are recovering after treatment. Although we are
compliant with the requirements of the same sex accommodation policy, we have
particular challenges within endoscopy facilities due to the physical environment.
We recognise the importance of eliminating mixed sex accommodation as a core
part of respecting patients’ privacy and dignity and we have therefore retained this
improvement priority for 2011/12.
Aim/goal for 2011/12
The aim is to complete a programme of alterations to our endoscopy units by
September 2011 which will enable us to declare compliance and eliminate breaches
in this area.
Monitoring and reporting
We will continue to monitor the patient experience to ensure we maintain the
elimination of mixed sex accommodation in all areas and to ensure a continued
positive user experience with regard to privacy and dignity and same sex
accommodation. Assurance on our reporting processes will be tested through audit.
Any breaches will continue to be reported and investigated, the detail will be
considered for any corrective action. The Trust will continue to comply with the
national and local reporting requirements.
8
Priority 5
Meeting the nutritional needs of patients.
Description of the issue and the rationale for prioritising
In February 2011 the Care Quality Commission (CQC) undertook an unannounced
visit to Pilgrim Hospital, Boston as part of a planned review of our compliance
against the CQC regulations. The CQC reported as part of their findings that the
Trust was failing to comply with regulation 14 (outcome 5) relating to meeting
nutritional needs.
Meeting the nutritional needs of our patients is an essential part of the care and
treatment that is provided and we have therefore identified the need to establish an
improvement programme for nutritional care across all of our services during
2011/12.
Aim/goal for 2011/12
We will build upon the programme of work that has already been undertaken relating
to protected mealtimes and the productive ward mealtime module. We aim to make
sure that we improve compliance with assessment of nutritional status for patients on
admission, care planning and on-going monitoring of nutritional status and to make
sure that patients that require help and support with their meals receive it.
We will also continue to develop our programme of support to patients using
mealtime companions.
Monitoring and report of improved nutritional outcomes
We will measure and report compliance with nutritional assessment at least quarterly
and will make the information available publicly. We will undertake a series of
observational audits of nutritional care and reviews of patient records and will report
progress quarterly.
9
Statements of assurance
Review of services
During 2010/11, United Lincolnshire Hospitals NHS Trust (ULHT) provided and/or
subcontracted 48 NHS services.
We have reviewed all the data available to us on the quality of care in all of these 48
services.
The income generated by the NHS services reviewed in 2010/11 represents 90.5%
of the total income generated from the provision of NHS services by the Trust for
2010/2011.
Participation in clinical audits
Between 1 April 2010 and 31 March 2011, 44 national clinical audits and four
national confidential enquiries covered NHS services that ULHT provides.
ULHT participated in 86% of the national clinical audits and 100% of the national
confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that ULHT was eligible
to participate in, and for which data collection was completed during 1 April 2010 to
31 March 2011, 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.
National audits
Peri- and neonatal
Perinatal Mortality (CEMACH)
Neonatal Intensive and Special
care (NNAP)
Children
Paediatric Pneumonia (British
Thoracic Society)
Paediatric Asthma (British
Thoracic Society)
Paediatric Fever (College
Emergency Medicine)
Childhood Epilepsy (RCPH
National Childhood Epilepsy
Audit)
Paediatric Intensive Care
(PICANet)
Paediatric Cardiac Surgery
(NICOR Congenital Heart
Disease Audit)
Diabetes (RCPH National
Paediatric Diabetes Audit)
Acute care
Emergency Use of Oxygen
(British Thoracic Society)
ULHT
participation
Reporting period
Number and %
required
Yes
Yes
Ongoing
Ongoing
100%
100%
Yes
1 November 2010 - 31
January 2011
1 November 2010 - 30
November 2010
1 August 2010 - 31
January 2011
ULHT has registered to
participate 2011
10
This audit is only
applicable to specialist
centres
This audit is only
applicable to specialist
centres
2010 - 2011
N/A
Yes
Yes
N/A
Early Adopter
sites only Year
1 2010
N/A
N/A
Yes
Yes
1 October 2010 - 15
November 2010
10
6
150 (100%)
N/A
N/A
Not available
Not available
Adult Community Acquired
Pneumonia (British Thoracic
Society)
Yes
Currently submitting
data closing data for
submissions 31/05/11
Data currently
being collected
National audits
ULHT
participation
Reporting period
Non Invasive Ventilation (NIV) –
Adults (British Thoracic Society)
Yes
Pleural Procedures (British
Thoracic Society)
Cardiac Arrest (National Cardiac
Arrest Audit)
Vital Signs in Majors (College of
Emergency Medicine)
Adult Critical Care (Case Mix
Programme) ICNARC
Potential Donor Audit (NHS Blood
& Transplant)
Long term conditions
Diabetes (National Adult Diabetes
Audit)
Heavy Menstrual Bleeding
(RCOG National Audit of HMB)
Chronic Pain (National Pain
Audit)
Ulcerative Colitis & Chron’s
Disease (National IBD Audit)
Parkinson’s Disease (National
Parkinson’s Audit)
COPD (British Thoracic
Society/European Audit)
Adult Asthma (British Thoracic
Society)
Bronchiectasis (British Thoracic
Society)
Elective procedures
Hip, Knee and Ankle
Replacements (National Joint
Registry)
National Elective Surgery Patient
Reported Outcome Measures (
National PROMs Programme) (4
operations)
1.Varicose Veins
2.Groin Hernia
3.Hip Replacement
4.Knee Replacement
Cardiothoracic Transplantation
(NHSBT UK Transplant Registry)
Yes
Yes
Currently submitting
data closing date for
submissions 31/05/11
1 June 2010 - 31 July
2010
1 November – 30
November 2010
1 August 2010 – 31
January 2011
2010 - 2011
Number and %
required
Data currently
being collected
Yes
2010 - 2011
Not available
No
N/A
N/A
Yes
Yes
1 February 2011 – 31
January 2012
Underway March 2011
Yes
2010 - 2011
No
N/A
Data currently
being collected
Data currently
being collected
Data currently
being collected
N/A
N/A
N/A
Not available
No
1 September 2010 – 31
October 2010
N/A
Yes
2010 - 2011
Yes
1 April 2009 –
December 2010
N/A
Liver Transplantation (NHSBT UK
Transplant Registry)
N/A
This audit is only
applicable to specialist
centres
This audit is only
applicable to specialist
centres
Yes
Yes
No
Yes
11
11/11 (100%)
150 (100%)
1796 (100%)
N/A
Information not
provided by
Registry
All procedures
66.30%
1. 46.40%
2. 52.40%
3. 76.0%
4 79.20%
N/A
N/A
National audits
ULHT
participation
Reporting period
Coronary Angioplasty (NICOR
Adult Cardiac Interventions Audit)
Yes
2010
Peripheral Vascular Surgery
(VSGBI Vascular Surgery
Database)
Carotid Interventions (Carotid
Interventions Audit)
Coronary Artery Bypass Graft
(CABG) and Valvular Surgery
(Adult Cardiac Surgery Audit)
Cardiovascular disease
Familial Hypercholesterolemia
(Management of FH)
Acute Myocardial Infarction &
Other Acute Coronary Syndrome
(MINAP)
Yes
2010 – 2011
Data currently being
submitted
2009 - 2010
Yes
Number and %
required
Not available data
taken from BCIS
data
Not available
report due June
2011
16
N/A
This audit is only
applicable to specialist
centres
N/A
Yes
2010
1 (100%)
Yes
2010 - 2011
Heart Failure
Yes
Pulmonary Hypertension
N/A
Acute Stroke (SINAP)
No
Stroke Care (National Sentinel
Stroke Audit)
Renal disease
Renal Replacement Therapy
(Renal Registry)
Renal Transplantation (NHSBT
UK Transplant Registry)
Patient Transport (National
Kidney Care Audit)
Renal Colic (college of
Emergency Medicine)
Cancer
Lung Cancer (LUCADA)
Yes
2009 - 2010
Joined January 2010
This audit is only
applicable to specialist
centres
Trust submitting data to
East Midlands Stroke
Registry – upload to
SINAP 2011
1 April 2010 - 30 June
2010
1170
Final data
submission to be
completed by 31s
May
20 per month 91
(150%)
N/A
Bowel Cancer
No
Head & Neck Cancer (DAHNO)
Yes
Trauma
Hip Fracture (National Hip
Fracture Database)
Yes
N/A
138
Yes
2010 - 2011
Not available
Yes
2010 - 2011
Not available
Yes
2010
Not available
Yes
1 August 2010 – 31
January 2011
100 (66.6%)
Yes
November 2008 –
October 2009
Unable to participate
due to completion of
other cancer audits
2009
369 (100%)
N/A
64 (100%)
1 April 2009 – 31 March 601 (81%)
2010
12
National audits
ULHT
participation
Reporting period
Falls and non-hip fractures
(National Falls & Bone Health)
Trauma Audit Research Network
(TARN) Trauma
Psychological conditions
Depression & Anxiety (National
Audit of Psychological Therapies)
Prescribing in Mental Health
Services (POMH)
National Audit of Schizophrenia
(NAS)
Blood transfusion
O neg blood use (National
Comparative Audit of Blood
Transfusion)
Platelet Use (national
Comparative Audit of Blood
Transfusion)
Confidential enquiries
NCEPOD Cardiac Arrest
Yes
1 April – 30 June 2010
Number and %
required
55 (92%)
Yes
2010 - 2011
(21 – 40%)
N/A
Not applicable to acute
trusts
Not applicable to acute
trusts
Not applicable to acute
trusts
N/A
Yes
2010
Not available
Yes
2010 - 2011
Not available
Yes
NCEPOD Surgery in Children
Yes
NCEPOD Peri-operative Care
Yes
CMACE Head Injuries in Children
Yes
1 November – 30
11/11 (100%)
November 2010
1 April 2008 – 31 March No children met
2010
the requirements
of the audit.
March 2010 - March
16/16 100%
2011
14 May 2010
100%
N/A
N/A
N/A
N/A
Please note the following:
The percentage required by the terms of the audit could be a specific number, for
example stroke 60 cases or compared to Hospital Episode Statistics (HES). This has
been noted where available.
NHS Blood and Transplant Potential Donor - Covers all patients who die in intensive
care units Lincolnshire patients would be included in the East Midlands figures.
Heart Failure - ULHT joined the audit January 2010 therefore only three months of
data included in the 2010 report. The 2011 annual report will include data from April
2010 to March 2011 a complete year’s data.
Head and neck cancer - Covers patients diagnosed with specific head and neck
cancer types between November 2008 and October 2009.
Lung cancer - This is patients first seen in 2009 and subsequently diagnosed with a
cancer.
Childhood Epilepsy (RCPH National Childhood Epilepsy Audit) - This audit during
the first year 2010 has focused on developing audit tools and engaging trusts to
express an interest in participating in the audit. Three regions were chosen as early
13
adopter sites Dundee, South East Wales and Cambridge. The ULHT has expressed
an interest in joining the audit during 2011.
National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Reports will be published for the following enquiries during 2011: Surgery in children
is due spring 2011, peri-operative care November 2011 and cardiac arrest will be
published summer 2012.
The reports of nine national clinical audits were reviewed by ULHT between 1 April
and 31 March 2011 and the Trust intends to take the following actions to improve the
quality of healthcare provided.
Descriptions of actions:
National audit
NJR: Hip and knee
replacements
Heart failure
Myocardial Ischaemia National
Audit Project MINAP (heart
disease)
Headline results and actions taken
The national joint registry records activity but does not
provide recommendations for local implementation. The
Trust consent rate is improving 88% in 2010 compared to
89% nationally. Data collection process under review to
improve consent rate further.
2009/10 Heart Failure Report showed that:
Echocardiography - A key investigation was performed in
79% of cases.
Specialist services - Inpatient and outpatient are associated
with better prescribing and better outcomes
Beta- blockers are underused.
Data completeness for core fields was good.
ULHT local data analysis is similar to national findings.
Action includes improve prescribing of medications such as
beta-blockers.
MINAP results 2009/2010 show that:
77% of patients suffering a heart attack were given a clot
busting drug at ULHT (nationally 77%).
Patients discharged on the appropriate secondary
prevention drugs national standard 80%:
Aspirin: ULHT score 94% (national average 90%)
Beta blockers: ULHT score 81% (national average 94%)
Ace Inhibitor: ULHT score 85% (national average 93%)
Clopidogrel: ULHT score 86% (national average 94%)
Statin: ULHT score 90% (national average 97%)
ULHT is working hard to improve the number of patients
discharged on secondary prevention drugs.
The reports of 126 local clinical audits were reviewed by ULHT between 1 April 2010
and 31 March 2011 and the Trust intends to take the following actions to improve the
quality of healthcare provided. (See tables below of speciality audits and the
examples of action table at the end)
Local audit speciality
Accident and emergency
Anaesthetics
Breast surgery
Clinical audits registered on Trust
clinical audit database (number =374)
36
34
7
14
Cardiology
Chronic pain
Clinical biochemistry
Clinical neurophysiology
Colorectal
Critical care
Cytology/pathology
Dermatology
Diabetes
Diabetic retinopathy
Dietetics
EAU
Elderly care
Endocrinology
Endoscopy
ENT
Gastroenterology
General medicine
General surgery
Gynaecology
Haematology
Imaging
Infection control
Intensive care
Maxillofacial
Medical physics
Medicine
Neurophysiology
Nephrology
Nursing and Allied Health Professionals
Nutrition
Obstetrics
Obstetrics and gynaecology
Occupational therapy
Ophthalmology
Orthopaedics
Paediatrics
Pain management
Pharmacy
Physiotherapy
Radiology
Rehabilitation services
Renal
Respiratory
Retinopathy
Rheumatology
Stroke
Surgery
Theatres
Trauma
15
1
1
1
1
1
1
8
1
1
4
1
15
5
1
5
6
1
28
1
1
1
2
2
4
1
14
4
1
1
1
23
3
7
11
31
33
2
8
5
7
1
1
7
2
1
1
1
1
1
15
Ultrasound
Urology
Vascular
1
15
5
Examples of actions taken locally:
Local audit
Acute Kidney Injury (AKI)
Role of Hand Hygiene in Hospital
Acquired Infection
Venous Thromboembolism Prophylaxis
in medical patients
Blood transfusion
Liverpool care pathway (care of the dying
patient
Continuous subcutaneous insulin
infusion pump
Compliance with NICE guidelines in
patients with Atrial Fibrillation (AF)
Risk stratification in Acute Coronary
Syndromes
Record keeping
Consent
Actions
Increase awareness of AKI via
presentations and posters.
Introduction of AKI and fluid resuscitation
protocols to standardise care for junior
doctors.
Recognised nationally by Department of
Health (DoH) renal lead as a good example
of a local audit. Presentation to patient
safety commission (DH) planned.
Observational audit of hand washing
Continue with education and raising
awareness of hand washing.
Risk assessment implemented continue
with regular audits to ensure compliance
with risk assessment.
Work on-going to reduce wastage
Implementation of updated version of the
pathway.
Education and reminders given at clinic to
ensure patients are able to manage the
pumps.
Medical staff scores patient on admission
using the CHADS2 scores. Improving
prescribing of medicines for controlling
atrial fibrillation.
Medical staff admitting patients
documenting risk stratification at the time of
admission using the GRACE score to
ensure optimal treatment for high risk
patients.
Improve documentation. Project via a
quality improvement initiative involved the
development of new admission folders work
will continue to monitor documentation in
case notes.
Policy updated six monthly audits to
monitor compliance.
Participation in clinical research
The number of patients receiving NHS services provided or sub-contracted by United
Lincolnshire Hospitals NHS Trust in 2010/11, who were recruited during that period
to participate in research approved by a research ethics committee, was 1,315,
against year-end target of 912 for portfolio studies. Total number of participants
recruited for portfolio and non-portfolio studies was 1,585.
These patients/participants were recruited from a range of specialities and included
patients with cancer, stroke, diabetes, dementia and neurodegenerative diseases
16
and from paediatrics. This is an increase on 2009/10 when 700 patients were
recruited.
This increasing level of participation in clinical research demonstrates ULHT’s
commitment to improving the quality of care we offer and to making our contribution
to wider health improvement. In addition, by participating in National Institute for
Health Research portfolio trials and recruiting patients, the Trust is playing an
important role in improving patient care and in developing new and innovative drugs,
treatment and services. The Trust has implemented findings of trials which has
helped us in improving patient care and cost saving
The Trust is involved in conducting 181 clinical research studies.
By the end of March 2011, for cancer randomised controlled trials, we recruited 220
patients against year-end target of 184.For cancer non-randomised controlled trials
we recruited 376 patients against year end target of 225
Since the establishment of the Comprehensive Research Networks, the Trust has
used the national system for approving all studies (portfolio and non-portfolio) and
risk assessments. Of the 50 studies given permission to start in 2010/11, 100% were
given permission to start by the authorised person within 30 days from receipt of a
valid completed application.
More than half of the studies were established and managed under national model
agreements.
In 2010/11 the National Institute for Health Research supported 40 of these studies
through its research networks.
In the last three years, 80 publications have resulted from our involvement in clinical
research, helping to improve patient outcomes and experience across the NHS.
The Research and Development Department is committed to playing an important
role in the following areas:
•
•
•
•
•
•
•
To promote research and innovation
To develop a culture in which research is seen as integral to clinical practice
To support clinical directorates in developing specialist clinical services
To support all healthcare staff undertaking research
To support research activity by developing an infrastructure, which ensures all
research is carried out in accordance with the ‘NHS Research Governance
Framework’ and regulations
To increase the number of staff within the Trust with skills in research
To work closely with R&D departments within the other Lincolnshire health
providers to incrementally increase patients recruitment over the next five
years period
Commissioning for Quality and Innovation (CQUIN)
A proportion of United Lincolnshire Hospitals NHS Trust’s income in 2010/11 was
conditional on achieving quality improvement and innovation goals agreed between
ULHT and NHS Lincolnshire and any person or body they entered into a contact,
17
agreement or arrangement with the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2010/11 and for the following 12 month period
are available on request from www.ulh.nhs.uk
(The total amount of income in 2010/11 which was conditional upon achieving quality
improvement and innovation goals was £5 million and the payment received by the
Trust was £3.5 million).
Care Quality Commission (CQC) statements – registration and periodic
reviews
United Lincolnshire Hospitals NHS Trust is required to register with the Care Quality
Commission and its current registration status is full registration with concerns.
Following registration with the CQC, and as a result of a subsequent responsive
review visit in June 2010, a number of minor/moderate concerns were identified
relating to the following regulations/outcomes:
Regulation 17/Outcome 1
Regulation 11/Outcome 7
Regulation 13/Outcome 9
Respecting and involving people who use
services
Safeguarding people who use services
from abuse
Management of medicines
Regulation 23/Outcome 14
Supporting workers
Remedial action plans to address the issues raised and ensure compliance with the
above regulation were agreed with the CQC and have been addressed. The
outcome of this responsive review has been superceeded by the review of
compliance visits later in the year (see below).
The CQC undertook a planned review of compliance with the Essential Standards of
Quality and Safety following an unannounced visit to both the Lincoln County
Hospital and Pilgrim Hospital, Boston sites in early February 2011.
The CQC has taken enforcement action against the United Lincolnshire Hospitals
NHS Trust during 2010/11.
Following the visit to Pilgrim hospital, the CQC found that the Trust was failing to
comply with the following regulations/outcomes:
Regulation 9 /Outcome 4
Regulation 14 /Outcome 5
Care and welfare of people who use services
Meeting nutritional needs
The Trust was issued with warning notices and asked to take corrective action to
meet compliance with these regulations by 31 May 2011.
Remedial action plans to address these failures have been developed and are being
addressed.
18
In addition at Pilgrim hospital, the CQC identified minor/ moderate concerns relating
to the following regulations/outcomes:
Regulation 17 /Outcome 1
Regulation 24 /Outcome 6
Regulation 11 /Outcome 7
Regulation 12 /Outcome 8
Regulation 15 /Outcome 10
Regulation 22 /Outcome 13
Regulation 23 /Outcome 14
Regulation 11 /Outcome 16
Regulation 19 /Outcome 17
Regulation 20 /Outcome 21
Respecting and involving people who use
services
Cooperating with other providers
Safeguarding vulnerable people who use services
Cleanliness and infection control
Safety and suitability of premises
Staffing
Supporting workers
Assessing and monitoring the quality of service
provision
Complaints
Records
Remedial action plans to address these concerns are being developed and are being
addressed.
Following the visit to Lincoln County Hospital the CQC found the hospital to be
compliant with the 11 out of the 16 outcomes but identified minor/moderate concerns
relating to the following regulations/outcomes:
Regulation 24 /Outcome 6
Regulation 15 /Outcome 10
Regulation 10 /Outcome 16
Regulation 19 /Outcome 17
Regulation 20 /Outcome 21
Cooperating with other providers
Safety and suitability of premises
Assessing and monitoring the quality of service
provision
Complaints
Records
Remedial action plans to address these concerns are being developed and are being
addressed.
ULHT has not participated in any investigations by the CQC during 2010/11.
United Lincolnshire Hospitals NHS Trust has participated in the data collection for a
Care Quality Commission Special Review of support for families with Disabled
Children for Lincolnshire during 2010/11.
Data quality
United Lincolnshire Hospitals NHS Trust will be taking the following actions to
improve data quality:
•
•
•
Process maps produced for patient flow through hospital (outpatients, day
cases, inpatients) and data quality reports identified at key stages to ensure
any data input errors are flagged earlier and highlighted to relevant teams for
correction and any training needs identified
Implementing actions identified by the 2010 Payment by Results Assurance
Audit (mainly around clinical coding, produced by the Audit Commission on
behalf of NHS Lincolnshire)
Review data quality function to ensure the team supports the needs of the
business
19
NHS Number and General Medical Practice Code validity
United Lincolnshire Hospitals Trust submitted records during April to February
2010/11 at the Month 11 inclusion date to the Secondary Uses Service for inclusion
in the Hospital Episode Statistics (HES), which are included in the latest published
data. The percentage of records in the published data:
1) Which included the patient’s valid NHS number was:
99.4% for admitted patient care (national performance 98.5%)
99.6% for outpatient care (national 98.8%)
97.4% for accident and emergency care (national 91.7%)
2) Which included the patient’s valid General Medical Practice Code was:
100.0% for admitted patient care (national performance 99.8%);
100.0% for outpatient care (national 99.8%)
100.0% for accident and emergency care (national 99.7%)
The patient NHS Number is the key identifier for patient records. Improving the
quality of the NHS Number data has a direct impact on improving clinical safety,
including reducing the number of patient misidentification incidents.
Accurate recording of the patient’s General Medical Practice Code is also essential
to enable the transfer of clinical information about a patient from the Trust to the
patient’s General Practitioner.
Clinical coding error rate
United Lincolnshire Hospitals NHS Trust was subject to the Payment by Results
clinical coding audit by the Audit Commission during the 2010/11 reporting period.
Trust performance is measured using two indicators - healthcare resource (HRG)
accuracy and clinical coding accuracy. The performance of the Trust, measured
using the HRG error rate, is similar to the national average using the 2009/10 full
year results. The Trust’s average HRG error rate is 8.8% compared to the 2009/10
national average of 9.1%.
HRG’s are based on diagnosis and procedure codes which generates the HRG on
which payment is based. The percentage of diagnosis and procedures incorrectly
coded at the Trust is 10.7%. This is an improvement on the 2009/10 national
average of 11%. This year there were 1,351 diagnoses and procedures and there
were 145 errors or 10.7% were incorrect.
Clinical coding translates the medical terminology written by clinicians to describe a
patient’s diagnosis and treatment into standard recognised codes. The accuracy of
this coding is a fundamental indicator of the accuracy of the patient records.
Please note: these are technical errors of coding within patient records, not clinical
errors in terms of actual diagnosis.
Information Governance Toolkit attainment levels
The United Lincolnshire Hospitals NHS Trust score for April 2009 to March 2010 for
information quality and records management, assessed using the Information
Governance Toolkit was 44%.
20
The information quality and records management attainment levels assessed within
the Information Governance Toolkit provide an overall measure of the quality of data
systems, standards and processes within an organisation.
21
Part 3
Review of quality performance
This section is where you will find information relating to the quality services that we
provide. The section includes details of:
•
•
•
•
Organisational arrangements and initiatives to embed quality
Priorities for improvement identified for 2010/11
External regulation and assurance
A quality overview including performance against selected metrics and
national targets and indicators
Organisational arrangements and initiatives to embed quality
In the introduction to this Quality Account, our vision for quality was set out:
“To deliver the safest, most effective health care that is recognised
by all to be world class”
To help us deliver our vision for quality, we developed and implemented a range of
plans and strategies that reflect the three domains of quality – safety, patient
experience and effectiveness of care. These strategies and plans are pulled together
through our 2009-2011 Quality Plan, which describes our goals for quality
improvement. These quality improvement goals have been developed to take
account of the views of our patients, staff and commissioners.
A summary of our plans and initiatives to embed quality in the organisation is
described below. If you would like further information on any of these plans please
contact communications@ulh.nhs.uk
Patient safety
We have an established and expanding commitment to patient safety supported by a
dedicated Patient Safety Team with a full time Patient Safety Manager. The team
supervises our actions and membership of the national Patient Safety First
campaign, which focuses primarily on improving safety in critical care, perioperative
care and medications management.
Our executive team has sponsored our further commitment to the national safe care
work stream Safety Express, which targets improvement in four key areas: pressure
ulcers, venous thrombo-embolism, catheter-acquired infections and patient falls.
In all of these areas, widespread staff training and education in patient safety, human
factors and improvement methodology is essential. In this Trust, our patient safety
team includes a human factors specialist who leads patient safety training for all staff
groups.
The Trust is actively engaged, through the development of safer clinical systems and
through patient safety training of front-line staff, in creating a safety culture which
places patient safety at the centre of care. Part of this depends on learning from
incidents and near-misses. Our organisation was once again in the highest 25% in
terms of volume of safety incident reports filed with the National Patient Safety
22
Agency (www.npsa.org.uk) and we continue to report more ‘no-harm’ events than
many comparable Trusts. This is an indicator of a good reporting culture.
Patient experience
To assist and support the Trust in putting the patient at the centre of care we will
commence widespread use of patient experience surveys and collect real-time
feedback to enable our staff to be more responsive to users needs.
The Trust will collect information on handheld devices from inpatients and some
outpatient areas. Kiosks will also be placed in the emergency and outpatient
departments to collect the information from users of our services. This data collection
will provide feedback for sharing with our users, our staff and assurance to the Trust
Board on how we are doing to meet needs of our users.
The Trust will use the new patient experience survey systems alongside other
approaches to get feedback from service users when new services are being
developed or to test improvements in services.
Success of the implementation of the system will be measured through improved
patient experience and feedback. Further success can be measured through service
changes made as a result of the feedback.
Effectiveness of care
Over the last year, we have continued to focus on further developing our measures
that demonstrate the effectiveness of the care that we provide.
We developed and agreed a set of indicators that form part of a quality performance
scorecard. These indicators of effectiveness include:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
HSMR (Hospital standardised mortality ratio)
Readmissions by diagnosis
Readmissions by procedure
Length of stay by procedure
Day case rate by procedure
CQUINs (national, regional and local)
Thrombolysis call to needle time within 60 minutes
Thrombolysis door to needle time within 30 minutes
National Sentinel Stroke indicators
Baby friendly standards achievement
Caesarean section rate
Obstetric complications
Patient reported outcome measures (PROMS)
Trauma - fracture neck of femur patients operated on within 36 hours
National Service Frameworks implementation e.g. cancer, older people ,
coronary heart disease
Incidence of MRSA and Clostridium Difficile infections
Surgical site infection
Proportion of complaints responded to within agreed timescales
For further details see the quality overview section on page 39.
23
The quality indicator dashboards are reviewed monthly at each directorate
performance review and performance is also reported to the performance and
finance sub-committee of the Trust Board and the Trust Board.
Monitoring and learning
A key feature of effective clinical governance arrangements and the provision of
quality healthcare is to ensure that lessons are identified, learned and shared across
the organisation and to ensure that the serious incident investigations are monitored
for quality and adequacy.
To address this we have two processes that complement one another. The first is a
monitoring function. The Incident Review Group considers the adequacy and quality
of serious incident investigations. This is chaired by the Medical Director. All serious
incident reports are reviewed by this group or are considered within the relevant
committee framework. For example, infection prevention and control incidents are
monitored through the Infection Prevention and Control Committee.
The second is a formal structured process of ‘sharing the lessons learned'. The
principle of sharing the lessons learned is simple, in that key lessons to be learned
from all of the various clinical governance activities and performance reviews are
identified and presented to a forum chaired by the Trust Chief Nurse.
The forum then considers the learning reports and ensures that important lessons to
be learned are shared across the organisation. A key role of the forum is to review
the lessons learned from Serious Incidents (SIs), claims, complaints, external
reviews and significant events.
The forum disseminates important lessons to be learned in a number of ways
including:
•
Sharing the lessons learned reports (one liners) in the Trust risk newsletter
•
Internal alerts for immediate feedback
•
Feedback reports to clinical directorate management teams within the Trust
•
More detailed specific learning reports through existing Trust leads e.g. Risk
Manager
Innovation and improvement
Our improvement priorities for 2010/11 were to improve quality and safety of
services whilst increasing productivity. The quality, innovation, productivity and
prevention (QIPP) programme has been focussed on reducing length of stay, limiting
the number of unnecessary follow up appointments in outpatients and improving day
case rates.
Our focus has been on reducing unnecessary variation in length of stay by reviewing
patient pathways. Up until the end of November 2010 we reduced the total number
of days patients needed to stay in hospital by 4,790 for our top ten conditions ,
including stroke and chest pain. By the end of the financial year we hope to save
23,200 bed days. We have more work to do on improving our day case rates and the
24
number of unnecessary follow up appointments in outpatients. We will do this in
2011/12 as part of our new Transformation Programme.
The Transformation Programme will be focused on patients admitted as
emergencies (urgent care) and as electives (planned care). The Chief Executive held
an urgent care summit in January 2011 and from this a number of urgent care
standards have been developed which will be used to improve patients’ experience,
improve quality and safety and help us to reduce our costs. We plan to develop
planned care standards in 2011/12.
As part of our Trust improvement priorities we have also implemented a number of
initiatives that are designed to remove unnecessary waits and delays to allow staff to
spend more time with patients and implement best practice care and treatment. Two
examples are:
The Productive Series aims to equip staff with structured methods to reduce
unnecessary waits and delays and release time for improving the safety and quality of
patient care. The trust has implemented the Productive Ward on 45 wards (out of 60
wards) and is currently implementing the Productive Operating Theatre at Lincoln and
Pilgrim hospitals. The trust has also applied the principles of the Productive Series to
A&E and outpatient clinics. Currently all three main A&Es are implementing Productive
A&E and Productive Clinic has been trialled in cardiology (heart) and dermatology (skin)
out patients.
Benefits include:
• 97% of staff report that the Productive Series has improved their working
environment and 71% of staff feel that they have more time with patients
• An 8% increase in the time that nurses have to spend with patients
• An average of 432 hours per ward per year released by improving staff handover
Reducing emergency medical length of stay is designed to ensure that patients are
able to be admitted to the correct ward first time and go home when ready without
unnecessary delay. The improvement, which is planned over 12 months, was started at
Pilgrim hospital in October 2010. The plan for discharge for each patient is reviewed five
times a day to ensure action is taken in a timely way. The next stage is to work with
wards to improve the ‘plan for every patient’.
Benefits include:
• Length of stay on medical wards at Pilgrim reduced by 29.76%
• 70.4% of staff feel it has had a positive impact upon patient care
“Innovation is about doing things differently or doing different things to achieve large
gains in performance.” 1
25
Regional Innovation Funding awards:
•
In 2009/10 the trust was successful in gaining a regional innovation award to apply
the principles of the Productive Series to doctors (Releasing Medical Time to
Improve Patient Safety). The project is now being implemented at Lincoln County
Hospital on up to eight wards and aims to develop a safety culture amongst junior
doctors, improve the way that junior doctors’ days are planned to remove waste and
release time. The time saved will be used to improve handover between junior
doctors and review the way that ward rounds are undertaken to improve planning of
care, treatment and discharge.
•
In 2010/11 the trust was awarded funding to develop a step down nurse-led
intravenous therapy outreach service to allow eligible patients to remain in their own
home whilst receiving a course of intravenous antibiotics. This delivery method is
known as Outpatient Parenteral Antimicrobial Therapy (OPAT). Although the
patients have to report to the hospital weekly for assessment the treatment is
delivered entirely at home freeing up beds that would otherwise be occupied. Initially
the pilot will cover the area around Grantham and District Hospital. The service is
currently being planned for implementation.
Local innovation
There are many examples of local innovation. Here are a few:
•
Implementation of Primary Percutaneous Coronary Intervention. The service
started in December 2010 and is currently available at Lincoln County
Hospital for eligible emergency heart attack patients to open up blocked
arteries from the most severe form of heart attack. The procedure uses a
balloon to open up blocked arteries. PPCI, also known as primary angioplasty,
is clinically more effective than clot-busting drugs (thrombolysis), with the vast
majority of patients having their artery unblocked with angioplasty compared
to only 70% with thrombolysis. PPCI represents the best available treatment
for patients presenting with a heart attack. It has been shown to save lives,
and substantially reduce the risk of stroke associated with conventional ‘clotbusting’ treatment. The programme aims to roll out over the next 12-14
months, ultimately offering PPCI to all Lincolnshire patients 24 hours a day
and seven days a week
•
Introduction of cardiology nurse practitioners at Lincoln County Hospital to
support the implementation of PPCI and achieve national best practice
standards. The team’s role is to assess chest pain and manage heart attacks.
Data from the first three months indicate that the team is adding quality to the
initial treatment of heart attacks, reducing chest pain admissions and length of
stay
•
Design and implementation of Take Note! A new system of documentation to
deliver a single, uniform system of documentation for all adult inpatients
across Lincolnshire’s hospitals. This will take the format of a universal folder
that will stay with the patient from admission to discharge, even if they move
wards
•
Implementation of key hole laparoscopic colorectal surgery for patients with
tumours of the bowel
26
•
Improving diabetes care by implementing Think Glucose, a national
improvement project designed by the NHS Institute for Innovation and
Improvement. The project has been piloted on two wards at Pilgrim hospital
and new prescription charts are being trialled as part of the improvements
•
Implementation of a new one-stop shop shoulder service at Pilgrim hospital
for those attending hospital for shoulder consultations, diagnosis, review and
pre-assessment
•
Implementation of protected mealtimes to make nutrition a visible priority to
supporting patients to receive good nutrition and hydration
•
Dignity in Dementia Care conference, the sixth in a programme of
conferences aimed at improving dignity in care for all patients, aiming to help
healthcare staff develop knowledge and skills to ensure dignity in dementia
care
To help us foster and support innovation we are currently working with the NHS
Institute for Innovation and Improvement to assess our organisational culture for
innovation. The assessment is based on seven dimensions of culture in an
innovative organisation and the results will allow us to know how well we are doing
and where we need to improve to stimulate and support a culture for innovation.
Commissioning for Quality and Innovation (CQUINS)
We have supported innovation through CQUINS funding which is designed to help
improve quality and safety. As part of meeting our CQUIN priorities for 2010/11 we
have implemented the Enhanced Recovery Programme in colorectal surgery across
the Trust.
Enhanced Recovery Programme
The enhanced recovery programme is about improving patient outcomes and speeding
up a patient's recovery after surgery. It also aims to ensure that patients always receive
the right care at the right time. There are four elements to the enhanced recovery
programme:
1. Pre-operative assessment, planning and preparation before admission
2. Reducing the physical stress of the operation
3. A structured approach to immediate post-operative and during operation
management, including pain relief
4. Early mobilisation
The ERP was implemented for colorectal patients in October 2010 and now the scheme
is used for all emergency and planned colorectal patients
Benefits:
The length of stay for all colorectal resection patients has reduced from an average of
14.6 days (Jan – July 2010) to 10.5 days (in October 2010).
Reference
1 NHS Institute for Innovation and Improvement (http://www.institute.nhs.uk/)
27
Supporting our workforce to deliver high quality care
We know that high quality care is a team effort. Our Quality Plan is supported by
staff development interventions. The corporate and clinical training teams have
developed leadership programmes that concentrate on the development of all
potential leaders within the Trust. These have incorporated a Leadership Qualities
Framework, individual performance coaching and behaviour analysis.
A total of 15,928 in-house courses were completed in the last year, at an average of
2.7 courses per person. During the year, 79% of the workforce completed at least
one work-related course, which is significantly higher than the national average for
acute trusts. A training action plan has been developed with emphasis on continuing
development of preceptorship programmes for newly qualified nurses, which are
seen as important in promoting the delivery of high quality care in clinical areas. The
ward leader programme focuses upon the development of strategic clinical leaders
who are committed to improving the quality of the patient experience and the ongoing health and wellbeing of their clinical teams.
Additional emphasis in training is also being placed on maintaining good practice in
infection prevention and antibiotic prescribing. We have also been focusing on
demonstrating our commitment to improving the health of the patients by supporting
the health and wellbeing of staff.
Outcome evaluation has been based on feedback from staff and patients via a
number of major sources:
•
•
•
•
National Staff Survey
National Patient Survey
Staff Work and Wellbeing Survey
Motiv8 Lincs survey
Key indicators from the National Staff Survey have shown significant progress in a
number of indicators, including uptake of both appraisal and training, which are
linked to delivery of high quality care.
We recognise that our staff are individuals and their needs are unique. We are
developing a wellbeing programme specifically for the development of staff; a
programme that is tailor made, based on our understanding of the corporate culture,
individual objectives and long term goals.
We have also further developed our staff training and development programmes to
help them fulfil their potential within their roles. Examples of these programmes
include the patient wellbeing champion programme, essential skills training, assistant
practitioner foundation degree, safeguarding programmes and National Vocational
Qualifications.
28
2010/11 improvement priorities
For 2010/11 we selected five priority areas for improvement linked to the three
domains of quality to improve patient safety, clinical effectiveness and patient
experience:
Further reducing our hospital standardised mortality ratio (HSMR)
Continuing to improve the timeliness in response to complaints
Further reducing infection rates for MRSA and Clostridium difficile
Ensuring patients have had a venous thrombo-embolism (VTE) risk assessment
on admission to hopsital
Delivering the same sex accommodation requirements
These areas for improvement were identified through discussion with our service
users, our staff and our Trust Board. Progress against these improvement objectives
have been monitored throughout 2010/11.
29
Priority 1 – Effectiveness
Reducing our hospital standardised mortality ratio (HSMR).
What have we achieved?
During the last year the Trust has maintained the improvements made to our
mortality ratio. Although we have not reduced the hospital standardised mortality
ratios (HSMR) by the 20% target we set when compared nationally our mortality is
lower than a number of other Trusts. The latest data for the period January 2010 to
December 2010 show Trust HSMR in line with the national average.
Where we are now ?
In some areas of care we have made significant improvements, for example the
HSMR for patients with fractured neck of femur is 66.3, whilst in other areas the
HSMR is higher than national levels.
For this reason we need to continue to work to reduce the HSMR in those areas
where it remains high.
How we will continue to improve the quality of care?
Monitoring and improving the quality of care is a priority for the Trust. Over the last
few years reviewing deaths in hospitals has become a standard way of monitoring
the quality of care provided. However there was not a tool which is used throughout
the NHS. To make sure there is a consistent approach across the whole of the NHS
during the coming year the Government will be introducing the standardised mortality
ratio (SMR). We will continue to monitor our mortality closely in the coming year.
We felt we already had a good process in place for monitoring and improving HSMR,
but we also learned from our work last year the value of a having a team that meets
regularly to monitor and report on HSMR. We now have a team who meet monthly.
The team is lead by a senior doctor and membership includes a senior nurse and the
Trust’s Patient Safety Manager.
Because there are many reasons for a high HSMR the team review the data and use
it as a trigger for further investigations. A high HSMR may be due to coding (coding
is how we identify and record the main conditions patients are treated for).
Alternatively there could be areas where the Trust needs to improve care.
Where there are areas of concern we support the front line clinicians to review the
care patients have received. In this way we have found things that need to be
improved and are putting the impetus for change in to the hands of the clinicians who
care for the patients.
Using this process has meant we have already made a number of improvements.
For example we have updated a number of clinical guidelines (guidelines are used to
provide information about a particular illness) and put in place pathways (pathways
are used to support the care people get during their hospital stay) and improved our
coding system.
During the coming year we are going to audit the care patients received against the
guidelines to make sure our patients are receiving the recommended standard of
30
care. Putting it another way, we want to make sure we are doing what we say we
should be doing.
What does this mean?
Patients can be assured that even though our mortality ratio is better than other
Trusts in England we are committed to continued reduction in HSMR and
improvement in the care we offer. Staff can feel proud that the mortality ratio
accurately reflects the care they provide.
31
Priority 2 – Patient experience
Improving the handling of complaints.
What have we achieved?
The number of formal complaints has reduced due to the implementation of a new
customer care service designed to resolve issues and concerns within a very short
(24 hour) timescale.
To improve the quality and independence of investigations for our more complex
complaints, a pool of senior managers have been trained to undertake investigations
of high risk/complex complaints. In addition, for these complex complaints, the Trust
has introduced the concept of a family liaison officer to improve communication with
complainants through the investigation process.
Description of the issues and rationale for prioritising
The Trust had set internal targets to reduce the number of formal complaints
received by at least 10% and to respond to at least 80% of formal complaints within
agreed timescales. We recognise that as well as reducing the overall number of
complaints, it is important that we focus upon making sure that our investigations
and responses to complaints are managed in a timely way and therefore the Trust
agreed to focus on these objectives as a priority.
Current status
Number of complaints received
32
Number of complaints vs number of concerns received
Number of enquiries received by the customer care team
Reply to complaints performance rate %
33
How did we do this?
We altered the way in which issues and concerns raised by service users are
reviewed within the customer care team and developed clear guidance on what
could be resolved at an earlier stage. To support this, a customer care advisor was
appointed to take calls from patients/relatives and, with the support of the relevant
departments, resolve their concerns.
Matrons and sisters undertake regular ‘walk rounds’ on the ward to ensure they
provide patients with the chance to raise any concerns they may have at the point of
delivery. The Customer Care Advisor has provided a clear contact point for enquiries
to be made to the organisation and recorded at a centralised point.
To support an improvement on timeliness, a clear pathway has been devised to
involve Trust executives at an earlier point when there has been non-compliance.
What do these results mean?
We have demonstrated through our implementation of our Patient Experience and
Customer Care Strategy that we are able to reduce the number of complaints
received by the Trust through early intervention and support. With an increase in low
to medium risk dissatisfactions being resolved at an earlier point, the complaint
cases are of great complexity, which has meant a decrease in the number of
complaints being responded to by the deadline agreed. A new challenge is faced by
those investigating complaints and greater support and training is needed to guide
the process.
34
Priority 3 – Safety
Reducing healthcare associated infections.
What have we achieved?
We have performed better than trajectory for both MRSA bacteraemia and
Clostridium difficile during 2010/11, building upon our reductions in previous years.
This means that there were seven fewer MRSA bacteraemia cases post-48 hours of
admission in 2010/11 and 65 fewer C difficile cases post-three days of admission
than in the previous year.
Description of the issue and rationale for prioritising
Reducing healthcare associated infection remains one of the key national priorities
for the NHS and we are aware that infection remains a key concern when patients
are considering the quality of care that they receive.
Although we have exceeded the requirements to reduce MRSA and C difficile over
the last two years, we have continued to identify areas of practice that we can
improve upon to ensure that we have a truly zero tolerance approach to infections.
Current status
The Trust has continued to improve its performance in terms of reducing healthcare
associated infections such as MRSA and C difficile and we have performed better
than trajectory for three consecutive years.
MRSA BACTERAEMIA
post 48 hours
35
30
31
25
20
15
10
16
12
12
9
5
0
2008/ 09
Act ual
Target 09/ 10
2009/ 10
Target 10/ 11
Act ual
2010/ 11
Act ual
35
CLOSTRIDIUM DIFFICILE
POST 3 DAYS
250
200
211
211
150
159
144
100
92
50
0
2008/ 09
Act ual
Target 09/ 10
2009/ 10
Target 10/ 11
Act ual
2010/ 11
Act ual
How did we do this?
During 2010/11, we focused upon four key priority areas as part of our programme to
reduce infection further. These areas included environmental cleanliness, antibiotic
prescribing, care and management of intravenous lines and urinary catheter
management.
A revised electronic audit system for monitoring clinical practice has been developed
in partnership with an external company which will enable us to produce and report
real time public data on how we are complying with various aspects of clinical
practice.
Each part of our plan has been monitored by the local hospital infection prevention
and control committees which in turn report to the Trust Infection Prevention and
Control Committee. Quarterly reports on the progress that we are making against our
plan are presented to the Trust Board.
What do these results mean?
Patients can be assured that we are making good progress in the prevention of
healthcare associated infections and that the progress is being sustained. Patients
can also be assured that we will continue to focus on infection prevention as an
improvement objective and that we have already begun to review our performance
against infections other than MRSA and C difficile as part of our zero tolerance
approach.
36
Priority 4 – Safety
Ensuring patients have had a venous thrombo-embolism (VTE) risk assessment on
admission to hospital.
Description of the issue and the rationale for prioritising
VTE is a significant patient safety issue and measuring of VTE risk assessment sets
an effective foundation for appropriate prophylaxis. This gives the potential to save
lives. This was identified as one of our key quality goals for 2009-2011
VTE was one of the national CQUINs for 2010/11. The aim of the scheme was to
introduce risk assessments on admission to hospital for inpatients. This helped us
plan for effective prophylaxis (prevention) strategies and improve outcomes for our
patients.
What have we achieved?
The Trust has been actively working towards achieving the 90% goal to ensure all
adult patients admitted to hospital will have a VTE risk assessment.
During 2010/11 we:
•
•
•
•
•
•
•
•
•
•
Implemented the national VTE risk assessment tool
Appointed VTE co-ordinators for six months
Delivered training to clinical staff
Raised awareness
Implemented a system for monitoring
Reported on a monthly basis into the National Unify system
Reported performance at the quarterly review meetings with NHS Lincolnshire
Reported to the Performance and Finance Committee and Trust Board
Performed spot audits
Engaged junior doctors in this initiative via education sessions
How did we do?
Latest data for the month of March 2011 shows VTE risk assessment performance
for the Trust is 76.80%.
This shows a considerable improvement for the year, which has been realised
through education and awareness sessions, better use of information systems and
spot audit and feedback.
37
P erform ance
Trust VTE Risk Assessment Performance
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11
Month
The Trust was able to demonstrate improvements following the implementation of
the monitoring system. The graph above clearly shows that the Trust is now risk
assessing the majority of adult patients on admission.
Patients can be assured that the Trust is making significant progress in risk
assessing patients on admission to hospital to prevent VTE and will continue to
improve this further during 2011/12.
Current initiatives to improve performance further are around junior doctor audit
projects, streamlining data systems and targeting key areas.
38
Priority 5 – Patient experience
Delivering same sex accommodation requirements.
What have we achieved?
The Trust has eliminated mixed sex accommodation from general ward areas. A
small problem remains in the endoscopy units across the Trust despite improvement
work on the patient pathway and administration to minimise patients having to share
accommodation with the opposite sex as they recover from a procedure.
The situation will only be fully resolved in endoscopy units by the provision of a
separate recovery area for men and women for this day case care. At Pilgrim
Hospital, Boston the situation will be resolved when the unit moves to temporary
facilities when a new endoscopy unit is created from May 2011. Business cases for
new recovery facilities are being prepared for June 2011.
We monitor complaints regarding mixed sex issues and since April 2010 there have
been two relevant complaints both relating to Lincoln (A&E and Alexandra short stay
ward). The data below taken from the incident reporting database demonstrates
improvements made:
Month
Sept 2010
Oct 2010
Nov 2010
Dec 2010
Jan 2011
Feb 2011
Mar 2011
April 2011
Numbers of
unjustified breaches
1013
1443
884
409
124
44
41
13
We can reassure any potential users that for endoscopy, this relates to day case
procedures and patients are not sleeping overnight in mixed sex accommodation.
In January we undertook a survey to determine the opinion of patients using the
services in endoscopy units across the organisation, where the vast majority of the
problems remain, to seek assurance on practice caring for patient’s privacy and
dignity in this area. The feedback was overwhelmingly positive.
39
Feedback
The Trust welcomes feedback from the public and patients on the quality of services
it provides. The Trust would therefore also like to know what you think about this
report on quality.
We would also like to know if you have any suggestions for the content for future
reports including any areas of improvement you would like the Trust to focus on in
future reports.
If you would like to make any comments or suggestions then please send them to
customercare@ulh.nhs.uk
40
External regulation and assurance
Care Quality Commission (CQC)
The Trust is required to register with the Care Quality Commission and its current
registration status is full registration with concerns.
For further details please see Care Quality Commission statements – Registration
and Periodic Reviews on page 18 of this report.
National Health Service Litigation Authority (NHSLA) assessment
The Trust has undertaken a Level 1 assessment with the NHS Litigation Authority
Risk Management Standards for Acute Trusts. This reviews policies and approved
documents covering five standards around the topics of governance, competent and
capable workforce, safe and secure environment, clinical care and learning from
experience.
The assessor has confirmed Level 1 compliance with these standards. The Trust
intends to build evidence to demonstrate compliance at Level 2 demonstrating that
the policy documents are in use in practice and undergo an assessment within the
next year.
Information standard
ULHT has been certified as a quality provider of health and social information by the
Information Standard, which is a new certification scheme for health and social care
information. In order to be accredited the Trust had to pass rigorous, independent
assessment of its patient information production processes and content against a set
of standards approved by the Department of Health.
The Trust is committed to producing high quality approved patient information which
is clear, relevant, evidence-based, authoritative, complete, secure, accurate, welldesigned, readable, accessible and up-to-date.
The Trust’s aim is to produce a corporate standard of written information for patients
which meets nationally recognised criteria. All patient information produced will
comply with the Production of Written Patient Information Policy and NHS Identity
Guidelines. The Trust also conforms with the NHS Litigation Authority standards for
patient information.
The Information Standard has been established to help people make informed
choices about their lifestyle, conditions and treatment/care options, by providing a
recognised and trusted quality mark that will indicate reliable sources of health and
social care information. Research has shown that the quality of health and social
care information on offer varies widely, that the quality of many patient information
materials is poor and not reliable, and that people can feel overwhelmed by the array
of information on offer.
Clinical Negligence Scheme for Trusts (CNST)
CNST is part of the NHS Insurance Litigation Authority (NHSLA). This ensures that
all maternity services recognise risks, have in place robust risk management
strategies and ensure the quality and safety for all women who use maternity
services. The NHSLA have produced maternity standards which Trusts are
encouraged to follow.
41
Level 1
Demonstrate that we have robust guidelines in place that follow the recommended
standards and ensure safety of women who access the service.
Level 2
Provide evidence that the policies and guidelines are being followed. We can provide
this evidence by ensuring that we document care as per policy in 100% of the
women we care for.
Level 3
Demonstrate that we monitor compliance against the CNST standards by a robust
audit programme.
The Trust is committed to achieving CNST level 3 to ensure the women accessing
our services are cared for safely. Achieving the levels also brings a significant
financial reward for the service through a reduction in our insurance. The Trust has
successfully achieved Level 1 and is working toward Level 2, with assessment due in
January 2012.
UNICEF Baby Friendly Initiative (BFI)
The Baby Friendly Initiative is a worldwide programme of the World Health
Organization and UNICEF. It was launched in 1992 to encourage maternity hospitals
to implement quality standards for breastfeeding mothers the Ten Steps to
Successful Breastfeeding and to practice in accordance with the International Code
of Marketing of Breast milk Substitutes. The Baby Friendly Initiative came to the UK
in 1994.
Evidence demonstrates that once implemented breastfeeding initiation and duration
improves.
“The proportion of babies breastfed at birth increases by more than 10% on average
over 4 years when hospitals implement the Baby Friendly standards” (Radford,
2001).
ULHT believes that breastfeeding is the healthiest way for a woman to feed her baby
and recognises the important health benefits now known to exist for both the mother
and her baby. There is q commitment to achieve BFI UNICEF full accreditation within
the Trust.
The accreditation process is in stages:
•
•
•
•
•
•
•
Register of intent
Action planning visit
Certificate of commitment
Stage 1 - The mechanisms that have been developed to enable the standards
to be implemented and maintained are assessed.
Stage 2 - Staff knowledge and skills are assessed
Stage 3 - The care provided to pregnant women and mothers is assessed
Full accreditation - This lasts for two years after which a reassessment of all
the standards is carried out
42
United Lincolnshire Hospitals NHS Trust has successfully been awarded level 2
accreditation and is now working towards level 3.
43
Quality overview
Performance of ULHT against selected measures
Topic
Dr Fosters
Dr Fosters
Dr Fosters
Dr Fosters
Dr Fosters
Dr Fosters
Indicator
Hospital Standardised Mortality Ratio
Readmissions by diagnosis
Readmission by procedure
LOS by diagnosis
LOS by procedure
Day case rate by procedure
Fractured Neck Of Femur - Patients operated on
within 24 hours
Care pathway Fractured Neck Of Femur - Patients operated on
/ CQUIN
within 36 hours
Fractured Neck Of Femur - Patients operated on
Care pathway
within 48 hours
MINAP
Call to needle time within 60 mins
MINAP
Door to needle time within 30 mins
National Audit Participation in heart failure audit
National Audit Engagement in national clinical audits
PROMs
Orthopaedic - Hips & knees
PROMs
Surgery - Varicose Veins and Hernia
Care pathway
Target
2009 - 2010
April 2010 - March
2011
Most recent
performance (as of
start of May 2011)
90
100
100
100
100
100
105.8
95.2
98.5
113.9
112.5
92.5
101.6
96.9
96.9
103.1
104.1
87.9
107.6
97.2
98.0
100.1
103.8
86.0
70%
39.81%
45.95%
61.19%
80%
NA
66.87%
76.12%
95%
69.21%
80.32%
88.06%
68%
75%
Participation
Participation
Participation
Participation
64.96%
76.70%
Part year participation
Full year participation
Full year participation
Full year participation
64.58%
85.53%
Full year participation
Full year participation
Full year participation
Full year participation
64.29%
90.48%
82.4%
65.5%
79.7%
79.7%
Progress level 2
NA
Level 2 achieved
across Trust
71.56%
21.66%
Stroke
Performance against 9 process indicators for stroke
Maternity
Baby friendly standards progress
Maternity
Maternity
Breastfeeding initiation rates
Caesarean section rate
78%
24%
75%
NA
Level 2 achieved
across Trust
70.43%
21.75%
Maternity
Obstetric trauma WITHOUT delivery by instrument
34.59
NA
21.57
19.64
Maternity
Obstetric trauma WITH delivery by instrument
73.6
NA
63.93
63.49
C-Diff
MRSA
Incidence of Clostridium difficile (accumulative)
Incidence of MRSA bacteraemia (accumulative)
144
12
159
16
94
9
94
9
80%
54%
43%
36%
647 / year
719
505
505
Complaints
Complaints
Proportion of complaints responded to within agreed
timescale
Total number of formal complaints received
(accumulative)
Notes
Most recent performance figures - These figures are the most recent monthly (March) or quarterly (January 2011 to March 2011) figures available.
Dr Fosters indicators -These indicators show how well the trust is performing when compared to the national benchmark of 100%. The trust uses a colour
coding system so we can identify areas where improvement is needed. A score of over 100 is red, 91 to 99 is amber and 90 or below is green. Please note
annual performance is April 2010 to February 2011 for HSMR, LOS, day case and obstetric trauma, and most recent performance is based on Jan to Feb
2011 for HSMR, LOS, day case and obstetric trauma, Oct to Nov for readmissions.
MINAP - Is the data collection for all patients who come to hospital with symptoms suggestive of a 'heart attack' the medical term used is acute myocardial
infarction (AMI). We are monitoring how quickly patients who had a myocaridial infarction receive thrombolytic drugs.
The data collected is the time of a patient's call to emergency services, to the time of thrombolytic drug given. This is known as Call to Needle. Score is
based on success rate of within 60 minutes. Green = 68% and above. Further monitoring is done on the time of patients' arrival at hospital, to the time of
thrombolytic drug given, known as Door to Needle. Score is based on success rate of within 30 minutes. Green = 75% and above. Annual data available in
April - December 2010 and most recent is October - December 2010.
Baby friendly standards - The Baby Friendly Initiative is a worldwide programme of the World Health Organization and UNICEF. The Baby Friendly Initiative
works with the health-care system to ensure a high standard of care for pregnant women and breastfeeding mothers and babies. An assessment and
accreditation process recognises those that have achieved the required standard. The target for 2010/11 was to progress from level 1 to level 2.
Surgical site infections (SSI) - This shows the Trust performance for rates of surgical site infection when compared to other Trusts. The data collected is the
number of infections for hip and knee replacments. The target the trust has set is that no patients should get an infection following hip and knee
replacements. Data is April 2010 - Dec 2010.
44
National targets at a glance – March 2011
Indicator
Achieve
Year to
date
Total time in A&E: 4 hours or less
95%
95.01%
Waiting times for diagnostic tests (Excluding Audiology)
10
1023
Number of inpatients waiting longer than the 26 week standard
0.03%
Number of outpatients waiting longer than the 13 week standard
0.03%
Maximum waiting time of two weeks from urgent GP referral to
first outpatient appointment for all urgent suspect cancer referrals
2 week standard for non-suspected (symptomatic) breast
referrals
Maximum waiting time of 31 days from decision to treat to start of
treatment extended to cover all cancer treatments
31 day subsequent drug treatments
31 day subsequent surgery treatments
31 day subsequent radiotherapy treatments
Maximum waiting time of 62 days from all referrals to treatment
for all cancers
380
0.48%
1151
0.70%
93%
93.40%
93%
90.00%
96%
95.80%
98%
94%
94%
98.70%
98.50%
64.60%
85%
81.60%
62 day standard from screening programmes
90%
82.50%
(Cancelled ops) Number of patients whose operation was
cancelled, by the hospital, for non clinical reasons, on the day of
or after admission
0.80%
(Cancelled ops) Not treated within 28 days. (Breach)
5%
100
10.35%
Delayed transfers of care
3.50%
4.06%
MRSA Bacteraemia (Post 48 Hours)
Clostridium difficile (Post 72 Hours)
<12
<144
9
94
Thrombolysis - 60 minute call to needle time (Apr 10-Mar 11)
68%
63.93%
Waiting times for Rapid Access Chest Pain Clinic (2wk Wait)
Patients waiting longer than three months (13 weeks) for
revascularisation
98%
100.00%
0
0.00%
966
0.1%
1.22%
Data quality on ethnic group
>=85%
98.1%
Experience of patients
Pass
Satisfactory
Infant health & inequalities: smoking during pregnancy and
breastfeeding initiation
Engagement in Clinical Audits
Mixed Sex Accommodation (reported from December 2010)
Indicators highlighted have data older than current month
45
Pass
Pass
Yes
0
613
Stakeholder comments
NHS Lincolnshire
Commissioning high quality, safe patient services is our highest priority and the
areas identified will enhance the patient experience and improve patient safety and
clinical outcomes. NHS Lincolnshire therefore welcomes the focus that the Trust still
places on reducing the Hospital Standardised Mortality Ratio (HSMR)
In terms of performance against the 2010/11 CQUIN indicators, the following
indicators were achieved:
•
•
•
•
•
Improving responsiveness to patients
Numbers of patients with Fracture Neck of Femur operated on within 36 hours
Reduction in pressure ulcers
Reducing infection – catheter usage
Availability of Choose and Book slots
The following CQUIN indicators were partially achieved:
•
•
•
•
•
•
•
Reducing avoidable death, disability and chronic ill health from venous
thrombo-embolism (VTE)
Reduced the number of emergency admissions within 28 days of discharge
for patients with long term conditions
Implementing discharge, no delays and reduction in length of stay in
colorectal and orthopaedic surgery
Patient safety programme including reducing medication errors
Increasing breastfeeding initiation rates and maternity bookings within 12
weeks
Reduction in the mean emergency medical length of stay
Improving post stroke provision
The following CQUIN indicators were not achieved:
•
•
•
•
•
•
Percentage of procedures listed in the British Association of Day Surgery
carried out as day cases
Reduction in admission from A&E with less than zero length of stay for
children
Proportion of normal birth rate deliveries
Timeliness of outpatient follow up letters
Assessment at one stop clinic within 24 hours for Transient Ischaemic Attack
(TIA) assessment
Admission from A&E with zero length of stay for adults
NHS Lincolnshire supports the examples of the quality improvement schemes that
have been worked on during 2010/11 and areas that have been identified for
development within 2011/12. In particular the establishment of a dedicated Patient
Safety Team with a full time Patient Safety Manager, membership of the national
Patient Safety First campaign and the Trust’s top quartile performance in incident
reporting. However further work is required to ensure timely investigation and closure
of serious incidents and NHS Lincolnshire has strengthened this by the introduction
of a penalty within the quality schedule. Further work is also required to ensure the
timeliness and accuracy of discharge communication. NHS Lincolnshire is
46
disappointed that the Trust is not participating in the Bowel Cancer National Audit
given that there have been alerts associated with this.
NHS Lincolnshire notes that the Trust’s current registration status with the Care
Quality Commission is full registration with concerns. Further, it is noted that the
Care Quality Commission has taken enforcement action against ULHT during
2010/11 following the visit to Pilgrim Hospital where the CQC found that the Trust
was failing to comply with the following regulations/outcomes:
Regulation 9 / Outcome 4 – Care and welfare of people who use services
Regulation 14 / Outcome 5 – Meeting nutritional needs
NHS Lincolnshire will work with the Trust to monitor that corrective action is taken,
that remedial action plans to address these failures and to meet compliance with
these regulations are in place by 29 and 31 May 2011 respectively.
NHS Lincolnshire notes the considerable hard work undertaken by the Trust to
perform better than plan for both MRSA bacteraemias and C difficile during 2010/11,
building upon reductions in previous years. Specifically we note the Trust has made
progress on eliminating mixed sex accommodation generally and that further action
has been taken to improve the patients experience and comply with the Department
of Health requirements. It is acknowledged that a problem remains in the endoscopy
units across the Trust, despite work on the patient’s pathway that will only be
resolved through building work, the provision of 3 new units and the provision of an
additional recovery area and toilet facilities.
NHS Lincolnshire endorses the areas identified for improvement for 2011/12 and the
associated initiatives as detailed within the Quality Account as:
Continuing to improve the timeliness of response to complaints
Ensuring patients have had a venous thrombo-embolism (VTE) risk assessment
on admission to hospital
Infection Prevention – (MRSA/C difficile + new mandatory reporting
requirements)
Delivering the same sex accommodation requirements to minimise the number of
patients experiencing mixed sex accommodation
Meeting nutritional needs
Additionally, the priorities identified by NHS Lincolnshire as CQUIN indicators for
2011/12 include:
•
•
•
•
•
•
•
•
•
Acute Kidney Injury
Normalising birth rates
Discharge planning
Smoking – identification and advice
Stroke – improving treatment planning and reviews
High Impact Actions – falls, pressure sores, and catheter associated urinary
tract infections
Reduction in the number of emergency admissions
Reduction in pre-operative length of stay
Reduction in medical length of stay
47
•
•
•
Introduction of Acute Care Practitioners
Improvement in the ratio of new outpatient appointment follow ups
Notification of emergency admissions to GP with expected date of discharge
NHS Lincolnshire supports the work underway to capture real time feedback from
patients and to be more responsive to patients needs.
NHS Lincolnshire endorses the accuracy of the information presented within the
ULHT Quality Account and the overall quality programme performance will be
reviewed through the formal contract quality review process.
Overview and Scrutiny Committee and LINKs
This statement has been prepared jointly by the Lincolnshire Local Involvement
Network (LINk) and the Health Scrutiny Committee for Lincolnshire.
Priorities for 2011/12 The Lincolnshire LINk and the Health Scrutiny Committee for Lincolnshire endorse
the Trust’s five priorities for 2011/12. We recognise that four of these five priorities
have been carried forward from 2010/11 and aim to consolidate the progress, which
has already been made.
We acknowledge the improvements which have been made with regard to the
complaint arrangements during 2010/11. We therefore support the continued
inclusion of Priority 1 (Continuing to Improve the Timeliness in Response to
Complaints), in particular a target that there should be a response to 80% of
complaints within 15, 25 or 35 days, depending on the complexity of each complaint.
We would also like to comment that learning from complaints is important to the
development of an organisation and we hope that a robust complaints process will
lead to improved care for patients.
In terms of Priority 2 (Ensuring Patients have had a venous thrombo-embolism [VTE]
risk assessment on admission), we also support the intention that 90% of all adult
in-patients have a VTE risk assessment. This represents a significant increase from
the current performance level of 84%.
In relation to Priority 3 (Reducing Healthcare Associated Infections), we recognise
the Trust’s good progress during 2010/11 in reducing the incidence of MRSA and
clostridium difficile. We understand that new strains of infections are the reason for
the continued inclusion of this priority. We recognise that some patients on
admission to the Trust’s hospitals may already have a healthcare associated
infection and we stress the importance of continuing to screen patients, when they
are admitted or transferred from other hospitals.
We welcome the same sex accommodation already implemented. The delivery of
the same sex accommodation requirements (Priority 4) is strongly supported, as a
key element in improving the overall patient experience. We look forward to the
planned alterations to the Trust’s endoscopy units to meet this Priority by September
2011.
The inclusion of Priority 5 (Meeting the Nutritional Needs of Patients) is particularly
welcome. We recognise that the inclusion of this priority follows an inspection by the
Care Quality Commission at Pilgrim Hospital, Boston, in February 2011. There is
48
some disappointment that it took an inspection to lead to the inclusion of this priority.
Food and water are essential for the general wellbeing and recovery of patients, and
we believe that ensuring patients receive basic nutrition is a fundamental element of
nursing care. We welcome the Trust’s intention to publish the information on their
intended nutritional assessments and would like to see this done on a monthly basis.
Transformation Programme We are pleased to see the Quality Account referring to the development of the
Trust’s Transformation Programme, which includes the development of standards for
all patients admitted to the hospital, whether as an emergency or for planned care.
We recognise the importance of this programme for the future of the Trust.
Patient and Public Involvement The Health Scrutiny Committee has welcomed the development of strong working
relationships between the Committee and the Trust’s Chief Executive and other
senior managers during 2010/11. The Committee looks forward to this level of
engagement continuing throughout 2011/12.
Smoking Cessation The Joint Director of Public Health’s Annual Report for 2010 includes a
recommendation that more should be invested in smoking cessation services. We
note that the Trust’s role is not to deliver public health priorities directly, but we
suggest that more might be done to discourage patients from smoking around the
hospitals’ entrances.
Breastfeeding The Public Health Annual Report 2010 also includes a recommendation on
increasing the number of infants breastfed until six months of age. We note that the
Trust has received a level two accreditation as part of the UNICEF Baby Friendly
Initiative. We urge the Trust to seek level three of this accreditation, as we recognise
the importance of the Trust’s role in ensuring that mothers, who wish to breastfeed,
get all the breastfeeding support they need immediately after the birth of the child, so
that the prevalence of breastfeeding mothers may increase from its existing level.
Conclusion The LINk and the Health Scrutiny Committee for Lincolnshire would like to endorse
the content of the Quality Account of United Lincolnshire Hospitals Trust.
Patient Council
Overall we consider this to be a fair and balanced report.
We are pleased to note the significant improvement in hospital acquired infection
rates and also the reduction in mixed gender accommodation.
However, we continue to have concerns around the provision of a system for
ensuring optimum patient nourishment at all sites within the Trust.
49