Quality Report
For the Year 2012 - 2013
QUALITY REPORT
FOR THE YEAR ENDED 31 MARCH 2013
CONTENTS
PAGE
Section 1
Statement on Quality from the Chief Executive
Introduction to Derby Hospitals NHS Foundation Trust Quality
Account
2
3
Section 2
Priorities for Improvement and Statements of Assurance
2.1
The Trust Quality Strategy
2.2
Priorities for Improvement during 2013/14
2.3
Review of Services
2.4
Participation in Clinical Audits and National Confidential
Enquiries
2.5
Participation in Clinical Research and Innovation
2.6
Goals Agreed with Commissioners
2.7
Registration with the Care Quality Commission
2.8
Quality of Data
2.9
Delivery of National Targets
4
4
29
30
30
44
46
48
51
54
Section 3
Additional Information
3.1
Board to Ward Programme
61
61
Annex 1
Statements from Primary Care Trusts, Local Involvement Networks, 63
Improvement and Scrutiny Committees, and the Trust Council of
Governors
Annex 2
Statements of Directors’ Responsibilities in respect of the Quality
Report
67
Annex 3
Independent Assurance Report
68
Abbreviations used
71
STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
After two years as Chief Executive of this Trust this statement for the Quality Account is an opportunity
for me to share our progress with the Quality Strategy and to demonstrate the work and achievements of
our staff.
The Trust continues to build on aspects of care that matter most to patients. Forums were held over the
last year to ask patients, Governors, and staff what they wanted from their health service. Feedback has
influenced the development of our new strategy for the overall development of the Trust, which will
ensure that quality and compassion are at the centre of everything that we do. Patients want to work
with us, to be seen locally, supported to maintain their own health and wellbeing, and they want greater
sharing of information. The Trust aim will be Quality Through Partnership, ensuring a better patient
experience through the delivery of safety and quality in everything that we do. This includes improving
and maximising the efficiency of services and creating and strengthening networks with other health care
organisations, particularly for patients with complex health care needs. We aim to be a beacon of 21st
Century health care demonstrating by our example how health care can change and adapt to respond to
the changing needs of our patients.
The winter period has been exceptionally busy and many of our patients were very ill with more complex
needs. Additional medical beds were opened and extra staff brought in to ensure that patients continue
to receive safe care.
At Derby Hospitals developing our staff is the key to our success and a new Leadership programme has
been launched that will empower staff to be outstanding leaders at every level within the organisation.
This will help in the development of an environment where all staff feel valued and cared for, and where
they can then deliver compassion and care to their patients.
The Francis report published in February 2013 raised important issues relating to patient care. Two
forums were held for staff on the day of publication by myself, the Medical Director, and the Director of
Patient Experience and Chief Nurse who also held an on-line debate with staff. At the forums, which
more than 250 attended, staff were informed of the work that has already been carried out to safeguard
patients and additional measures to ensure continued quality and compassion in care.
In January 2013 the Prime Minister visited the Trust and said “the Royal Derby Hospital is a fantastic
example of how the NHS provides good quality care for patients”.
Quality of care is absolutely central to our ambition to become a beacon of 21st Century Healthcare and I
am pleased to commend this report, which documents the hard work we have been doing in this area.
The Board’s determination to achieve the highest possible quality of care, coupled with the skill,
compassion, and commitment of our staff, will enable us to deliver a service which is the Pride of Derby
and is valued and supported by the community that we have the privilege to serve.
This statement summarises Derby Hospitals NHS Foundation Trust’s view of the quality of the NHS
services that it provided or subcontracted during 2012/13. To the best of my knowledge the information
in this document is accurate and the Trust Board has received and endorsed the details set out in the
Quality Report document.
Susan James
Chief Executive
28 May 2013
2|Page
INTRODUCTION TO DERBY HOSPITALS NHS FOUNDATION TRUST QUALITY ACCOUNT
Current view of the Trust’s position and status for quality.
This report covers the financial year of 2012/2013 across the Derby Hospitals NHS Foundation Trust.
The first part of the report details how we performed against last year’s Quality Report, followed by an
overview of organisational quality and patient safety, and our performance against national and local
metrics in 2012/2013. The second section identifies our priorities for improving quality, safety, and
patient experience for the coming year, and where we believe further improvements are required to
enhance patient care.
Our 2011/2012 Quality Report detailed three quality improvement priorities:
Patient Safety
- reduction of medication errors
Clinical Effectiveness
- improving timely discharge and communication to optimise a patient’s
length of stay
Patient Experience
- Empower staff to respond positively to every patient and carer concerns
and to learn from concerns and change practice
3|Page
PART 2
PRIORITIES FOR IMPROVEMENT
2.1 THE TRUST QUALITY STRATEGY
In September 2011 the Trust Board approved a Quality Strategy for 2011-14 setting out how the Trust
will build on its objective to continuously improve the quality of care it provides to patients, staff and key
stakeholders. The strategy clearly sets out how this will be delivered systematically over the next three
years. The strategy provides a working plan for the whole Trust to maintain its focus on the key
objectives, and sets out what is to be done and how progress will be measured.
The strategy is based on the key principles of patient safety, clinical effectiveness and patient experience
and is linked through the Trust PRIDE objectives.
P
Putting Patients First
Effectiveness:
Safety:
Continually drive down the Trust Mortality rate
Improve the safety of patients whilst in the care of the Trust by reducing avoidable
harm
To continue to improve the patient’s journey through the Trust and increase the
number of patients who would be happy to recommend the Trust
Experience:
R
Right First Time
Effectiveness:
Safety:
Experience:
Reduce the 30 day readmission rate
Reduce medication errors
Ensure that patients who are at the end of life receive the most appropriate care,
e.g. End of Life Care, Right Care or the Liverpool Care Pathway.
I
Investing our Resources Wisely
Effectiveness:
Safety:
Experience:
Improving timely discharge to optimise a patient’s length of stay
Invest in appropriate acuity tools to optimise nursing levels across the Trust
Invest in a ward assurance tool to provide demonstrable evidence of delivery of
high standards of clinical care
D
Developing our People
Effectiveness
Safety:
Ensure all clinical staff have an annual personal development plan and undergo
appropriate continuous professional development
Work on achievement of mandatory training for all clinical staff in order to
standardise practice and empower front line staff to respond positively to every
patient concern every time
E
Ensuring Value through Partnerships
Effectiveness:
To further develop the Integrated Care Pathways for Respiratory, Dementia, End
of Life, Falls and Learning Disabilities and to initiate appropriate new pathways
such as Frail Elderly Care
To improve and sustain discharge communications with GPs and the wider health
and social care community
Through partnerships ensure that the patient pathway and experience of care is
seamless through the acute sector and community care
Safety:
Experience:
4|Page
The Trust is continually striving to improve all aspects of care and the following section reports on those
priorities identified in the 2011-12 Quality Account and against other elements of the Quality Strategy
addressed and targeted during 2012/13.
2013/14 is the final year of this Quality Strategy and the remaining objectives identified will be included in
reporting next year.
2.1.1 SAFETY
INFECTION PREVENTION AND CONTROL
The Trust remains fully committed to and takes very seriously the responsibilities for the prevention and
control of healthcare associated infections, including Methicillin Resistant Staphylococcus Aureus
(MRSA) and Clostridium difficile (C.diff).
Infection Prevention and Control Governance Review
The Commissioning PCT undertook a review of the governance arrangements around Infection
Prevention and Control in July 2010, which identified a high level of assurance in the rigour and support
being given to the delivery of the HAI agenda, and throughout the process a high level of organisational
drive has been evident
The Trust also commissioned an external review of the Infection Prevention and Control Team in June
2011. It identified that the Board could be significantly assured that the Infection Prevention and Control
team are providing an appropriate and effective service.
The Internal Audit programme in both 2011 and 2012 has included the management of C.diff. There
were no recommendations following this audit on either occasion.
The Clostridium difficile Review Group has requested Professor Mark Wilcox, Public Health lead on
C.diff to undertake a review of the work of the review group, including the root cause analysis process
and clinical engagement to provide assurances that the arrangements are effective and appropriate.
The section following outlines some of the key objectives of the Trust with particular focus on those
infections that form part of the national reporting requirements. A key part of Infection Prevention and
Control is the management of specific infections and their risks.
National Screening Programme for MRSA on Admission to the Trust
The Trust continues to screen all elective admissions for MRSA unless they are within the exemption
categories as determined by the Department of Health. All emergency admissions, with the exception of
Paediatric and Maternity, have been screened for MRSA since 1st December 2010.
Key focus on reducing the number of MRSA bacteraemia (MRSAb)
For 2012/13 the Trust was set a national target of no more than 2 MRSAb cases but had a year end
position of 3 cases. In 2011/12 there were 2 cases of MRSAb identified, against a trajectory of 7.
Key elements of clinical practice are delivered within a clear set of standards and scrutinised on a
regular basis. This includes a detailed and full investigation of each MRSAb to consider whether all
appropriate actions were taken, and identifies any learning points.
The Department of Health has issued a zero tolerance approach to MRSAb for 2013/14. The Trust is
required to have no MRSAb infections in this period.
5|Page
The graph below shows the monthly trajectory and the incidence of the three cases.
Department of Health MRSA Trajectory and Trust Performance Data 2012/13
3
2.5
2
Monthly Trajectory 2012/13
1.5
Number of Cases per Month
Cumulative Trajectory 2012/13
1
Overall Total 2012/13
0.5
0
Mar
February
Jan
Dec
Nov
Oct
Sep
Aug
July
June
May
Apr
The learning points from the three cases include:
Continued focus on Aseptic Non Touch Technique (ANTT):
The ‘Aseptic Non-Touch Technique’ (ANTT) aims to prevent micro-organisms on hands, surfaces and
equipment from being passed to a patient through invasive procedures such as catheter insertion/care,
infusion therapy access, cannulations, venepuncture and wound care.
It is essential to embed the principles of ANTT to minimise the spread of infection. Monthly ANTT audits
and action plans are included in the Infection Control Accreditation Programme. This is monitored
monthly at the Infection Control Operational group (ICOG).
The value of regular audit work undertaken through the Infection Control Accreditation Programme.
The Infection Control Accreditation Programme sets standards for infection prevention and control
practice in the Trust which aims to reduce infection rates when carried out consistently by clinical teams.
Monthly Hand Hygiene, environmental cleanliness, staff information, ANTT, peripheral cannula, central
line and urinary catheter care audits are undertaken in each clinical area in the Trust. Compliance is
monitored monthly at ICOG, along with any associated action plans.
Undertaking these audits locally on a monthly basis provides the clinical teams with real time data on
how they are performing against Infection Prevention and Control Policies and are able to identify and
rectify any areas of non-compliance.
Quarterly MRSA Bacteraemia Data, Produced by the Health Protection Agency Reported at a Rate
of 100,000 Bed Days.
The data identified for Derby Hospitals represents 1 case each quarter.
6|Page
7
6
April - June 2011
5
July - Sept 2011
Oct - Dec 2011
4
Jan - March 2012
3
April - June 2012
July - September 2012
2
October - December
1
0
Hospitals
University
Leicester
United
Lincolnshire
Forest
Sherwood
University
Nottingham
General
Northampton
General
Kettering
Derby
Hospitals
Royal
Chesterfield
Infirmary
There are currently no National Averages available.
Clostridium difficile (C.diff)
C.diff is an organism which is found in the intestines of approximately 3% of adults. It rarely causes
problems in children or healthy adults, as it is kept in check by the normal bacterial population of the
intestine. However, when certain antibiotics disturb the balance of bacteria in the gut, C.diff can multiply
rapidly and produce toxins which cause illness.
National targets were set for the Trust in 2011/12, with a target of no more than 120 cases(patients with
a positive test result 72 hours or more after admission), and the Trust ended the year with 76 cases. In
2012/13, the target was no more than 49 cases of C.diff and the Trust ended the year with 65 cases, 16
over its national trajectory. The Department of Health has issued the Trust with a target of no more than
42 C.diff episodes for 2013/14.
The graph below shows how the Trust has performed with a year-end position of 65 cases.
Department of Health C.difficile Trajectory and Trust Performance Date for 2012/13
Continuous review and assessment is crucial to ensure that the Trust is taking all appropriate action to
minimise the risk of patients developing the infection. A Root Cause Analysis (RCA) is undertaken for
each C. diff case and presented to ICOG.ICOG reviews RCAs on all Trust acquired cases of C.diff and
the community acquired cases, including GP samples if the patient has had an inpatient episode in the
four weeks prior to diagnosis. The outcomes of all RCAs are shared with the clinical teams and action
plans monitored.
7|Page
A Review Group was set up in February 2010 to approve and implement the Clostridium difficile Policy
and to review all patients with the infection to ensure optimum treatment and supportive care for the
patient.
The Trust continues to take all steps possible to ensure that its antibiotic prescribing is in line with the
management of C.diff whilst balancing the clinical needs of the patient.
The Trust has worked closely with the Heath Protection Agency (HPA) with regard to the diagnosis and
management of C.diff. The HPA are assured that the Trust has a comprehensive action plan for the ongoing diagnosis and management of C.diff within the organisation.
East Midlands Quarterly HCAI Reporting Comparison
The Quarterly Clostridium difficile Infection Data reported by the Health Protection Agency as a
Rate of Trust Apportioned Cases per 100,000 Bed days
Trust Apportioned C.diff Rate per 100,000 bed days
35
30
25
20
15
10
5
0
July - Sept 2011
Oct - Dec 2011
Jan - March 2012
U niv ers ity
H os pitals
Leic es ter
U nited
Linc olns hire
S herw ood
F ores t
N ottingham
U niv ers ity
N ortham pton
G eneral
K ettering
G eneral
D erby
H os pitals
C hes terfield
R oy al
Infirm ary
April - June 2012
July - Sept 2012
Oct - Dec 2012
There are currently no National Averages available.
Methicillin Sensitive Staphylococcus aureus (MSSA)
MSSA is a similar bacteria to MRSA, but it does not have the resistance to commonly used antibiotics
that MRSA does, therefore more treatment options are available. It has been a mandatory requirement
for the Trust to report all MSSA bacteraemia cases to the HPA since January 2011. There is no
trajectory set against MSSA bacteraemia at this time.
All MSSA cases continue to be reviewed by undertaking RCA. Since April 2012 there have been 73
MSSA bacteraemia cases identified, 54 of these were identified 48 hours or less after admission,
meaning the cases are not attributable to Derby Hospitals. This reflects the picture nationally, where the
majority of cases are identified within 48 hours of admission and are therefore not attributed to the
hospital.
The graph below demonstrates that the Trust has achieved a reduction of the number of post 48 hours
cases in 2012/13 compared to 2011/12.
8|Page
Trust Performance Data 2011/12 – 2012/13
6
5
4
3
2012‐2013
2
2011‐2012
1
Ju
ly
Au
g
Se ust
pt
em
be
r
O
ct
ob
er
No
ve
m
be
De
r
ce
m
be
r
Ja
nu
ar
y
Fe
br
ua
ry
M
ar
ch
Ju
ne
M
ay
Ap
ril
0
Quarterly MSSA Bacteraemia Data, Produced by the Health Protection Agency is Reported at a
Rate of 100,000 bed days.
The data identified for Derby Hospitals represents 6 cases each quarter since January 2011 and shows
for the first time that Derby Hospitals has the lowest MSSA Bacteraemia rate for October – December
2012.
20
18
16
April - June 2011
14
July - Sept 2011
12
Oct - Dec 2011
10
Jan - March 2012
8
April - June 2012
6
July - September 2012
October - December 2012
4
2
0
Univ ers ity
Hos pitals
Leic es ter
United
Linc olns hire
S herwood
Fores t
Nottingham
Univ ers ity
Northam pton
General
K ettering
General
Derby
Hos pitals
Ches terfield
Roy al
Infirm ary
There are currently no National Averages available.
Escherichia coli (E.coli) Bacteraemia
E. coli is a species of bacteria commonly found in the intestines of humans and animals. There are many
different types of E. coli, and while some live in the intestine quite harmlessly, others may cause a
variety of diseases. The commonest infection caused by E.coliis infection of the urinary tract, the
organism normally spreading from the gut to the urinary tract. E.colibacteria may also cause infections in
the intestine, causing diarrhoea. These are usually the result of a food poisoning illness. Overspill from
the primary infection sites to the bloodstream may cause infections which are referred to as E. coli
bacteraemia.
The Trust continues to report all E.coli bacteraemia cases to the HPA. Mandatory reporting of E.coli only
commenced in June 2011 with no trajectory set, and during the period to 31 March 2012 the Trust
9|Page
reported 290 cases. Since April 2012 there have been 321 E.coli bacteraemia cases identified at Derby
Hospitals. 269 of these were identified on samples taken less than 48 hours after admission, this reflects
the national picture in both the numbers of cases identified and that the majority of cases are community
acquired and not related to the hospital treatment and care.
The graph below demonstrates the rate of all samples identified by laboratories, per 100,000 bed days
for E.coli bacteraemia infections, from July 2011 – December 2012. This data is not currently broken
down into Trust apportioned and non-Trust apportioned cases.
Although Derby Hospitals appears to be one of the highest in the East Midlands in terms of E Coli
Bacteraemia infections, over 2/3rds of the cases are identified within 48 hours of admission.
Rate of E.coli bacteraemia (all cases) processed by each Trust laboratory in the East Midlands
per 100,000 bed days, by quarter, July 2011 to December 2012
Norovirus
Norovirus is a virus which causes diarrhoea and vomiting. Although there is an increase in winter
months, cases do occur throughout the year. In general the symptoms last for 24-48 hours. There are no
long term effects from Norovirus and most people will make a full recovery within 48 hours. The focus
within the Trust each year is to ensure the spread of the illness is minimised.
The table below demonstrates the significant reduction in the number of patients and staff affected by
Norovirus in 2012/13 compared to the same time period 2011/12.
10 | P a g e
Norovirus Trust Staff and Patients Affected – Local Data
20122013
20112012
Number
areas
affected
Number
full ward
closures
Number
confirmed
Norovirus
Number
patients
affected
Number
days
new
symptomatic
patients
Number
staff
affected
Number
days
new
symptomatic
staff
34
8
18
131
1.3
38
0.8
53
20
38
341
2.1
106
1.1
Winter Preparedness
The Infection Prevention and Control Team implemented additional Norovirus and Influenza training in
preparation for the winter season.
The Infection Prevention and Control and the Antimicrobial Prescribing intranet sites are kept up to date
with the latest information and guidance and includes ‘top tips’ documents for Norovirus and Influenza as
quick reference guides for staff.
Hand Hygiene
Hand hygiene has been high profile within the National Health Service (NHS) and also with patients and
the public for a number of years. It is crucial that good practice is embedded within an organisation.
Monthly 20 minute observational hand hygiene audits continue to be undertaken in all clinical areas,
assessing compliance against the Hand Hygiene Policy. Continuous monitoring of the hand hygiene
standard is reflected in the MRSA and E.coli bacteraemia Level 5 within the Trust.
Divisional Matrons receive the audit results each month in order that they can be reviewed and any
necessary actions identified at the earliest opportunity. The monthly hand hygiene audit results are
reviewed and discussed at the Infection Control Operational Group (ICOG).In addition all clinical staff are
required to undertake competency assessment every two years to ensure that they are applying the
correct technique for hand hygiene.
The table below demonstrates continued compliance by all professional groups with the hand hygiene
compliance standard.
Hand Hygiene Performance Derived From Local Trust Standard
May12
Jun12
Jul12
Aug12
Sep12
Oct12
Nov12
Dec12
Jan13
Feb13
YTD
Total
YTD
Total
2011/12
Doctor
100% 99%
99%
99%
97%
99%
100% 99%
97%
98%
96%
98%
97%
HCA
100% 100% 99%
99%
99%
99%
100% 100% 97%
99% 100% 99%
99%
Nurse
100% 99% 100% 100% 100% 100% 100% 100% 99%
98% 100% 99%
100%
Other
100% 99%
98%
98%
Apr12
98%
99%
98% 100% 99%
99%
98%
97%
99%
11 | P a g e
The Cleaning Service at Derby Hospitals
Cleaning Services are a key part of improving infection prevention and control. Monthly auditing and
reporting is carried out ensuring that high standards of cleanliness are achieved and sustained
throughout the Trust.
This Year the Patient Experience Assessment Team (PEAT) assessment has been superseded by the
Patient Led Assessment for the Care Environment (PLACE). The principles are the same as PEAT,
which is a non-technical view of the hospitals facilities, i.e. cleaning, nutrition & hydration, the
environment and privacy & dignity. The main changes with the PLACE assessment is that it is patient
led. The results and action plan generated following the assessment will be published nationally.
TISSUE VIABILITY – PRESSURE ULCER MANAGEMENT
It is nationally recognised that the incidence of pressure ulcers is a key quality indicator and that 95% are
deemed preventable. Pressure ulcers are painful and distressing for the patient, and require increased
support and input to the patient from a health care perspective. The Trust monitors the number of
patients with pressure ulcers primarily through its prevalence and incident reporting systems.
The Trust reported 164 grade 3 and 4 pressure ulcers on the National STEIS system 2011-2012 and 125
during 2012-2013. From April 2012 the Trust recorded if a pressure was acquired whilst the patient was
an in-patient at the Trust and if the ulcer was avoidable or not.
The Trust has taken a zero tolerance stance to hospital acquired avoidable pressure ulcers and the table
below shows the progress that has been made compared to the April 2012 baseline. Although the target
has not been achieved there has been a steady reduction in avoidable hospital acquired grade 3 and 4
pressure ulcers. The root cause analysis and investigation for the 4 pressure ulcers that occurred in
March is on-going.
The Trust has introduced a number of measures to improve pressure ulcer management and reduce the
incidence of avoidable pressure ulcers over the past year.
The Pressure Ulcer Prevention Group (PUPG)
PUPG has been set up to develop an effective Pressure Ulcer Prevention Strategy for patients within the
Trust and works with other elements of pressure ulcer prevention within the wider community to ensure
that patients receive the right care and management in the health community. Availability of resources
are being co-ordinated by PUPG to ensure a corporate response to any issues identified. This includes
auditing access to and the use of cushions, sliding sheets, continence aids, barrier protection, heel
protectors, splints, medical devices and devising strategies to facilitate and promote appropriate, timely
and effective use of resources. Initiatives are implemented across Primary and Secondary care.
The Safety Thermometer
The Safety Thermometer measures prevalence rates in pressure ulcers and indicates a 61% reduction
of Trust acquired pressure ulcers over the past year. Total Pressure Ulcers prevalence for Derby was
12 | P a g e
5.6% in January which compares favourably (2nd lowest) against a performance range of 4.8% to 8.9%in
other local Trusts. The Incidence data also supports a downward trend.
Root Cause Analysis (RCA)
RCA is carried out for all Stage 3 and 4 pressure ulcers. Overall learning from these Serious Incidents
(SIs) are being addressed both through education and the programmes identified below.
Medical Division, Multidisciplinary Collaborative Project
This project was initiated in response to RCA in the Medical Assessment Unit which proved very
successful in reducing acquired / or deteriorated stage 3 or 4 pressure ulcers by 80% in October –
December 2012. The introduction of Skin Assessment stickers in the Triage area ensured early
recognition of at risk or damaged skin which prompted preventative interventions at the earliest
opportunity. The introduction of a Turning Clock to remind patients and staff of the need to keep the
patient moving also proved helpful in reminding staff to check patient’s skin. The organization plans to
roll out these initiatives to other areas.
The Skin Care Bundle
This has been incorporated into the Pressure Ulcer Prevention documentation which supports putting all
information regarding a patient’s skin in one place to enable staff to carry out their assessments and care
planning. The Trust will use this in conjunction with “Intentional Rounding” as a regular focus on moving
patients in a way that should deliver sustainable pressure relief or redistribution.
NUTRITION AND HYDRATION
With more than 3 million people in the United Kingdom (UK) being at risk of malnutrition, 96 % of whom
are living in the community, the emphasis is on risk assessing patients on admission to the Trust to
identify patients that may be at risk of malnutrition and require close monitoring. The Ward Assurance
tool undertaken throughout the Trust measures the percentage of patients who are screened on
admission. In addition to this the Chief Executive has pledged support to the ‘Mind the Hunger Gap
Campaign’. This campaign aims to highlight the levels of malnutrition in the UK today and calls for action
to support and tackle this.
The Trust has been very proactive over the last 12 months in supporting the development of many
nutrition and hydration initiatives:
• A Health Hub has opened at entrance 24 and the main entrance. This is an excellent resource for
staff and visitors to the Trust with information covering a variety of health promotion topics.
• The new seasonal Eat Well menu has been introduced.
• A selection of hot puddings available for patients.
• The addition of Category E menu choices to the modified diet menu which is available for
patients with swallowing difficulties.
• Implementation of National Patient Safety Agency (NPSA) guidance to facilitate the safe
management of Nasogastric Tubes within the Trust.
• Piloting of a new fluid balance/hydration chart.
• Representation at the Cluster wide Nutrition and Hydration Working party.
As well as the high national focus on nutrition and hydration the Trust has also ensured that this key area
of patient care has been subject to review, to ensure that it is consistently delivered to a high standard.
To facilitate this, a Strategy for Nutrition and Hydration has been developed.
13 | P a g e
A number of initiatives are included in the 2 year Nutrition Plan:
•
•
•
•
•
A task and finish Group will focus on developing ‘Nil by Mouth’ guidance.
Development of a Trust Dysphagia policy.
Improvement in the pathways for accessing snacks and special diets.
Delivery of the National descriptors training to clinical staff within the Trust.
Development of E-learning Nutrition packages to support the current training programme of ‘Enabling
Patients to Eat and Drink Safely.’
• Development of e-referrals for Dietetics and the Nutrition Team.
• Working group to review the use of nutritional supplements.
• Development of a new halal range of food choices.
PATIENT FALLS
Inpatient falls are the highest patient reported safety incident at the Trust, which is similar to the national
picture, accounting for approximately 35% of all adult safety incidents in NHS hospitals. The Trust has
introduced a number of initiatives in an effort to improve patient safety around falls management and
reduce avoidable harm to patients. This includes the introduction of robust assurance and monitoring
systems including Datix (incident reporting), Ward Assurance Tools, the Patient Safety Thermometer
and unannounced spot audits. These facilitate the measurement of falls incidence including low and
moderate harm as well as the mapping of compliance to key quality standards.
The Patient Safety Thermometer is a monthly prevalence audit undertaken across all hospitals on a set
day. One element of the audit involves determining the number of patients in the hospital setting who
have experienced a fall in the past 3 days. When compared with the Acute Hospital population across
the NHS, it can be seen that the Trust is consistently below the average and is following the national
trend of a decline in falls.
The ward areas report moderate harm following a fall to the Trust Incident Review Group, and an
investigation is carried out. Thematic reviews are undertaken throughout the year of falls reports that
result in patient harm; this facilitates the identification of areas where improvements can be made.
•
Monthly feedback by each Divisional representative at the Trust Falls Group on compliance on the
completion of a falls risk assessment, bed rail assessment and care planning.
•
A number of interventions around raising ALL staff awareness and training continue to be a focus
across the Trust.
•
The Falls Group is working closely with Loughborough University Department of Healthcare
Ergonomics & Patient Safety who are in the process of developing a full research programme. Their
proposal so far includes: demographic analysis, the use of split bed rails, patient lighting & signage.
In addition to this the University is supporting an audit of 50 patients which will lift elements from the
Falls Care Plan and audit our compliance against these.
•
Review of the Falls Interventional Care Plan highlighted that the nursing record where the plan is
currently held is not an ideal location and it will be moved to a more appropriate place.
•
Falls management has been added to the junior Doctors induction and is detailed in a prompt card,
and is also covered in the delirium teaching session.
•
A post falls assessment proforma has been developed and was initially piloted by the Hospital Out of
Hours Team and subsequent changes have been made. Currently it is being piloted by a small group
of trainee medical staff and following any further adjustment will be widely implemented across the
Trust.
14 | P a g e
LEADING IMPROVEMENTS IN PATIENT SAFETY (LIPS)
The Trust undertook the Leading Improvements in Patient Safety programme run by the NHS Institute of
Innovation at the end of 2010/11.
The Medical Director is the programme lead and has established a Patient Safety Team to embed the
programme in the Trust. The team comprises a Consultant Physician, Consultant Surgeon, Nurse
Consultant, Patient Safety Pharmacist, and the Head of Patient Safety.
As part of the programme the Trust set an inspirational aim to reduce harm by 50% by April 2012. This
target has been achieved and indeed surpassed with a reduction in harm now of 69%.
Harm is measured by the use of the trigger tool, a process that involves retrospective records review
looking for defined trigger events that are often associated with preventable harm (although for a
proportion of patients this harm is a recognised side effect of treatment). Using this methodology we
have demonstrated a reduction in harm from a baseline of 67 harm events per 1000 (67/1000) beds
days to a median of 30.6/1000 in 2011 and 21/1000 in 2012.
Our aim for 2012/13 was to sustain harm reduction and further reduce significant harm. Work streams
continue to take forward improvements in the areas of standardisation and zero tolerance to outliers. The
driver diagram below identifies these work streams.
Driver Diagram
CORE TEAM
TO REVIEW
TO 20 SETS
OF NOTES A
MONTH
JANUARY APRIL
PROTECTION FROM
STANDARDISE
PRACTICE
WHO THEATRE CHECKLIST
FALLS PREVENTION
PRESSURE ULCER
NUTRITION
VTE
RECOGNISING AND
RESPONDING TO THE
SUSTAIN HARM
REDUCTION AND
FURTHER REDUCE
SIGNIFICANT HARM
ADHERENCE TO MEDICINES
MANAGEMENT - OMISSION
ACTING ON RESULTS
CARE BUNDLES
HANDOVER
SAFETY CULTURE
ZERO
TOLERANCE
TO OUTLIERS
BED
CONFIGURATION /
MANAGEMENT
REDUCE
READMISSIONS
15 | P a g e
Progress to date
•
Reduction of harm identified from the Trigger Tool Audit – from a baseline of 67 harm events per
1000 (67/1000) beds days to a median of 30.6/1000 in 2011 and 21/1000 in 2012. This means that
3070 less patients will have been harmed.
•
Introduction of a Care Bundle for Community Acquired Pneumonia. An improvement in the
timeliness of diagnosis and first antibiotic administration for patients with Community Acquired
Pneumonia following the introduction of Care Bundles (Care Bundles are tools used to prompt staff
to complete key actions for patients with defined conditions).
•
Implementation of a further six care bundles. These are Chronic Obstructive Airways Disease, Acute
Kidney Injury, Pyelonephritis, Hyperkalaemia, Neutropaenic Sepsis and Severe Sepsis. These are
already demonstrating improvements. A further 2 are in development for Diabetic Foot Care and
Diabetic Ketoacidosis.
•
Revision of the Trust Early Warning Score (EWS) chart. An improved Early Warning System (EWS)
chart is now being used as the standard basic observation chart throughout all adult ward areas with
the exception of Obstetrics. The EWS is a tool used to help health care professionals recognise early
when a patient is deteriorating and ensure through its directed escalation response that they are
reviewed and treated in a timely and appropriate way.
Within this Trust any patient that breaches the ‘trigger threshold’ score of 4 will receive a review by
appropriate clinical staff. Early identification of and response to the deterioration of patients is
essential to ensure that wherever possible further deterioration and cardiac arrest is prevented.
•
Revision of the Trust SBAR (Situation, Background, Assessment, Recommendations) form. SBAR is
a communication tool which prompts staff to have all the correct information to hand when contacting
medical teams regarding a deteriorating patient. Issues were identified by the LIPS team and
changes made. The changes made make the form more easily available as it is now produced as an
A4 telephone pad and provides a documented record of the communication that remains in the
patients’ records.
•
Adoption of SBAR methodology when transferring patients within the hospital to a new ward. SBAR
methodology is currently being built into processes for handovers on wards and to the Hospital Out
of Hours Team.
•
A reduction in hospital cardiac arrests from a median of 0.68 /1000 bed days in 2011 to 0.53/1000
bed days in 2012. That represents 48 less patients suffering a cardiac arrest.
•
Standardised Falls Risk Assessment supported by focussed education, environment audit and
tailored equipment usage has led to a decrease in falls resulting in harm from a median of 2/1000
beds days in 2011 to 1.75/1000 beds days in 2012. This means that 80 less patients suffering harm
from a fall.
•
Standardisation of assessment and preventative care documentation for patients at risk of
developing pressure ulcers, supported with education and sustained by monthly local audit of
compliance has led to a decrease in hospital acquired pressure ulcers. The monthly patient safety
thermometer prevalence audit has shown a reduction from a median of 1.9% of patients
experiencing a hospital acquired pressure ulcer (March- August 2012) to a median of 1.3%
(September 2012 – February 2013). This means that 9 less patients have experienced a hospital
acquired pressure ulcer under our care within the hospital on a said day.
16 | P a g e
•
Introduction of Electronic Prescribing and Medicine Administration(ePMA) which enables nursing
staff to easily check following drug rounds that all medication has been given thus decreasing drug
omissions.
•
Implementing an enhanced discharge programme for patients identified at risk of re-admission which
includes a three day education programme, handover to community support and post discharge
follow up.
•
National Safety Weeks. Use of National Safety Weeks with activities to promote key drivers e.g.
theatre safety, pressure ulcer prevention.
•
Junior Doctor involvement in patient safety. Engagement with each new cohort of trainee medical
staff (Junior Doctor Safety Group). This group developed a set of prompt cards for new trainee
doctors covering key Trust guidelines and advise. They have been accepted to present this initiative
at the International Forum on Quality and Safety in Health Care in April 2013.
•
Patient Safety Thermometer Audit. Each month the Patient Safety Thermometer audit is undertaken
which is a prevalence audit measuring harm from falls, pressure ulcers, catheter associated urinary
tract infections and venous thrombo emboli. This indicates more than 97% of patients do not
experience these harms whilst in Trust care and is an improvement of more than 2% since auditing
began in March 2012. This represents 30 less patients who have experienced harm under our care
within the hospital on a said day.
THE CRITICAL CARE OUTREACH SERVICE
The Critical Care Outreach Team (CCOT) is an accessible critical care resource that provides a ‘routine’
and ‘emergency’ response to all acutely ill / deteriorating patients throughout the organisation. In addition
to the parent medical team, CCOT are integral to EWS escalation response for the deteriorating patient
and frequently support proactive management plans that may enhance patient safety, reduce avoidable
harm and improve patient outcome.
VENOUS THROMBOEMBOLISM (VTE) RISK ASSESSMENT
A national target of 90% of patients being assessed for their risk of developing a blood clot (VTE) has
been in place for the last three years. The graph below shows achievement of the target month by
month. An electronic tool has been developed to assist staff in data entry and to ensure that relevant
information can be collated automatically. The Trust continues to show that over 90% of patients each
month are risk assessed.
VTE Risk Assessment Trust Performance – Local Data
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The challenge for the coming year is to increase and sustain the percentage of recorded risk
assessments to 95% and to carry out an increasing number of root cause analyses on hospital acquired
thromboses.
2.1.2 CLINICAL EFFECTIVENESS
CONTINUE TO DRIVE DOWN TRUST MORTALITY
Mortality rates are a key measure of the clinical outcomes of a Trust. The established measurement
across the country and published in the Dr Foster Good Hospital Guide is the Hospital Standardised
Mortality Rate (HSMR). HSMR compares the expected rate of death with the actual rate of death, taking
into consideration the age of the patient and any other medical conditions that they had. The Department
of Health has also developed a national Summary Hospital-Level Mortality Index and national index
(SHMI) looking at all deaths in hospital and up to 30 days post discharge.
The HSMR reported in the Dr Foster Hospital Guide for 2011/12 was 102.8, “within the expected range”.
In addition to the high level HSMR, Dr Foster reviewed death rates on weekdays, at weekends, deaths
after surgery, deaths in low diagnosis groups and a number of diagnosis groups with higher or lower
than expected SMR. The Trust was “within the expected range” for all these. As regards the SHMI,
Derby’s rate was 109.1, “within the expected range”. Throughout the year the Trust has queried
numbers of deaths attributed to it as there have been discrepancies in the data, with a significant number
of additional deaths, as compared to Trust data. 30.45% of deceased patients within the time period
were coded with palliative care. Palliative care data from 2012/13 has not been published as yet.
The Trust scrutinises all issues relating to mortality with great care. The Mortality Review Group
receives data on all hospital deaths and chooses certain cases to review often with valuable clinical
lessons which have led to genuine changes in care. Dr Foster analysis of Trust data is examined
monthly and appropriate audits undertaken to examine any areas of concern. The Medical Director
leads this work which is reported monthly to Board.
It should be noted that many factors affect mortality. Demographic factors are important, in that Derby
as a city has some of the highest rates in the country for smoking and obesity. In addition, there is a
greater percentage of elderly people in Derby, compared to other large East Midlands centres,
Nottingham and Leicester. The acuity of the illness and the co-morbidities (other medical conditions)
that a patient has are important factors, as is the quality and timeliness of care, both in the community
before the patient is admitted to the Trust as well as in the Trust itself. The examinations and audits
carried out in the Trust look in particular for issues with care within the Trust.
REDUCING MEDICATION ERRORS
The Trust promotes a positive safety culture and encourages incident reporting, placing the Trust in the
top quartile of acute hospitals reporting to the National Reporting and Learning System (NRLS). There is
widely published evidence of reduced harm in industries and organisations which have a positive
reporting and learning culture. The latest data (Mar-Sep 2012) from the National Reporting and Learning
(NRLS) system shows upper quartile reporting in comparison with other large acute Hospital Trusts.
Harm remains well below the national average with 98.3% of all incidents leading to no or low harm
(93.9% average), 1.6% moderate harm (average 5.3%) and zero incidents resulting in severe harm or
death (average 0.7%). Medication errors make up 11.9% of all incident reports (12.1% Oct 2011- Mar
2012), against an EM average of 11.3%.
After slips, trips and falls, medication errors are the most common category reported but as detailed
above, the vast majority lead to no or low harm.
The Trust is pleased to note the downward trend in medication errors as evidenced as the proportion of
all incidents reported, which remains fairly constant at 5.8 incidents per 100 admissions.
18 | P a g e
NRLS data from October 2010-March 2011 indicated 16.4% of all incidents reported were medication
errors. Data from October 2011- March 2012 show a reduction to 12.1%, against a national average of
9.9% for large acute Trusts and 11.3% in the East Midlands.
This reduction is in part due to the successful implementation of the Electronic Prescribing and
Medicines Administration (EPMA)in medical inpatient and all adult out-patient areas. Approximately 1200
medicines are prescribed and 6000 doses administered electronically each day in the Trust.
Since roll-out, some errors have been identified as being associated with EPMA, none of these have led
to harm and the implementation team have responded to these issues as they come to light.
EPMA provides greater transparency and more accurate recording of medication use, and this in part
has led to an increased awareness of some errors, and issues in existing processes. Real-time data
capture provides detailed information and clinical reasons for decision-making such as omission of
medicines and possible remedial action if appropriate. The team are working proactively with clinicians
to ensure the system improves quality and efficiency. Further work is required to develop reporting to
support safe medicines practice and reduce prescribing variation.
EPMA in the iSOFT Clinical Management system (iCM) has been recently shortlisted in the National
Patient Safety Awards (Health Service Journal).
IMPROVEMENTS IN TIMELY DISCHARGE AND COMMUNICATION TO OPTIMISE A PATIENT’S
LENGTH OF STAY
Transformational change is required to meet current demands on our health services and staff must be
proactive at the earliest opportunity within an admission to ensure patients are discharged within their
expected date of discharge, and any post-discharge needs are pre-empted and organised causing no
delays. Since December 2012 the health & social care community has been brought together to
establish what needs to be done in order to proactively manage patient pathways and in particular when
patients are ready to be discharged from hospital care or transferred to another care provider.
A Discharge Hub is being developed within the Trust and the proposed model for 2013-14 demonstrates
a ‘shift’ away from service related management by bringing the inter-dependent health & social care
organisations and services together in one team known as the ‘Discharge Hub’.
The proposed model is expected to provide a number of desired outcomes & success measures; these
are as follows and will:
•
•
•
•
•
•
•
minimise avoidable admission to hospital
promote Right Care, Right Place, Right Time – access to timely assessment
facilitate discharging and transfer of patients to the right place
reduce re-admissions
reduce length of stay
improve the patient experience
support the older patient post discharge from hospital
The Trust is also considering electronic systems to support the discharge process.
In principle, patients will experience timely treatment, care and safe discharge, tailored to their individual
needs, in an appropriate setting.
UNICEF UK BABY FRIENDLY INITIATIVE
The Baby Friendly Initiative is a worldwide programme of the World Health Organization and UNICEF. It
was established in 1992 to promote and support breastfeeding, to encourage maternity hospitals to
19 | P a g e
implement the Ten Steps to Successful Breastfeeding and to practice in accordance with the
International Code of Marketing of Breast Milk Substitutes.
In addition, it strengthens mother-baby and family relationships. Support for these relationships is
important for all babies, not only those who are breastfed. The health and well-being of all babies is at
the heart of the UNICEF UK Baby Friendly Initiative and our work within the Trust. Supporting women to
breastfeed not only improves the quality of life for women through the reduction in incidence of breast
cancer, but for children through reducing acute and chronic diseases.
The Maternity Service and Neonatal Intensive Care Unit at the Royal Derby Hospital, have been
assessed against this quality, evidenced based criteria, and have been accredited with the UNICEF UK,
Baby Friendly Initiative Standard award following yearly assessment continuously since 1998.
2.1.3 PATIENT SAFETY INCIDENTS 1ST APRIL 2012 – 31st MARCH 2013
The NHS Commissioning Board publishes a six monthly retrospective Organisational Patient Safety
Incident Report from data uploaded by the Derby Hospitals NHS Foundation Trust to the National
Reporting and Learning System (NRLS). The latest available report was published in March 2013 and
covers the period 1st April 12 – 30th September 12 Fig. 1). This shows the Trust as the 6th highest
reporter out of the 39 large acute organisations listed by the NHS Commissioning Board, indicating that
the organisation supports an effective patient safety culture as organisations that report more incidents
usually have a better and more effective safety culture, as they are more likely to understand and
address problems identified through incidents.
The second 6 monthly report for this reporting period will be published by the NHS Commissioning Board
later on this year.
NRLS Organisation Patient Safety Incident Chart 1 April 2012 – 30 Sept 2012
(Found at http://www.nrls.npsa.nhs.uk/patient-safety-data/organisation-patient-safety-incidentreports/directory/?entryid33=25682&char=D)
20 | P a g e
The guidance issued by Monitor requires the number of patient safety incidents reported to the NRLS
causing severe harm or death to be expressed as a percentage of all patient safety incidents reported to
the NRLS in reporting period.
The degree of harm for patient safety incidents is defined as follows:
‘severe’ – the patient has been permanently harmed as a result of the patient safety incident; and
‘death’ – the patient safety incident has resulted in the death of the patient.
The total number of patient safety incidents reported to the NRLS 2011/12 was 12,694, incidents of
which 0.14% resulted in “severe harm or death”.
The total number of patient safety incidents reported to the NRLS 2012/13 was 12,112, incidents of
which 0.07% resulted in “severe harm or death”. The definition of harm can be found at
http://www.npsa.nhs.uk/corporate/news/npsa-releases-organisation-patient-safety-incident-reportingdata-england/.
There were also three reported Never Events; the definition of Never Events can be found at
https://www.gov.uk/government/news/never-events-list-update-for-2012-13.
2.1.4 PATIENT EXPERIENCE
DEVELOPMENT OF THE PATIENT EXPERIENCE FRAMEWORK
As part of the overall approach to improving the experience of patients the Trust has developed a Patient
Experience Framework. The Framework has been developed to help shape and guide the Trust on the
key elements of Patient Experience and what this would mean for us and for our patients.
There are 10 parts to the framework which link to 10 ‘Always’ Events.
It is important that we link the framework into things which are meaningful to patients and other people
who use our services, therefore we have come up with the idea of ‘Always Events’. These are things
which we as a Trust would try our very best to always do. We have drafted a set of Always Events,
however we want to engage with a range of people, including patients, public, and staff to ensure that we
have got these right. Below is a diagram which shows how our Framework links to our Always Events.
21 | P a g e
PATIENT EXPERIENCE FRAMEWORK AND ALWAYS EVENTS
EMPOWERING FRONT LINE STAFF TO RESPOND POSITIVELY TO EVERY PATIENT CONCERN
EVERY TIME
Ensuring that our staff has the skills and confidence to respond positively to concerns is very important
to us. When people first start their jobs they must go through our induction process and supporting
patients to raise concerns is an integral part of that process. Alongside this the Trust has in place a
number of learning and development plans to further support staff in improving the patient experience. In
2012/13 over 1,000 staff had complaints and concerns awareness training.
As part of the Trust response to the key themes emerging from complaints and concerns, there is a
particular focus on communication and attitude of staff. The Trust is developing a programme of learning
related to the Fundamentals of Care. The Fundamentals of Care programme looks at some of the most
important skills that our staff need to deliver high quality care. Some elements of the programme are:
•
how to deliver personal care and what this means
22 | P a g e
•
•
•
•
effective communication skills
ensuring respect and compassion in care
good team working, and
record keeping
The Fundamentals of Care programme focuses on putting the patient at the centre of what we do, and
how we can make sure that care is personalised for that individual to meet their needs.
The Trust also has in place Recruitment for Attitude programme which looks at behaviours linked to the
Trust CARE (Care. Attitude. Respect. Equality) Values.
DIGNITY AND RESPECT
Providing our patients with dignity and respect is one of the most important things that we can do. In the
most recent National Inpatient Survey the Trust performed well against a number of the key questions
which related to privacy, dignity and respect. Below the chart shows the results the Trust has received
for the last 3 years, which show consistently good feedback from patients about respect and dignity.
2011
2012
Variation
2011-12
Enough privacy in the Emergency Department
96
94
94
=
Enough privacy when discussing condition
96
96
96
=
Treated with respect and dignity overall
98
98
98
=
Position
against
2011
Questions Relating to Privacy and Dignity
2010
Care Quality Commission Survey: Experiences of Inpatient Services in NHS Hospitals – Derby
Hospitals NHS Foundation Trust Performance Data
⇒
⇒
⇒
It is clear that this positively reflects the high standards of privacy and dignity that the Trust requires for
all its patients.
Care Quality Commission Survey: Experiences of Inpatient Services in NHS Hospitals
East Midlands Reporting Comparison 2012 - Questions Relating to Privacy and Dignity
Derby
Hospitals
Chesterfield
Royal
Hospital
Nottingham
University
Hospitals
University
Leicester
Hospitals
Sherwood
Forest
Hospitals
Enough
privacy in the
Emergency
Department
Enough
privacy when
discussing
condition
8.7/10
About the
same
8.7/10
About the
same
8.4/10
About the
same
8.5/10
About the
same
8.5/10
About the
same
8.8/10
Better
8.3/10
About the
same
8.3/10
About the
same
8.3/10
About the
same
8.6/10
About the
same
Treated with
dignity and
respect overall
8.9/10
About the
same
8.8/10
About the
same
8.7/10
About the
same
8.7/10
About the
same
8.9/10
About the
same
23 | P a g e
REAL TIME PATIENT EXPERIENCE FEEDBACK
During 2012-13 the Trust began to implement the ‘Family and Friends Test’. The test was designed to
help understand how likely patients would be to recommend the services they had received to a friend or
family member. The aim of the test is to help improve the quality of care and patient experience as well
as supporting wards and departments in highlighting potential areas for action or improvement. The
question is given to inpatients when they were being discharged from the hospital.
The Your Views Matter Campaign was put into place in December 2012 and was designed to support
and enhance the Family and Friends test. The campaign was set up to raise awareness of the different
ways in which people could tell us about their experiences. To support this a new ‘postcard’ style
feedback card was designed which incorporated the Family and Friends question, plus 4 further
questions which focused on safety, information and communication. There is also a section for people to
leave comments or suggestions on where we are doing well or where we could improve.
As part of the campaign posters highlighting who to speak to on the ward have been put up in ward
areas. Banners advertising the campaign have been placed across the Trust and information for staff
and patients has been put onto the Intranet and Internet.
The outcomes to date have been very positive with the majority of people responding to the additional
questions and identifying that they have had a positive experience, with particular focus on the positive
and caring attitude of staff.
IMPROVING THE PATIENT’S JOURNEY THROUGH THE TRUST AND INCREASING THE NUMBER
OF PATIENTS WHO WOULD BE HAPPY TO RECOMMEND THE TRUST
Over a period of 12 months (April 12-March13) the Trust has received over 11,000 responses to the
Family and Friends Test. The majority of people responded positively saying that they were either ‘highly
likely’ or ‘likely’ to recommend the Trust.
The Trust performance in this area has been consistent over the year, with a rise in the overall score
since the introduction of the Your Views Matter Campaign.
Net Promoter – Derby Hospitals NHS Foundation Trust Performance Data
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COMPLAINTS AND COMPLIMENTS
In 2012/13 the Trust focused on improving the overall approach to complaints to ensure we effectively
and efficiently answer any concerns and continually use this information to improve our services.
Overall complaint numbers have increased from 2011/12, the table below shows the number of
complaints each year since 2010. Concerns and Compliments have also risen year on year.
Number of Complaints
Number of Concerns
Number of Compliments
2010/11
517
440
206
2011/12
573
798
333
2012/13
602
808
420
The increase in Concerns, Compliments and Complaints is encouraging. Whilst we do not wish there to
be more complaints, the fact that informal concerns and compliments are also rising demonstrates that
more people are telling us about their experience, both positive and negative.
The Trust has also been focusing on ensuring that we improve our responsiveness to complaints. The
Trust has undertaken a review of the complaints and Patient Advice and Liaison Service (PALs):
•
•
•
reviewing the Policy and Procedures for Complaints
reviewing the data system for complaints
review of the PALs Team
To ensure that we share information and learning from complaints and concerns the overall numbers,
response times and themes of complaints are analysed by each of our Divisions and as an overall Trust.
This helps us to see any trends or patterns which may be emerging over time. To support the process of
sharing and learning the Trust has established the Complaints, Concerns and PALs Review Group. The
group includes both staff and Trust Governors. Complaints and PALs data is reviewed every month and
is an integral part of the Trust reporting mechanisms through to the Trust Board.
COMPLAINTS RECEIVED BY THE HEALTH SERVICE OMBUDSMAN
A person may refer a complaint to the Health Service Ombudsman (HSO) if they do not feel that the
Trust has responded to all of their concerns, or they are unhappy with the way in which we have dealt
with their complaint. The HSO gives the Trust the opportunity to ensure that all local resolution has taken
place to try and resolve any issues, if this is the case the Ombudsman will give an independent view on
the complaint.
In 2011/12 39 complaints were received by the HSO. 2 of these complaints were accepted for
investigation. Of these 1 complaint was reported and 1 complaint was reported and upheld.
Overall 18 complaints were referred to the Health Service Ombudsman during 2012-13, 10 have had no
further action taken and of the remaining 8 only 2 are being considered for further investigation.
CONSULTATION AND ENGAGEMENT WITH WIDER COMMUNITIES
As part of the overall Trust Strategy the Trust has been engaging with different community groups by
going out to various forums, meetings and events in order to build on relationships to share patient
experience. These groups include retired nurses, Local Neighbourhood Forums, Carers Association,
Derby City Council Diversity Forum & Voices in Action Leads, Southern Derbyshire Health and Social
Care Forum, Derby City Health and Well Being Forum. This is an on-going project which will expand
and develop as the Trust continues to build relationships within the community.
25 | P a g e
As part of the process the Trust has engaged with the following groups:
•
•
•
•
The Derby Over 50’s Forum
The Derby Deaf Society
Derby and Derbyshire Local Involvement Networks
Sight Support Derbyshire
Sight Support Derbyshire has been working closely with the Trust and in 2012 they carried out a joint
audit of the environment for people attending the Eye Clinic. This covered both the internal and external
environment of the King’s Treatment Centre. As a result of the audit improvements were made to the
facilities including lighting, sight lines, signage and patient information.
As part of the work to improve the care for the frail elderly population the Trust engaged with the Derby
over 50’s Forum to share the proposed new model of working. The Trust has made a commitment to the
Forum to return with further information on the changes to ensure that the Forum is able to remain
involved as these changes develop.
The Trust has developed a Patient Panel which consists of a range of people who have been service
users themselves or have had direct experience through a family member. The Panel identified a range
of areas for focus. These included:
•
•
•
•
Development of the Outpatients and Integrated Care Pathways
Pharmacy- With a particular focus on waiting for medicines when being discharged
Food and Environment including PLACE Audits
Patient Information
As an integral part of working with diverse communities the Trust has established a Disability Forum.
This Forum brings together a range of key groups including the local deaf community and Derby Sight
Support which works with the visually impaired community. The group supports the Trust in developing
areas of work to support improvements for the disabled community.
In relation to this, a number of changes have been made to support both the deaf community and visual
impaired community these changes include:
Video Entrance Systems
A special doorbell was installed at the entrance of the Labour Ward so that deaf and hearing impaired
visitors ring a dedicated call bell; a member of staff in the department is then alerted that they need to
come out of the department to speak to the person ringing the bell. The current system utilised an
intercom system which is difficult for deaf and hard of hearing people to communicate through.
The British Deaf Association has tested the system and there has been a positive response from visitors
and Labour ward staff. We believe this is the first installation of this type in the Country.
An additional 11 areas at the Trust will have the dedicated buzzers installed as they currently have
access control intercoms.
Car Park Access
A further issue was raised with regards communication at the car parking barriers, again the Trust uses a
verbal intercom system which is very difficult for deaf and hard of hearing people to use. A new system
was introduced in November 2012. If a deaf or hearing impaired patient and/or visitor experienced
problems with the entry barrier at any of the car parks, they will be able to text a dedicated phone
number which will inform them help is on the way. The dedicated number will be linked to a pager and
will be available 24 hours a day.
26 | P a g e
The Sight Line and Eye Clinic
Working with the visual impaired community the Trust has implemented a number of changes within the
outpatients Eye Clinic. A ‘sight line’ which helps to guide people to the clinic has been put into place. To
further support patients all signage has been updated in line with best practice guidelines and is
distinctive from all other signs in the outpatients’ area. As well environmental changes, all patient
information leaflets have been updated to reflect the feedback from patients, as have the badges which
the staff wear, so that they are also more accessible to people who have a visual impairment.
DEMENTIA CARE
The Trust has started the development of a framework to improve the experience of patients with
dementia as part of the overall approach to enhancing the quality of care for frail elderly people.
The Trust will set key actions and goals each year to help us to achieve improvements in care for
Dementia patients.
The Trust has a designated lead nurse, who supports the provision of care and support to carers and
staff of those patients with a diagnosis of dementia or acute confusion.
As part of the Commissioning for Quality and Innovation (CQUIN) programme of work there has been a
dedicated CQUIN focusing on early diagnosis, and referral for people over the age of 75.
The Trust has improved the recognition, assessment and referral for specialist care of patients with a
diagnosis of dementia.
The Trust has a range of training and development programmes to improve dementia awareness and
expertise in caring for this patient group delivered to front line staff and clinical leaders. During 2012-13
over 2000 staff have received Dementia Awareness training.
Senior members of nursing staff have also been trained in delivering ‘Best Practice in Dementia Care’
course. This training has enabled them to become qualified facilitators of the same training so that they
are now able to lead others within the Trust through the programme.
In wards that specifically have high numbers of elderly patients and those with a diagnosis of dementia a
number of initiatives have taken place, this has included the introduction of the ‘Memory Café’ and the
Rem-Pods which are designed as rooms which replicate certain eras and offer patients a place of
consistency and calm whilst in the hospital setting. The Trust has also participated in the ‘Enhancing the
Healing Environment’ programme provided by the Kings Fund. This training now enables staff members
to undertake specialised environmental audits to enable the Trust to further improve the environment for
people with Dementia.
LEARNING DISABILITIES
The Trust has a Learning Disability Nurse specialist to support patients, carers and staff in improving the
experience of this patient group. Individualised Patient pathways have been developed for patients
undergoing surgical procedures taking account of the needs of the patient and family / carers. The Trust
has developed a system which allows us to identify people with a learning disability on our Admissions
system. This system supports staff in ensuring that they can then access specialised expertise from the
Learning Disability Nurse who can help support a holistic approach to that episode of care.
As well as the development of individualised care specific information and communication cards are
available for people with learning disabilities, this helps to support both staff and patients to ensure the
best possible experience for patients.
27 | P a g e
Pre-admission information has been developed to reduce the anxiety felt for patients with a planned
admission. A series of short films have been developed for the Trust’s Internet website to show what
may happen to a patient on admission. Photographic journeys have also been developed as another aid
for patients admitted to hospital.
DEVELOPMENT AND IMPLEMENTATION OF WARD ASSURANCE TOOL
Ensuring the quality of care we provide to all our patients is the core element in the provision of care in
the Trust. To enable us to understand and where necessary improve the quality of care on wards the
Trust developed a Ward Assurance Tool. The tool was designed to help staff bring a range of
information together to ensure that wards had easy and quick access to data which would help them to
assess the performance of their wards against key indicators of quality. The indicators include areas that
are extremely important to patient experience and safety, such as privacy and dignity, nutrition, pain
management and discharge planning.
The results of the Ward Assurance are reported to the Trust Board to help give the Board assurances
about the overall quality of care that is being provided.
ENSURING THAT PATIENTS WHO ARE AT THE END OF LIFE RECEIVE THE MOST
APPROPRIATE CARE
The Trust is extremely committed to ensuring the quality of care provided to patients (their families/ close
friends and carer’s) in the last months of life. As part of the work within the Trust to improve End of Life
Care the Trust was successful in its application to be part of the second phase of the National End of Life
Care Programme ‘Transforming End of Life Care’. The requirement is for Trusts to set key goals for
improvements based on work which is already underway. The Trust will be able to access national
support and to demonstrate the improvements at a national level.
Work continues with the implementation of the AMBER Care Bundle (ACB) which began in July 2012,
initially within the Medical Directorate. The ACB helps teams identify those patients approaching the end
of their lives that are unstable and have an uncertain recovery but are not imminently dying (ie patients
that should be on the Liverpool Care Pathway). By doing this there is a greater opportunity to involve
patients and their families in discussions about treatment and future care. This can lead to:
•
•
•
•
•
Greater satisfaction and quality in care.
Earlier discharge and transfer to preferred place of care/death reducing avoidable readmission.
Less invasive treatment and a reduction in unnecessary interventions.
Improved discussions about end of life care between patients, families and the healthcare team.
Better preparation for end of life and therefore improved recovery for the bereaved.
The ACB encourages the clinical team to discuss prognosis and uncertainty with patients, families and
carers as early as possible to help them make informed decisions about care and treatment.
In the most recent National Care of the Dying (Liverpool Care Pathway) audit the Trust achieved positive
results. In one element the Trust gained 100%, this element related to how well across the organisation
staff understood what the Liverpool Care pathway was and when to use it. These results demonstrate
the commitment from staff and overall achievements in supporting patients at the end of their life.
A project began in January 2013 as a 3 month pilot with a questionnaire being given to relatives/carers
whose loved one had been cared for whilst on the Liverpool Care Pathway (LCP). The questionnaire
was to help us understand any concerns or issues that a person may have so that we could support or
address them. The project will be extended into 2013/14.
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The Trust also introduced carer’s diaries for patients near the end of life. The aim of the diary is help
support the sharing of information between the patient, family and staff particularly in relation to
decisions of care at the end of life; this also allows families/carers to voice any concerns they may have
around the care of their loved ones. This information is then read by staff and acted upon as necessary.
The diaries have initially been used on 4 pilot wards within the Trust. They will be made available to the
family/carers of patients who are being cared for on the Liverpool Care Pathway.
2.2 PRIORITIES FOR IMPROVEMENT DURING 2013/14
The Trust continues to ensure that the Quality Strategy is embedded throughout the organisation and
that the specified objectives are achieved. The objectives were developed from both organisational
learning and from patient feedback and surveys and no further consultation was undertaken.
Staff views were taken into account following work developed as part of the Quality in Action event which
all Trust staff from the Trust Business Units and Corporate Team attended.
All objectives and targets will form part of the performance management arrangements for each Division
within the Trust and subject to regular review and scrutiny by the Quality Committee and Trust Board.
Monitoring and measurement of progress will be undertaken with the appropriate Trust committees and
groups. These will report into the Quality Review Committee, Quality Committee and the Trust Board.
The following objectives will be included:
Patient Safety:
Implementation of the post infection Review Toolkit for the investigation of
all MRSA bacteraemias
Continue zero tolerance to pressure ulcers
Roll out of Medical project initiatives.
Update the Education Strategy regarding pressure ulcer prevention
Clinical Effectiveness:
To further develop integrated care and new pathways, in particular for the
frail elderly.
Development of the Discharge Hub
Continue delivery of the 2 year Nutrition Plan
To ensure that all clinical staff have a personal development plan and
undergo appropriate continuous professional development.
Patient Experience:
Implement Experience Based Design of Patient Pathways through
Transformation Programmes
Redesign the elective pathway to improve the experience of our patients
Implement a Dementia Framework to improve the quality and experience
of people with Dementia using our services and their carers
Review our maternity services model to improve patient experience and
safety promoting midwifery led care.
Work in Partnership with health and social care partners to transform our
approach to discharge ensuring it is timely and safe for patients with
complex needs
Development and Implementation of “Getting Healthy, Staying Healthy”
strategy
Continue to develop and monitor complaints management processes.
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2.3 REVIEW OF SERVICES
The Trust provides a wide range of secondary care NHS services and since April 2011 has continued to
provide the adult Community services across the City Centre.
During 2012/13 Derby Hospitals NHS Foundation Trust provided and/or sub-contracted 96 relevant
health services. The Derby Hospitals NHS Foundation Trust has reviewed all the data available to them
on the quality of care in 96 of these relevant health services.
The income generated by the relevant health services reviewed in 2012/13 represents 100% per cent of
the total income generated from the provision of relevant health services by the Derby Hospitals NHS
Foundation Trust for 2012/13.
2.4 PARTICIPATION IN NATIONAL CLINICAL AUDITS AND NATIONAL CONFIDENTIAL
ENQUIRIES
Audit is integral to providing evidence that the Trust is meeting national targets and demonstrating
compliance with the recommendations and guidance from the National Confidential Enquiries of Patient
Outcome and Death (NCEPOD), the National Institute for Health and Clinical Excellence (NICE) and the
Department of Health.
The Trust Audit Group has an important role in assisting Divisions in the prioritisation of audits and
monitoring progress against the Divisional Annual Audit Programmes and Action Plans when
improvements are indicated and checking that re-audits are carried out. The Trust Audit Strategy and
Audit Policy are available for staff on the Trust Intranet.
During 2012/13 24 national clinical audits and 4 national confidential enquiries covered relevant health
services that Derby Hospitals NHS Foundation Trust provides. The Audits and Enquiries for which data
collection was completed during 2012/13 are shown in the tables below. This data includes the number
of cases submitted to each audit or enquiry as a percentage of the number of cases required by the
terms of that Audit or Enquiry.
During 2012/13 Derby Hospitals NHS Foundation Trust participated in 76% of national clinical audits and
75% of national confidential enquiries of the national clinical audits and national confidential enquiries
which it was eligible to participate in.
NATIONAL CONFIDENTIAL ENQUIRIES INTO PATIENT OUTCOME AND DEATH (NCEPOD)
REPORTS
The aim of NCEPOD audits is to maintain and improve standards of patient care in all specialties by
reviewing the care of patients in confidential surveys and making the results and recommendations
available to the Trust and relevant Clinicians and Departments. The Trust has an NCEPOD
Ambassador who is responsible for the formalised process of review and management of National
Confidential Enquiry reports and recommendations. The process includes identification of a designated
Clinical Lead and a robust reporting structure via reports to the Mortality Review Group, Clinical Audit
Group and Clinical Effectiveness Committee.
The national clinical audits and national confidential enquiries that the Derby Hospitals NHS Foundation
Trust was eligible to participate in during 2012/2013 are as follows:
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National Confidential Enquiries
Participated
During
2012/13
Cases
Submitted
% of
Required/Eligible
Cases
NCEPOD
9
100%
NCEPOD
6
100%
1
100%
3
100%
Title
Cardiac Arrest Procedures
NCEPOD
Bariatric Surgery
NCEPOD
Subarachnoid Haemorrhage
NCEPOD
Alcohol Related Liver Disease
NCEPOD
NCEPOD
NCEPOD
Completed
Report
awaited
Report
awaited
The following NCEPOD Reports were received in 2012/13 and reviewed by the appropriate subcommittee of the Board.
Bariatric Surgery: Too Lean a Service?
The aim of this study was to identify variability and remedial factors in the process of care for patients
undergoing Bariatric Surgery for weight loss. The study included assessment of the whole patient
journey from referral to six month follow up.
National Recommendations
• Bariatric surgery is not for the occasional operator. The Specialist associations involved should
provide guidance on the number of procedures that should be achieved to optimise outcomes.
• All patients must have access to a full range of specialist professionals appropriate to their needs.
• There should be greater emphasis on psychological assessment and support and at an earlier stage
in the care pathway. Screening tools may be valuable in identifying patients who need psychological
intervention.
• A two stage consent process should be used with sufficient time lapse and benefits and risks should
be clearly described and supported with written information. Consent should not be taken on the day
of surgery.
• Patients should have clear post-operative dietary advice and a complete discharge summary with
full clinical details and a post discharge plan to ensure safe and seamless care. This must be
provided to the GP as soon as possible preferably within 24 hours.
• A clear continuous long term plan must be made for every patient. This must include surgical,
dietician, GP and nursing input. If necessary an assessment for physician and
psychology/psychiatric input must be carried out and provided.
Trust Self Assessment
The Trust was compliant in 13 of the 16 recommendations and partially compliant in 3.
The partial compliance is outlined below:
•
•
•
Follow-up of patients should commence within 7 days of surgery and frequently afterwards to
complement outpatient follow up. The Bariatric Specialist Nurse telephones patients within the first
week of gastric band surgery. They are seen in clinic within 6-8 weeks and then monthly.
A two stage consent process with sufficient time lapse should be used, risks and benefits should be
clearly described and supported with written information.
All information is given verbally and in writing at the first consultation. A letter is sent to the GP
giving specific information re the proposed treatment plans. An information booklet is given and the
patient can watch a video about the procedures. At this time the actual procedure may not be
agreed and there is up to 18 months between the consultation and the actual operation.
Surgery and follow up data on all patients undergoing bariatric surgery in the NHS and independent
sector should be entered into the National Bariatric Surgery Register (NBSR).
The Trust does not enter data onto the NBSR, although each clinician does keep their own data.
31 | P a g e
Time to Intervene? - A Review of Patients who Underwent Cardio –
Pulmonary Resuscitation (CPR) as a Result of an In-Hospital Cardio-Respiratory Arrest
The aim of this study was to describe and identify remedial factors in the process of care of adult
patients who receive cardio-pulmonary resuscitation as a result of an in-hospital cardio-respiratory
arrest. Data in the report was taken over a two week period and 11/12 events were submitted. This
included factors affecting the decision to initiate resuscitation and the outcome.
National Recommendations
• Clerking, examination and recording standards should be improved and communicated to doctors
and audited six monthly via the clinical governance structure.
• Hospitals must ensure appropriate supervision for junior doctors. Delays in escalation due to lack of
recognition of severity of illness are unacceptable and place patients at risk.
• All acute admissions must have Consultant review within 12 hours, or earlier if required and this
must be audited.
• NICE Clinical Guideline Number 50, Acutely Ill Patients In Hospital, is not applied universally. All
hospitals must comply with this guidance.
• There must be clear instructions re observations required. Where track and trigger systems are used
this must be stated clearly by the admitting doctor.
• CPR status must be clearly documented for all acute admissions and there must be an effective
system for recording all decisions.
•
Where patients continue to deteriorate there should be escalation to a senior doctor. Any reasons
for non-escalation must be clearly documented.
•
Defibrillation for shockable rhythms must be delivered within 3 minutes.
•
Each Trust should set a goal for reduction in cardiac arrests leading to CPR and report regularly to
the Trust Board.
•
All CPR attempts and the proportion of patients who have had a Do Not Attempt Cardio Pulmonary
Resuscitation (DNACPR) decision in place prior to the arrest and should not have had CPR should
be audited. This should include the period prior to cardiac arrest to consider warnings of potential
cardiac arrest and what the clinical response was. A national audit tool should be developed.
Trust Self Assessment.
The Trust was compliant in 9 of the 21 recommendations and partially compliant with 12.
Care was found to be less than good in 7 out of the 10 cases submitted.
• Deficiencies in the period prior to the arrest were noted as being part of the admission process,
consultant involvement, recognition of illness and appreciation of the severity of the illness and
escalation to medical staff.
• Ceilings of treatment were noted in Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR)
decision making.
Actions
Review of admissions documentation re:
• New Medical Admissions Unit (MAU) clerking booklet developed and in the approval process.
• Development of a Surgical Admissions Unit (SAU) clerking booklet similar to MAU.
• Addition of the question-"Have you considered a discussion re DNACPR?” will be added to the MAU
clerking booklet and a resuscitation status question included in the “stop moment” proforma which
should be completed prior to a patient transfer from MAU.
• Addition of physiological monitoring plan. If the Early Warning Score (EWS) triggers then patient
observations must be increased to at least hourly. A re-audit is currently being considered.
• Current escalation response on EWS directs review by more senior doctor if patient's condition does
not improve, The EWS chart is being updated to incorporate the National Early Warning Score
(NEWS)
• Development of a medical clerking booklet for direct admissions, e.g. stroke patients.
32 | P a g e
•
•
•
•
•
Annual re audit to examine factors that warn of potential cardiac arrest and the clinical response.
To continue to raise the profile of issues surrounding DNACPR and the “Time to Intervene “Report.
Further sections added to the Trust Internet DNACPR site include: Training information, DNACPR
forms and NCEPOD publications.
The DNACPR policy and proforma have been reviewed including how decisions will be made
following changes in care following discharge.
A review following all post arrest call events examines the appropriateness of the escalation. An IR1
is generated for each inappropriate call and reported to the Chair of the Critically Ill Patient Group
(CIPG).
A monthly report on potentially avoidable cardiac arrests will be presented at the Resuscitation
Group. This will include issues relating to DNACPR.
NATIONAL AUDITS
Participation in National Audits 2012-13
The national clinical audits and national confidential enquiries that Derby Hospitals NHS Foundation
Trust participated in, and for which data collection was completed during 2012/13, 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. Chart also identifies audits for which data
collection is continuous.
Title
Acronym
Trust Wide
National Audit of Dementia
NAD
Children
Childhood Epilepsy
RCPH National Childhood
Epilepsy Audit
Diabetes
RCPH National Paediatric
Diabetes Audit
Acute Care
Emergency Use of Oxygen
British Thoracic Society
Adult Community Acquired
Pneumonia
British Thoracic Society
PNDA
Cardiac Arrest
National Cardiac Arrest Audit
NCAA
Adult Critical Care
ICNARC CMPD
Completed
NAD
ICNARC
Potential Donor Audit
NHS Blood & Transplant
Audit
Long-term Conditions
Diabetes
National Diabetes Audit
Participated
in
2012/13
ANDA
Cases
Submitted
% of required/
eligible
cases submitted
40
100%
35
100%
642
100%
100
100%
90
100%
1097
100%
137
100%
2979
100%
Data
collection
on-going
Data
collection
on-going
Data
collection
on-going
Data
collection
on-going
Data
collection
on-going
Data
collection
on-going
Parkinson's Disease
National Parkinson's Audit
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Title
Acronym
Adult Asthma
British Thoracic Society
Elective Procedures
Hip, Knee & Ankle
Replacements
National Joint Registry
National PROMs
Programme
Heavy Menstrual Bleeding
National PROMs Programme
Cases
Submitted
Data
collection
on-going
1
RCOG
PROMs
NHSBT
Peripheral Vascular Surgery
National Vascular Database
VSGBI
Heart Failure
Heart Failure Audit
Completed
NJR
Liver Transplantation
NHSBT UK Transplant
Registry
Cardiovascular Disease
Acute Myocardial Infarction &
Other ACS
MINAP
Participated
in
2012/13
MINAP
HF
Data
collection
on-going
Data
collection
on-going
Data
collection
on-going
Data
collection
on-going
Data
collection
on-going
% of required/
eligible
cases submitted
100%
1907
96%
156
100%
741
67.3%
100%
175
100%
284
100%
20 per
month
100%
Renal Disease
Data
collection
on-going
Data
collection
on-going
Data
collection
on-going
Renal Replacement Therapy
Renal Registry
Renal Transplantation
NHSBT UK Transplant
Registry
Renal Colic
College of Emergency
Medicine
Cancer
Lung Cancer
National Lung Cancer Audit
Bowel Cancer
National Bowel Cancer Audit
Programme
Head & Neck Cancer
DAHNO
Oesopho-gastric Cancer
National OG Cancer Audit
Trauma
Hip Fracture
National Hip Fracture
Database
Severe Trauma
Trauma Audit & Research
Network
100%
100%
100%
NLCA
304
100%
NBOCAP
110
100%
DHANO
168
100%
NAOGC
330
100%
44
50%
NHFD
TARN
Data
collection
on-going
Data
collection
on-going
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Title
Fractured Neck of Femur
College of Emergency
Medicine
Blood Sampling & Labelling
NCA of Blood Transfusion
End of Life
Care of the Dying
NCDAH
Acronym
Participated
in
2012/13
Completed
Cases
Submitted
Data
collection
on-going
Data
collection
on-going
% of required/
eligible
cases submitted
100%
114
100%
30
100%
National Audit Reports 2012-13
The reports of 8 national clinical audits were reviewed by the Derby Hospitals NHS Foundation Trust in
2012/2013 and the Derby Hospitals NHS Foundation Trust intends to take the following actions to
improve the quality of healthcare provided.
National Care of the Dying Audit (NCDAH)
The Liverpool Care Pathway (LCP) is recommended for use as a best practice tool in the last days of life
in the national End of Life Care Strategy. The National Care of the Dying Audit in Hospitals (NCDAH) is
based on the standards of care within the LCP and included patients who died on a variety of wards
within the Trust. A significant number of patients died on the Specialist Palliative Care Unit. The
Palliative Medicine Research Team carries out a biannual audit on this Unit of all deaths on the LCP
during a calendar month. The results of this audit are routinely fed back to the staff thus increasing
compliance.
National Findings
• Compliance with the documentation of care is relatively well adhered to within the LCP.
• The results from the Organisational audit show that the Trust is in line with the national average.
• Although slightly above the national average for anticipatory, when required, prescribing, the results
for the on-going assessment of pain, agitation and respiratory secretions were slightly below the
national average.
• Communication systems with the Primary Health Care Team/GP and appropriate services are not yet
in place across the Trust.
• The Trust needs to consider key performance indicators that reflect compliance to the LCP.
Trust Actions
•
•
•
•
•
The current implementation programme for the updated Liverpool Care Pathway (LCP Version 12) is
continuing.
The End of Life Education Programmes will aim to focus on the assessment and management of
patient symptoms.
The formation of the Trust End of Life/ LCP Champions network group aims to promote best practice
in End of Life Care within the clinical areas.
Timely referral to the Hospital Palliative Care Team for advice and support in controlling difficult
symptoms will also be promoted.
There is now a process for informing a GP that a patient has commenced the LCP and is now in
place in the Specialist Palliative Care Unit and will be implemented throughout the Trust.
National Cardiac Arrest Audit
The National Cardiac Arrest Audit (NCAA) is the National Clinical Audit for in-hospital cardiac arrest. The
purpose of NCAA is to promote local performance management through the provision of timely, validated
comparative data to participating hospitals. NCAA is a joint initiative between the Resuscitation Council
(UK) and ICNARC (Intensive Care National Audit & Research Centre).
35 | P a g e
NCAA monitors and reports on the incidence of and outcome from, in-hospital cardiac arrests and aims
to identify and foster improvements, where necessary, in the prevention, care delivery and outcome from
cardiac arrest. This Trust collects and enters data according to the NCAA data collection scope and
comprehensive dataset specification. The NCAA dataset was developed to ensure that all hospitals
collect the same standardised data, so that accurate comparisons can be made.
The NCAA Report provides an overview of the completeness of the data that the Royal Derby Hospital
has reported. To include analysis of activity; stratified analysis of activity (drawing comparisons between
this Trust and national data); and basic, anonymised comparative analysis (non-risk adjusted).
Trust Interim Findings
The Trust entered into the NCAA and commenced submitting data from April 2012. The most recent
report which has been received is only for the period April - September 2012. It is predictable that a more
accurate reflective report will be evident with 12 months of data.
The following graph represents the reported number of cardiac arrests per 1,000 hospital admissions for
adult, acute hospitals in NCAA (for the period that this Report covers).
Comparison Reporting from NCAA Audit for In-hospital Cardiac Arrest
This section provides an initial comparative analysis on resuscitation outcomes for our hospital. These
are not risk adjusted. A multivariable risk model, required to make fair comparisons, is under
development.
This data is presented for all NCAA participating hospitals (our hospital in red) in a funnel plot with two
standard deviation (dotted) and three standard deviation (solid) lines relative to the percentage of overall
survival.
The 2 standard deviation and 3 standard deviation lines are wider at lower sample sizes given the
greater imprecision with small numbers.
Data points for higher sample sizes indicate a more accurate value and therefore the 2 standard
deviation and 3 standard deviation lines are narrower.
36 | P a g e
Comparison Reporting from NCAA Audit for In-hospital Cardiac Arrest
Trust Key Actions
• To continue with the quality of data collection and maintain the speed of data collection/entry.
• Compare outcomes with the other NCAA participating hospitals and examine what other factors (e.g.
age, etc.) might be causing only variations seen.
• Examine survival rates following cardiac arrests if they fall under the NCAA scope and review any
unexpected patterns in patient outcome?
• To continue to identify and review specific resuscitation team calls for unexpected patterns in patient
outcome, escalation or issues surrounding resuscitation status.
• To continue to circulate the NCAA reports to key individuals within the Trust, Medical Director,
groups and committees.
National Bowel Cancer Audit
The National Bowel Cancer Audit report was published at the end of 2012. It covers patients diagnosed
with bowel cancer between 1.8.2010 and 31.7.2011. This is a collaborative audit which includes rectal
and colon cancer. It aims to improve the quality of care and survival of patients with bowel cancer. The
report included 30,000 patients.
National Results
• 87% of the expected number of patients were submitted
• 75% of patients received surgical intervention with 60% having major resections
• One fifth of patients had emergency major resections which were associated with higher postoperative mortality than elective cases.
• Colon cancer patients tended to be diagnosed at a later stage and more frequently as emergency
patients and had poorer post-operative outcomes.
• 90 days post operative mortality has decreased for the last 4 years
• Laparoscopic resections have increased over the last 4 years to 37% in 2011
• 14% were readmitted within 90 days of discharge
• 8% were returned to theatre within 28days, 13% of these died within 90 days
• 57% of rectal cancer patients still had a stoma after 12 months
National Recommendations
• All units need to revisit the care of elderly, increased risk patients particularly if presenting acutely
• Care Pathways are likely to increase post-operative survival
37 | P a g e
•
•
•
•
The impact of the length of time patients may have a stoma should be made clear pre-surgery and
patients need support in the community
Laparoscopic surgery should be considered in all suitable cases
Histo-pathological staging data is vital to determining outcomes
Audits should be carried out on reasons for non-resection, post-operative deaths.
Results nationally showed that there has been a continuous improvement in post-operative mortality, a
significant number of patients were still not undergoing major resection, excellence in Imaging and the
successful introduction of new surgical techniques.
Trust Results
The national average and Royal Derby Hospital specific data are compared below and are comparable if
not better than average since then. Data for Trusts and laparoscopic rates are not given but the national
average has increased to 37%, at that period in time this Trust rates were around 20%. An additional
laparoscopic surgeon has been appointed. It is noted however that laparoscopic patients were of a lower
American Society of Anaesthesiologists (ASA) grade, had smaller cancers and almost exclusively were
elective operations.
Results show that Trust mortality remains better than average, radiotherapy rates are high but
permanent stoma, Abdominoperineal Excision of the Rectum (APER) rates are low which may be linked.
There were 146 patients recorded as undergoing major surgery in the year at the Royal Derby Hospital.
Trust V National Results
Case ascertainment
Discussed at MDT
Seen by clinical nurse specialist
Staging CT reported
Median Lymph node harvest
30 day mortality (adjusted)
90 day mortality (adjusted)
MR performed for rectal cancer
Radiotherapy for rectal cancer
APER rate for rectal cancer
Stoma present at 1 year for rectal cancer
National Average (%)
87
98
87
88
18
3.3
5.0
84
39
24
57
Royal Derby Hospital (%)
95
95
86
91
16
2.9
4.4
86
57
14
57
National Heavy Menstrual Bleeding (HMB) Audit (2nd Annual Report)
This is a 4 year audit that began in February 2010 and aims to:
• Describe the severity of menstrual problems experienced by women referred to NHS Outpatient
Clinics and the care given prior to referral.
• Care after the initial Outpatient appointment including severity of symptoms and the effect of
treatments on their health and quality of life.
HMB is a common condition affecting more than 1 in 5 women of reproductive age. It is the 4th most
common reason for referral to Gynaecological services and over 30,000 women each year have surgical
treatment. 16,000 questionnaires were completed which is estimated to be representative of 20% of
women affected.
Nationally results up to date showed that overall:
• 74% of women had had symptoms for over a year
• 54% had severe or very severe pain at their first outpatient visit
• 31.2% had no initial treatment in Primary Care-this percentage increased with age.
• Those referred to Secondary Care were those with prolonged symptoms and in severe or very
severe pain.
38 | P a g e
•
•
1/3 of these women had received no previous treatment
Recommendations are awaited.
National Parkinson’s Disease Audit
There are 127,000 patients in the UK who have Parkinson’s. This diagnosis includes many problems for
the patient and for their family including problems with speech and swallowing, memory, mood, sleep,
pain and incontinence. The aim of this audit is to help Parkinson’s services to measure their practice
against NICE 2006 Guidelines. Earlier audits focused on Neurology and Elderly Care Services but now it
is recognised that an integrated medical, nursing and therapist model of care is needed for these
patients.
National Results
This audit included 6106 patients and 325 services and showed that:
• 39% of newly diagnosed patients were not given written information about Parkinson’s
• 1/3 of patients waited more than 6 weeks to see a specialist
• Patients treated with dopamine agonists were not monitored for compulsive/impulsive behaviour
• 405 of patients on ergot dopamine therapy were not monitored.
• 1/3 of therapists did not receive updated Parkinson’s training
• 1/3 of therapists do not use standardised assessments
• 90% of Occupational therapy referrals did not include the patient’s history, reason for referral or
medications
• 1.4% represented black and ethnic minority groups similar to previous audits.
National Recommendations
• Giving patients information re the Parkinson’s UK website
• Monitoring for treatment risks
• Updated training for health professionals
• Use of standardised assessment
• Referrals to contain relevant information
• More engagement with black/ethnic minority groups
There is no report of individual Trust results but relevant clinicians are responding appropriately to the
National report.
National Paediatric Diabetes Audit
The National Paediatric Diabetes Audit is the 8th report and covers data audited in 2010/11. The audit
reports the quality of care for children with diabetes mellitus in England and Wales and includes details
on the number of infants, children and young people with diabetes, the care processes and outcome
measures.
National and Local Results
This audit was published in September 2012 and included data for 23,516 infants, children and young
adults from 178 paediatric units across England and Wales.
There have been many improvements nationally, but the percentage of children who have had all care
processes as defined by NICE guidance remains low nationally at 5.8%. 58.4% of Derby children have
missing recorded care processes, which is in the middle of national data. However, only 0.8% are
missing recorded HbA1c data which is amongst the best nationally. The Trust median HbA1c for Derby
clinic population is 8.6% (8.7% for England).
HbA1c data:
National
Derby
<7.5%
15.8%
16.7%
>7.5 - <9.5%
55.5%
>9.5%
28.7%
39 | P a g e
Trust Actions
• Data contribution to the national audit will continue
• The outcome of national peer review for the Paediatric Diabetes Service is awaited.
• The database is now web-based
• More team support has been agreed (Band 4 appointment) which will help with data consistency.
• Electrolytes have been added to the annual review, which will add to the care processes.
National Health Promotion in Hospitals Audit
This is web based audit which measured the delivery of health promotion to hospital patients in England.
The aim was to provide details of the numbers of patients assessed for smoking, alcohol, obesity and
physical inactivity risk factors. Other criteria included whether patients had received verbal or written
health promotion advice or referral to a specialist or service.
National Results
• Most Trusts have a health promotion champion on their Board and a Trust Co-ordinator for Health
Promotion.
• Half of all Trusts have a Health promotion Group
• 84% of patients were assessed for smoking
• Smokers asked if they wanted to quit were more likely to receive health promotion
• 52% were assessed for obesity which was a significant increase from 2009 data.
• Repeated audit demonstrated the need for staff training in the use of the screening tool
Trust Actions
• A Trust Health Promotion Strategy has been developed
• A training programme has commenced and will be cascaded to all ward staff.
• An E Learning package is being developed.
• The Trust works closely with Fresh Start, Hospital alcohol Liaison Team (HALT) and the local Alcohol
Dependency Solution (ADS).
Royal College of Physicians Child Health: Epilepsy Audit
The aim of this audit is to facilitate health providers and Commissioners to measure and improve the
quality of care for children and young people with seizures and epilepsy, and contribute to improved
outcomes for them and their families.
National Results
• 2 (5.7% had evidence of a neuro-disability
• 20 (57.1) had evidence of epilepsy (2 or more epileptic seizures) by the first Paediatric Assessment
• 14 (40%) had evidence of epilepsy at 12 months after the first Paediatric assessment
• 14 (40%) were prescribed anti-epileptic drugs.
Trust Results
The Trust audited 35 cases.
•
•
•
•
•
The Trust was a negative outlier for an appropriate first clinical assessment
5 (80%) were given Carbamazepine-4 without defined contraindications, 1 where it was
contraindicated
There is no Paediatric Neurologist on site
25% discussed pregnancy and contraception
21.4% had syndrome classification.
Trust Actions
• Staff education re first examination and Carbemazepine prescription
• Follow NICE Guidelines for MRI/Neurological imaging
40 | P a g e
•
•
Leaflets regarding contraception to be available in the Teenage Epilepsy Clinic
Paediatric Neurology input –this has already improved since the audit.
DIVISIONAL AUDIT ACTIVITY
The Clinical Audit Department within the Trust continues to promote and support adherence to the
approved Clinical Audit process to ensure the provision of accurate clinical audit information for the Trust
and external organisations. Clinical audit also identifies improvements in patient care, good practice and
excellence in the services provided by the Trust.
The Clinical Audit Department works closely with the Post Graduate Medical Education Centre and
Foundation Programme Director to co-ordinate the Foundation House Officer, Year 2 of training (F2)
Audit Programme. This ensures active involvement of the F2 in the audit process and their ability to
select and complete a clinical audit that is of value to patient care within the trust and add to their
professional development.
Each Division develops a local Clinical Audit Forward Programme that is monitored by the Audit
Department as part of the overall Trust Clinical Audit Forward Programme. Topics include, National
Guidelines, NICE Guidance, National Service Frameworks, Clinical Risk and Clinical Indicators.
The Clinical Audit Department provides support and resources to facilitate audits throughout the Trust.
All audits are registered and monitored through to completion.
Local Clinical Audit Activity by Division
In
Progress
Medicine
Emergency
Dept
MAU
Medicine
Clinical Support
Services & Cancer
Rehabilitation
Paediatrics
Critical
Care
Cancer
Services
Imaging
Pharmacy
Surgery
Pathology
Surgery
T&O / Hands
Obs& Gynae
GUM
OVERALL
%
In
Progress
Completed
%
Completed
Continuous
%
Continuous
Abandoned
%
Abandoned
National
Audits
%
National
Audits
Audits
Against
NICE
%
Audits
Against
NICE
16
80%
3
15%
1
5%
0
0%
4
20%
7
35%
6
43%
8
57%
0
0%
0
0%
0
0%
3
21%
29
45%
33
52%
2
2%
0
0%
8
13%
14
22%
22
59%
15
41%
0
0%
0
0%
20
74%
7
3%
2
5%
7
18%
11
31%
7
20%
27
47%
19
33%
5
9%
6
11%
4
7%
2
4%
4
27%
7
47%
4
27%
0
0%
1
7%
1
7%
9
30%
16
53%
5
17%
0
0%
3
10%
2
7%
19
79%
5
21%
5
21%
0
0%
5
21%
3
13%
10
45%
8
36%
4
18%
0
0%
11
50%
1
5%
41
41%
22
22%
2
2%
36
36%
2
2%
11
11%
32
44%
30
41%
0
0%
11
15%
0
0%
3
4%
37
71%
8
15%
7
14%
0
0%
12
23%
11
21%
272
53%
181
33%
37
9%
60
6%
61
11%
65
12%
The reports of 17 local clinical audits were reviewed by the provider in 2012/13 and Derby Hospitals
NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.
41 | P a g e
Title of Audit
Additional Opioid
Requirements Following Hip
and Knee Surgery on the
Enhanced Recovery
Pathway
Aim
To establish whether the
analgesia regime was
adequate for the majority
of patients
Steroid Prescribing in the
Nightingale MacMillan Unit
To improve the quality of
steroid prescribing for
Palliative Care patients
Acute Kidney Injury(AKI):
Audit of Basic Care
Standards
To assess the current
management of AKI
across the Trust
NICE Guidelines for the
management of Diabetes in
Children
To assess the
management of children
with a new diagnosis of
diabetes
Malignant Otitis Externa
Management in the Ear
Nose and Throat (ENT)
Department
Obesity in Pregnancy
To review management
against the agreed
protocol
Unexpected admissions
after ear Nose and Throat
(ENT) surgery
Key Findings
Although some patients
required additional
analgesia. The audit
confirmed that the
analgesia regime was
satisfactory
85% of patients had
appropriate prescriptions
on admission and 100%
had prescriptions
reviewed. 70% had a PPI
prescribed. 30% of nondiabetic patients had
blood sugar checks
Significant increase in
documentation of fluid
balance. Decrease in the
number receiving medical
reviews
Significant improvement
over the last 4 years
100% of patients referred
on same day by GP and
added to the Diabetic
Register
96% screened for
Coeliac and thyroid
disease
All cases were compliant
with the protocol
To audit performance
against Clinical
Negligence Scheme for
Trusts (CNST) standards
with particular emphasis
on Anaesthesia referral
and input during delivery
100% of patients had
their BMI recorded
88% were offered referral
to anaesthetists
56% had a documented
Anaesthetic Plan
To establish admission
rates following ENT
surgery
Significant increase in
admission rates from
2007 audit.
Inaccurately coding of
day cases
Most admissions for
bleeding or epistaxis and
pain
Documentation
unspecific for 50% of
patients
Actions
None required
Guidelines to be
developed
Tutorials for junior
doctors
Discussions being held re
blood sugar monitoring
for non-diabetic patients
Care Bundles for AKI in
doctors Induction
E Learning package
Co-ordination with
Pharmacy re medical
management
Improvement in
documentation-proposed
new proforma
Continue to support and
educate GPs
None needed
Obesity in Pregnancy
Pathway
Improved training in the
Maternity IT programme
ANC information in junior
doctors Induction
Improved
communications with
Anaesthetists
Option for patients to
choose anaesthetic
referral date
Raise awareness of the
need for accurate
documentation
Coding to be addressed
42 | P a g e
Neonatal Intensive Care
(NICU) Rapid Safety Alerts:
Admissions Audit and Blood
Gases
100% had observations
recorded within the first
hour. 79% had blood
gases recorded within 4
hours.
Re-audit showed 100%
results for observations
and blood gases
No correlation between
BSI and failures with
aseptic technique
BSI more likely during
insertion than pre or post
procedure
Adult Central Venous
Catheter (CVC) Insertion
To assess compliance
with Matching Michigan
Guidelines and related
blood stream infections
Management of patients
with Diabetes Mellitus (DM)
on the Step Down Unit
To compare
management of these
patients with local
guidelines
100% of patients with diet
controlled DM had a preoperative assessment
60% of Insulin
Dependent DM patients
admitted on surgery day
and No Step Down Unit
discharges delayed.
Surgical Management of
Localised Renal Carcinoma
To determine current
practice in the
management of Renal
Cell Carcinoma
The mainstay of
treatment is currently
Laparoscopic renal
Nephrology
Operating Waiting Times
for Patients with Mandibular
Fracture and the Influence
on Post-operative Outcome
To establish waiting
times and post-operative
outcomes
Impact of the revised 120
Pathway on the emergency
management of patients
presenting with low risk
chest pain
To assess how
successful the change in
Pathway has been
Clinical Effectiveness of
Care for Acute Exacerbation
of Chronic Obstructive
Pulmonary Disease (COPD)
To audit compliance with
the COPD Care Bundle
and NICE Guidance
Post-Operative
Effectiveness of Carpel
Tunnel Surgery
To evaluate the
effectiveness of Carpel
Tunnel Surgery after 3
months now there is no
longer a follow up
appointment
Almost all patients had
fast-track surgical
intervention. Waiting
times had no direct
impact on post-operative
outcome.
Reduction in the length of
stay in the Emergency
Department
Small numbers put on the
Pathway despite high
numbers presenting with
chest pain
Patients had prompt:
Check X Ray, ECG, O2
prescribing, response to
acidosis, bronchodilator,
steroids and Respiratory
Specialist review within
24hours
There was no significant
change in outcome since
the follow up appointment
was discontinued
Promotion of accuracy of
documentation via
posters and a
presentation for all
Neonatal Unit staff
Education and retraining
of Consultants and
Anaesthetic trainees
Awareness raising
Expand audit to include
follow up data e.g. date of
removal
Diabetic patients should
be first on the operative
lists. Hourly recording of
blood sugar with Sliding
Scale Insulin
High risk patients to be
identified in pre-operative
assessment and
management planned
Laparoscopic Partial
Nephrectomy currently in
development and may
reduce Chronic Kidney
Disease
New trauma proforma to
be developed to improve
documentation.
Audit appropriateness of
patients on the pathway
and others that could be
Raise awareness of the
Pathway with the team
Improve awareness of
COPD Care Bundle
Documentation of
smoking and referral to
Fresh Start
Guidelines for antibiotic
prescribing in COPD
Development of clear
post-operative
information leaflets
Develop an algorithm for
GPs to simplify referrals.
43 | P a g e
Colles Fracture: Adequate
or Inadequate Plaster
To evaluate plastering of
Colles fractures in the
Emergency Department
and Fracture Clinic
Overall recognised
standard of positioning
and plastering
One patient had remanipulation due to
inaccurate plastering
Continue to audit a
minimum of 50 patients
2.5 PARTICIPATION IN CLINICAL RESEARCH AND INNOVATION
RESEARCH
Derby Hospitals NHS Foundation Trust is a research active teaching hospital, with research taking place
in most disease areas and specialties across the full patient age spectrum.
At the end of November 2012, the INFANT (Intelligent Fetal Monitoring Study) study opened to
recruitment within the Trust. The INFANT trial will test whether use of decision-support software can help
midwives and doctors improve the care that they give in response to abnormalities of the baby’s heart
rate during labour and whether this will lead to fewer babies being harmed because of a lack of oxygen.
A reduction in the number of these babies would reduce the associated mortality and, amongst
survivors, the burden of ill-health and incapacity. Approximately 46,000 women in labour from
approximately 20 hospital Trusts will take part in this study. From the study opening at the end
November 2012 to the end of March 2013, 408 women consented to take part in the trial in Derby.
At the opposite end of the patient age spectrum, the SPDU study is a pilot study to explore the
effectiveness of a Specialist Parkinson’s Disease Unit (SPDU) for urgent admissions compared to usual
care. This study is led by Dr Rob Skelly, Consultant Physician at Derby Hospitals and is funded by a
grant awarded to Dr Skelly by Parkinson’s UK. Many people with Parkinson’s Disease (PD) are
dissatisfied with the care that they receive in hospital. Management of their PD sometimes suffers while
other medical problems are being addressed. Hospital staff may not be familiar with the common
complications of PD nor realise the importance of giving medications on time. Previous research has
shown that patients suffering heart attacks do better on coronary care units than on general wards and
stroke victims have improved survival following care on specialist stroke units. Previous research has
also shown that a specialist, multidisciplinary PD rehabilitation unit can improve walking and self-care
abilities. This study will compare the experience of patients with PD who need urgent admission to
hospital before and after the introduction of an SPDU. The study data have now been collected and are
being analysed. The analysis will look at the effect of the SPDU on drug errors, patient satisfaction and
length of stay and will explore the feasibility of a definitive, larger, multi-centre trial to see if the findings
from this study could be broadly adopted.
In 2012-13, research studies and clinical trials took
gastroenterology, cancer and palliative care,
musculoskeletal disease (including physiotherapy),
paediatrics/neonates, Parkinson’s Disease, general
medicine, rehabilitation, and accident and emergency.
place in cardiology, hepatology, renal medicine,
lymphoedema, diabetes, rheumatology and
dermatology, ophthalmology, audiology, stroke,
surgery, obstetrics & gynaecology, respiratory
The number of patients receiving relevant health services provided or sub contracted by Derby Hospitals
NHS Foundation Trust in 2012/13 that were recruited during that period to participate in research
approved by a research ethics committee was 2,158.
In addition to this, patients were recruited to non-portfolio studies, including commercially-sponsored
clinical trials not adopted onto the UKCRN portfolio and student studies (e.g. Doctor of Medicine (MD),
Doctor of Philosophy (PhD), Master of Science (MSc) etc.) all of which support the growth and
development of research capacity and capability within Derby Hospitals and the wider NHS.
44 | P a g e
In 2012/13, the Trust was involved in conducting 338 clinical research studies and approximately 100
new studies were given permission to start in the Trust. This level of participation in clinical research
demonstrates the Trust’s commitment to improving the quality of care we offer and to making our
contribution to wider health improvement. Our clinicians stay abreast of the latest possible treatment
possibilities and active participation in research leads to successful patient outcomes. Our engagement
with clinical research also demonstrates the Trust’s commitment to testing and offering the latest medical
treatments and techniques.
A number of applications have been made by Chief Investigators within the Trust for National Institute for
Health Research (NIHR) and other high quality research funding. Applications have been made to NIHR
Research for Patient Benefit; British Renal Society; BMA; BUPA; Dunhill Medical Trust; Pfizer; NIHR
Health Technology Assessment (HTA); Kidney Research UK; Medical Research Council (MRC) DPFS.
The outcomes of many of these applications are still awaited; as at 01.03.2013, we are awaiting the
outcome on applications worth approximately £5,046 592, with £71,027 of funding having been secured
in this financial year.
INNOVATION
Derby Hospitals NHS Foundation Trust continues to enhance the quality of its services and develop new
sources of income through its innovative staff and the support provided by the Research & Development
Department. The Trust has an Innovation and Horizon Scanning Group, which identifies and develops
any potential clinical and technological developments which may impact on clinical services within the
Trust and to link these to the Trust Strategy.
The most successful companies anchor innovation in their strategies, i.e where they want to take their
organisation, how to create competitive advantage and how to best serve customers. In recent years
there has been an increasing emphasis on innovation as a key contributor to organisational success.
Innovation is about developing new ideas and “inventions” to generate new products or services (product
innovation) and new ways of working (process innovation).
East Midlands Health Innovation and Education Cluster
East Midlands Health Innovation and Education Cluster, known as EM HIEC, is tasked with enabling
high quality patient care and services by quickly bringing the benefits of research and innovation directly
to patients, and by strengthening the co-ordination of education and training, so that it has the breadth
and depth to support excellence.
The EMHIEC Board has identified potential future HIEC support for two projects within this Trust i.e.
Improving outcomes in acute kidney injury - Dr Nick Selby and Education to improve Lymphoedema
Services – Professor Christine Moffatt.
Product Innovation & Intellectual Property
NHS Innovation Hub Membership
Having previously been a member of the East Midlands NHS Innovations Hub, which is no longer in
existence, in January 2012 the Trust became a member of Health Enterprise East Ltd, also a NHS
Innovations Hub which will provide financial support and personnel to enable the Trust to take forward,
commercialise and disseminate its innovations.
Some funding has been provided by the nascent East Midlands Academic Health Sciences Network to
support the Trust in 2013-14 in protecting and commercialising its intellectual property.
Trademarks
The Trust has trademark protected the use of “Pulvertaft” for the Hand Unit and “Jenny O’Neill” for the
Diabetes Centre.
45 | P a g e
Patents
Patent protection has been granted for the paediatric page-turner and the limb disinfection sleeve; the
latter also has US patent protection.
In 2012-13, it was agreed that the patent protection for the paediatric page-turner would be allowed to
lapse as the company to which it had been licensed had gone into receivership and no other licensees
had been identified.
A new licensee is also being sought for the limb disinfection device to improve the commercial return on
this product. Discussions with interested parties are underway.
Design Rights and Collaborations
The Derby Door which won the Best Interior Product Award and the Patients’ Choice Award at the
Building Better Healthcare Awards 2011, is an inflatable barrier which fits flush against walls and ceilings
on hospital wards to form a complete seal.
Production has now started in partnership with AirQuee Ltd in Bristol, an inflatables manufacturer. Derby
Hospitals will share the net profit from these sales and, as part of the manufacturing deal; the Trust will
receive 10 Derby Doors. In the last 12 months other NHS Trusts have also purchased the Derby Door
and sales are starting to rise. The Trust will be taking the lead on marketing the Derby Door with
AirQuee Ltd taking on the roles of manufacturing and sales.
Spin Out Company
Derby Hospitals NHS Foundation Trust is a significant share-holder and partner in iQudos Medical
Services. iQudos Medical Services provides a nurse-led service for management of benign prostate
disease. The company is in the process of setting up a similar service for stable prostate cancer and
other disease domains. The aim of the company is to provide hospital quality care “on the patient’s
doorstep”.
2.6 GOALS AGREED WITH COMMISSIONERS
CLINICAL QUALITY AND INNOVATIONS MEASURES (CQUIN)
A proportion of Derby Hospitals NHS Foundation Trust income in 2012/13 was conditional upon
achieving quality improvement and innovation goals agreed between Derby Hospitals NHS Foundation
Trust and any person or body they entered into a contract, agreement or arrangement with for the
provision of relevant health services, through the Commissioning for Quality and Innovation payment
framework. Payment of £8.7million was made by the NHS Derby City (the Co-ordinating Commissioner)
and this included East Midlands Specialist Commissioners.
Further details of the agreed goals for 2012/13 and for the following 12 month period are available online
at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/146715/dh_133859.pdf.
pdf
Year
2011/12
2012/13
Tariff Income
Non Tariff
Income
Total Income
Tariff Income
Non Tariff
Income
Total Income
£000's
£268,962
CQUIN
£3,828
£101,943
£1,520
£370,905
£270,915
£5,348
£6,237
£107,778
£2,487
£378,693
£8,724
1.44%
2.30%
46 | P a g e
Derby Hospitals CQUIN Year-End Position 2012/13
Acute Services
Goal Type
Goal
Numbe
r
Indicator
Number
National
1
1
National
2
2
National
Indicator Name
Indicator Weighting
(% of CQUIN scheme
available) and
Expected Financial
value of indicator (£)
5.60% = £449,564
3a
VTE
Composite indicator on
responsiveness to personal
needs
Dementia – Screening
3b
Dementia – Risk Assessment
0.80% = £64,223
3c
Dementia – Referral for
Specialist diagnosis
0.80% = £64,223
4
4
5a
5b
Local
5
5c
5d
6a
Regional
6
6b
6c
6d
Local
7
7
Safe Care – do not harm –
thermometer data collection
Safe Care – Progress
towards elimination of
avoidable grade 2, 3 and 4
pressure ulcers by December
2012.
Safe Care – Reduction in the
total number of patient falls
(all levels of harm) over the
year, through the full
implementation of an agreed
improvement plan and
improvement in the number
of risk assessments
completed on admission
(within 24 hours).
Safe Care – Reduction in the
incidence of urinary tract
infections as a result of
urinary catheterisations
whilst in the care of the trust.
Safe Care – improvement in
the number of patients who
have received appropriate
VTE prophylaxis
Patient Experience –
Establish question and
baseline score
Patient Experience – Board
and Commissioner Reporting
Patient Experience – Weekly
Reporting
Patient Experience –
Performance Improvement
Progress towards
preparedness for achieving
the relevant HII for 2013/14
Achieved
5.00% = £401,397
Achieved
1.60% = £128,447
Achieved
On target to
achieve (confirmed
data not available
until May 2013)
On target to
achieve (confirmed
data not available
until May 2013)
3
National
Year End Result
6.20% = £497,732
Achieved
3.00% = £240,838
Achieved
3.00% = £240,838
Achieved
3.00% = £240,838
Achieved
3.00% = £240,838
Achieved
3.10% = £248,866
Achieved
3.10% = £248,866
Achieved
3.10% = £248,866
Achieved
3.10% = £248,866
Partially achieved
6.00% = £481,676
Achieved
47 | P a g e
Local
8
8
Local
9
9
Regional
10
10
Local
11
11
National
1
1
2a
Local
2
2c
Local
3
3
Local
4
4
Follow-up reduction
Improving patient level
clinical information
Non Elective Activity
Reduction
Outpatient
Safe Care – Safety
thermometer data
collection
Safe Care - Progress towards
elimination of avoidable grade 2, 3
and 4 pressure ulcers by December
2012.
Safe Care - Reduction in the total
number of patient falls (all levels of
harm) over the year, through the full
implementation of an agreed
improvement plan and improvement
in the number of risk assessments
completed on admission (within 24
hours).
Safe Care - Reduction in the
incidence of urinary tract infections
as a result of urinary catheterisations
whilst in the care of the trust.
The percentage of people
discharged from hospital and
benefiting from intermediate
care/rehabilitation
enablement who are still
living at home three months
after discharge from hospital
To increase the number of
12.40% = £995,464
Not Achieved
12.40% = £995,464
Achieved
12.40% - £995,464
Achieved
12.40% - £995,464
Achieved
30% = £67,451
Achieved
10% = £22,483
Achieved
10% = £22,483
Achieved
10% = £22,483
Achieved
20% = £44,969
Achieved
20% = £44,969
Achieved
48 | P a g e
people who are able to die in
their place of choice
2.7 REGISTRATION WITH THE CARE QUALITY COMMISSION (CQC)
Derby Hospitals NHS Foundation Trust is required to register with the CQC and its current registration
status is registered without any conditions. During the year the Trust received 3 visits from the Care
Quality Commission.
The Care Quality Commission has not taken enforcement action against Derby Hospitals NHS
Foundation Trust during 2012/13.
Derby Hospitals NHS Foundation Trust has participated in special reviews or investigations by the Care
Quality Commission relating to the following areas during 2012/13.
Derby Hospitals NHS Foundation Trust intends to take the following action to address the conclusions or
requirements reported by the Care Quality Commission. Derby Hospitals NHS Foundation Trust has
made the following progress by 31st March 2013 in taking such action.
2.7.1 TERMINATION OF PREGNANCY
This review was part of a themed inspection programme of Outcome 21: Records on 28th May 2012 to
assess the use of records relating to Termination of Pregnancy. It is a legal requirement of the Abortion
Act (1967) that an HSA1 form is completed and certifies that the requirements for a Termination of
Pregnancy have been met and that the form has been signed by 2 doctors before the procedure is
carried out.
A random sample of medical records was examined however the reviewers did not speak to service
users. The reviewers found that the Trust was compliant with the standard relating to the HSA1 forms
and no actions were necessary.
2.7.2 DERBY HOSPITALS PERIODIC REVIEW
Derby Hospitals NHS Foundation Trust is subject to periodic reviews by the Care Quality Commission
and the last review was on the 16th and 17th of October 2012 as part of a routine unannounced
inspection of the following standards:
•
•
•
•
•
•
•
Consent to care and treatment
Care and welfare of people that use services
Meeting nutritional needs
Safeguarding people who use services from abuse
Supporting workers
Complaints
Records
The Trust met all the standards except for complaints and records where it was felt that action was
needed by the Trust. The majority of patients reported that they were satisfied with the care and service
they received and felt involved in decisions that were made about their care, treatment and discharge
planning. However some patients were concerned about the time they had to wait for test results and
discharge medication.
•
•
•
Patients were aware of their right to change previously agreed decisions about care and their right to
have an advocate to help them understand their options and make decisions.
The Trust had policies and procedures when a person lacked capacity to make decisions and staff
were able to demonstrate that they had acted in patients’ best interests.
Most patients were satisfied with the meals and drinks provided for them although there were some
patients that did not like the food and said it failed to meet their dietary needs.
49 | P a g e
•
Patients felt that the staff were friendly and helpful and that they communicated with them
appropriately. They also felt safe and that they could report any concerns to the staff. However, when
asked, most patients did not know how to complain about their care or concerns.
Complaints
The Trust did not meet this standard as it was felt that there was not an effective complaints system in
place for identifying, receiving, handling and responding appropriately to complaints and judged that this
would have a moderate impact on service users.
•
•
•
Most patients said that they felt they would be listened to and were able to raise concerns however
most did not know how to make a complaint.
As patients had not seen or read the Ward Information Handbook it was felt that the complaints
procedures were not widely publicised or understood by patients or were available in different
languages.
Staff were advised in the Handbook to contact the Patient Advice and Liaison Service (PALS) if they
had concerns but this only covered office hours Monday to Friday and not out of hours or at
weekends. It was felt that there was not a consistent approach to managing informal complaints as
these were dealt with differently in different areas.
Actions
• Review of the Complaints Policy and Procedures
• Review of the Complaints Data System
• Review of monthly PALS data
Progress
• The Complaints Policy and Procedures is undergoing the consultation process
• The Trust has purchased the Complaints Module of the Datix system and is in the process of
implementing this within the organisation.
• PALs have developed systems to ensure robust analysis of data
Records
The Inspectors judged that this standard was not being met as the care records did not provide an
accurate record of the care and treatment given to patients and this lack of information did not protect
patients from the risk of inappropriate care and treatment. This was judged to have a moderate impact
on patients and advised the Trust to take action.
•
•
•
•
The level of information recorded on the Assessment Units was generally detailed and in all areas
well organised.
The information level recorded varied in patient care records and in some areas were brief, and did
not match the care and treatment and support patients were given.
The care records were not completed to a consistent standard and had not been adapted to meet
patient’s individual needs.
A lack of pre and post transfer information did not protect the patient and was contrary to Trust Policy
and Procedures regarding Transfer.
Actions
A short term working group has been set up to review the care planning documents with the aim of
making them easier to adapt for individual patients’ needs and to raise awareness of the need to
continuously update the patient records correctly. The Group consists of ward based nursing staff from
all areas.
Progress
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The Trust is currently piloting new nursing documentation in clinical areas with the aim of implementing
changes by September 2013.
2.7.3. PATIENTS DETAINED UNDER THE MENTAL HEALTH ACT
This review on 7th March 2013 was a planned visit to the Trust to check the systems in place and
compliance with the Mental Health Act (1983) and Code of Practice.Between April 2012 and February
2013 health records for 5 patients under Section 136 and health records for nine patients under section
5(2) which were reviewed.
The report showed:
• There is good liaison with the local police and Emergency Department (ED)
• The Radbourne Unit bleep-holder assists with referrals by clarifying the relevant community team.
• Staff were unsure about the extent of powers to act in patients’ best interests under the Mental
Capacity Act.
• Derbyshire Voice advised the ED on improving the service for patients
• A Mental Health Awareness Day is planned
• Referrals for assessment by the Mental Health Crisis Team took 4-6hours and was particularly
problematic out of hours
• It was a hospital rule that patients must be transported to the Radbourne Unit by ambulance although
this was on the same site.
• Support may be needed by staff dealing with patients who have Mental Health issues.
• Potential privacy and dignity issues in the Majors area of ED
• Copies of the Code of Practice were not kept in the ED or Medical Assessment Unit (MAU)
• Trust Policy and Procedures on the use of Section 5 (2) does not include guidance on ending the
power of detention.
• Records were not clear re patients on Section 136 being seen by an doctor and a AHMP and in one
case was incomplete. Records did not always include details of information given to patients
regarding their rights under the Mental Health act.
An Action Plan is currently being developed which will address all the areas highlighted in the report.
2.8 DATA QUALITY
Good quality information underpins the effective delivery of patient care and is essential if improvements
in quality of care are to be made.
Derby Hospitals NHS Foundation Trust will be taking the following actions to improve data quality:
•
•
•
•
•
Continue with the regular programme of audits
Working closely with the ED to improve collection of out of area GPs
Reviewed returned mail from GP practices to correct errors at source where old GP details were
being used – digital dictation should alleviate this problem.
Ensuring all Coders have undertaken refresher courses where appropriate and they have
implemented OPCS 4.6 procedure codes
Working with our local PCTs to reconcile Secondary User Service (SUS) data to contract data
Service Level Activity Monitoring (SLAM)
INFORMATION GOVERNANCE (IG) TOOLKIT ATTAINMENT LEVELS
The Derby Hospitals NHS Foundation Trust Information Governance Assessment Report overall score
for 2012/2013 was 72% and was graded red – this was because on 2 requirements – Mandatory IG
training and Pseudonymisation, the Trust achieved Level 1. Plans are in place to bring these up to Level
2 this year. The score was an improvement on 61% the previous year and reflects the continual
refinement and rigour of the requirements each year.
51 | P a g e
DATA QUALITY AUDIT
Derby Hospitals NHS Foundation Trust submitted records during 2012/13to the Secondary Uses service
for inclusion in the Hospital Episode Statistics which are included in the latest published data. The
percentage of records in the published data:
•
which included in the patient’s valid NHS Number was:
98.4% for admitted patient care;
99.8% for outpatient care; and
98.8% for accident and emergency care
•
which included the patient’s valid General Practitioner Registration Code was:
100% for admitted patient care;
100% for outpatient care; and
100% for accident and emergency care
2011/12 data was:
•
which included in the patient’s valid NHS Number was:
99.3% for admitted patient care;
100% for outpatient care; and
98.3% for accident and emergency care
•
which included the patient’s valid General Practitioner Registration Code was:
99.3% for admitted patient care;
100% for outpatient care; and
100% for accident and emergency care
Derby Hospitals NHS Foundation Trust has a regular programme of internal Data Quality audits to
ensure accuracy and completeness of the data held on the Trust’s Patient Administration System (PAS).
In addition there is an on-going programme of audit targeting specific areas of concern.
These audits cover the 3 dimensions necessary to fulfil Information Governance requirement 506.
These dimensions are as follows.
Admitted patient care
0.5% of the total Finished Consultant Episodes (FCEs) per annum
These audits are carried out by the Coding & Data Quality Manager & Deputy Coding & Data Quality
Manager concurrently with monthly coding audit as appropriate. Over 600 episodes were audited with an
average score of over 9 which gives a Data Output Quality Standard of Level 3.
Outpatients
0.2% of the total Outpatient (OP) attendances
These audits are carried out by each Data Quality Support Officer, numbers to be appropriate to the
number of OP attendances in each directorate. Over 200 attendances have been audited with an
average score of over 8 which gives a Data Output Quality Standard of Level 2.
Elective admissions
5% of the planned end of year waiting list census number
These audits are carried out by the relevant Coding Team Leaders. Nearly half of the required 600
patients have been audited for 2011-12 with an average score of over 6 which gives a Data Output
Quality Standard of Level 2.
A spreadsheet of the selected Commissioning Data Set (CDS) is produced from the PAS system listing
the key data items to be analysed. This data is then checked against the corresponding random sample
52 | P a g e
of sets of health records. Reports and action plans from these internal audits are submitted to the
Information Governance Action Group for approval. Should there be any unresolved actions from the
audits; the reports are escalated to the Information Governance Steering Group.
The Trust was subject to the Payment by Results Out Patient Data Quality Audit during the reporting
period ( 2009-10) by the Audit Commission (due to the level of assurance this audit will not be repeated
for 3 years) and the error rates reported in the latest published audit report for that period were;
Data Errors
Attendance Test
First/Follow Up Test
Treatment function Test
Procedure Test
All Tests
Incorrect appointments
1.3%
0.0%
0.0%
2.0%
0.8%
3.3%
KEY LINES OF ENQUIRY AREA DESCRIPTION SCORES
Accountability
There is clear accountability for data quality and the production of outpatient data.
Trust score 3 – performing well
Policies and Procedures
The Trust has put in place appropriate policies and procedures to support the accurate recording of all
outpatient activity
Trust score 3 – performing well
Data Entry
There are arrangements to ensure that all outpatient data is captured completely, accurately and
promptly at the Trust
Trust score 3 – performing well
CLINICAL CODING AUDIT
Derby Hospitals NHS Foundation Trust has a regular monthly programme of internal clinical coding
audits. These are conducted by the Clinical Coding and Data Quality Manager and the Deputy Clinical
Coding and Data Quality Manager, both of whom are NHS Connecting for Health Approved Clinical
Coding Auditors and Accredited Clinical Coders. Auditors must conform to the Auditors Code of Practice
and ensure that the NHS Connecting for Health Clinical Coding methodology version 3.0 is adhered to.
Reports and action plans from these internal audits are submitted to the Information Governance Action
Group for approval. Should there be any unresolved actions from the audits; the reports are escalated to
the Information Governance Steering Group.
To fulfil Information Governance requirement 505, the Trust must also commission a yearly audit of at
least 200 Finished Consultant Episodes (FCEs).
Derby Hospitals NHS Foundation Trust was subject to the Payment by Results (PbR) clinical coding
audit during the reporting period by the Audit Commission and the error rates reported in the latest
published audit for that period for diagnoses and treatment coding (clinical coding) were 11.7%.
In previous years the PbR assurance framework has reviewed the accuracy of clinical coding and
reported on the accuracy of the Healthcare Resource Group (HRG) assignment. In addition to reviewing
clinical coding this year the audit looked at the accuracy of all data items that affect the price
commissioners pay the Trust for a spell under PbR rules.
The new data items are:
53 | P a g e
•
•
•
•
age on admission;
admission method;
sex; and
Length of stay (LoS)
The results should not be extrapolated further than the actual sample audited; and therefore this error
rate reflects the fact that this sample was chosen because of concerns about the availability of
information and the impact this had on the accuracy of coding. Respiratory services were reviewed
within the sample.
Derby Hospitals NHS Foundation Trust will be taking the following actions to improve data quality:
•
•
•
improve the availability and condition of case notes for coding;
work with clinicians to make sure the information recorded in the case notes is consistent and
provides a detailed patient pathway; and
provide additional training for coders to address the error noted in this audit.
Previously the sample has been selected by focusing on areas identified as needing improvement. This
year the Audit Commission selected both samples from the Secondary Uses Service (SUS) provided by
the NHS Information Centre. This is to support the direction of travel indicated in the Operating
Framework that PCT clusters should ensure that providers use the Secondary Uses Service (SUS) for
performance monitoring, reconciliation and payments in 2012/13.
In order to give a wider indication of data quality across the whole trust’s PbR activity they randomly
selected 100 FCEs covered by a mandatory PbR tariff. The locally selected sample allows
Commissioners to focus on a specific specialty. In this audit the local selected speciality was
Gastroenterology.
The error rates reported in the latest published audit report for that period for diagnoses and treatment
coding were:
Primary Diagnoses incorrect
Secondary Diagnoses Incorrect
Primary Procedures Incorrect
Secondary Procedures Incorrect
4.5%
8.2%
2.9%
2.3%.
2.9 DELIVERY OF NATIONAL TARGETS
The following table reflects the national targets the organisation is required to report as part of its board
reporting:
Target
11-12
11/12
Full
Year
Monitor
Target
12-13
YTD
Target
to
March
13
Q4
Actual
to
March
13
Q4
Status
to
March
13
Actual
YTD to
March
13
Full
YTD
Statu
s
Incidence of Clostridium difficile
76
58
49
49
22
R
65
R
Incidence of MRSA Bacteraemia
7
2
2
2
1
G
3
A*
94%
95.02%
94%
94%
96.10%
G
95.24%
G
Indicator
Cancer: 31Day - Subsequent
Treatment - Surgery
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Cancer: 31Day - Subsequent
Treatment - Drugs
Cancer: 31Day - Subsequent
Treatment - Radiotherapy
Cancer: 62 Day Std - Urgent
Referral to Treatment
Cancer: 62 Day Screening
98%
99.38%
98%
98%
99.39%
G
99.19%
G
94%
97.44%
94%
94%
98.94%
G
96.93%
G
85%
87.01%
85%
85%
79.62%
R
83.08%
R
90%
89.54%
90%
90%
90.38%
G
91.70%
G
23
25.7
90%
90%
90.75%
G
92.32%
G
18
15.3
95%
95%
97.46%
G
97.53%
G
N/A
N/A
92%
92%
93.24%
G
93.24%
G
96%
97.98%
96%
96%
98.21%
G
98.08%
G
95%
93.68%
95%
95%
90.73%
R
93.92%
R
Cancers: 2 Week Wait - Breast
Symptoms
93%
96.93%
93%
93%
95.19%
G
95.66%
G
Cancer 2 Week Wait
93%
95.45%
93%
93%
93.71%
G
94.83%
G
Stroke - 90% of time on a stroke
ward
80%
70.26%
80%
80%
71.61%
R
78.84%
R
Referral To Treatment - Admitted
(95th percentile) - in weeks
Referral To Treatment - Non
Admitted (95th percentile) - in
weeks
Referral To Treatment Incompletes 92% (Snapshot)
Cancer: 31 Day Standard
Total time in A&E (95% seen within
4 Hours)
A
* Incidence of MRSA Bacteraemia - Although this has breached the trajectory of two for the year, the numbers are
De minimis and do not incur a score
Emergency Department Breach of the Four Hour Waiting Time Target
The Trust was found in significant breach of its authorisation in January 2012: Its general duty to
exercise its functions effectively, efficiently and economically; and its governance duty.
The decision was based on the trust’s financial performance and the challenges it is facing to improve its
position during the next twelve months and breach in the Emergency Department target.
Outcome of review of key actions with Monitor April 13:
Trust to develop an action plan in consultation with key stakeholders and Monitor that ensures
compliance with the A&E target for quarter 1 of 2013-14.
ADDITIONAL INDICATORS
Prescribed info
The data made available to the National Health
Service Trust or NHS Foundation Trust by the
Health & Social Care Information Centre with
regard to:
(a) the value and banding of the summary
hospital-level mortality indicator (SHMI) for the
Trust for the reporting period; and
(b) the percentage of patient deaths with
palliative care coded at either diagnosis or
specialty level for the Trust for the reporting
period.
Related NHS Outcomes
Framework Domain & Who
will report on them
Trust
Value
National
Average
High
Value
Low
Value
Oct 2011 – Sept 2012
Within expected (95%
confidence limit) 102.8%
Value
Banding
1.0851
1.06
1.2107
0.6849
2
2
3
1
Within expected (95% control
limits) 109.1%
55 | P a g e
*The palliative care indicator is a contextual
indicator.
Oct 2011 – Sept 2012
Percent
The data made available to the National Health
Service Trust or NHS Foundation Trust by the
Health & Social Care Information Centre with
regard to the Trust's patient reported outcome
measures scores for:
April 2012 – Dec 2012
Quarter 1: All procedures
1.90
1.04
3.2
0
Q2 Index Average
1,101 total eligible episodes
Q1 completed 741
Q1 linked 625
Linkage rate 84.3%
(i) groin hernia surgery
Participation rate 67.3%
No data
0.874
0.937
0.8
No data
0.834
0.883
0.772
0.794
0.767
0.838
0.667
(i) groin hernia surgery -
(ii) varicose vein surgery
total eligible episodes 281
- no data
(ii) varicose vein surgery total eligible episodes 60
- no data
(iii) hip replacement surgery, and
(iii) hip replacement surgery total eligible episodes 361
Q1 completed 309
Participation rate 85.6%
Q1 linked 269
Linkage rate 87.1%
Prescribed info
(iv) knee replacement surgery,
Related NHS Outcomes
Framework Domain & Who
will report on them
(iv) knee replacement surgery -
Trust
Value
National
Average
High
Value
Low
Value
0.734
0.709
0.796
0.589
7.72%
10.18%
22.93%
0%
(ii) 16 or over
12.90%
11.16%
22.94%
0%
2010/11 data:
(i) 0-15
7.91%
10.15%
25.80%
0%
(ii) 16 or over
12.91%
11.42%
22.93%
0%
2010/11 All England
72.80%
67.3%
82.60%
56.70%
67.40%
85.00%
56.50%
2011/12 All England
70.40%
total eligible episodes 399
Q1 completed 382
during the reporting period.
Participation rate 95.7%
Q1 linked 309
Linkage rate 80.9%
The data made available to the National Health
Service Trust or NHS Foundation Trust by the
Health & Social Care Information Centre with
regard to the percentage of patients aged:
(i) 0-14; and
(ii) 15 or over,
2009/10 data:
(i) 0-15
readmitted to a hospital which forms part of the
Trust within 28 days of being discharged from a
hospital which forms part of the Trust during the
reporting period.
The data made available to the National Health
Service Trust or NHS Foundation Trust by the
Health & Social Care Information Centre with
regard to the Trust's responsiveness to the
personal needs of its patients during the
56 | P a g e
reporting period.
2012/13 All England
SHA
The data made available to the National Health
Service Trust or NHS Foundation Trust by the
Health & Social Care Information Centre with
regard to the percentage of staff employed by, or
under contract to the Trust during the reporting
period who would recommend the Trust as a
provider of care to their family or friends.
The data made available to the National Health
Service Trust or NHS Foundation Trust by the
Health & Social Care Information Centre with
regard to the percentage of patients who were
admitted to hospital and who were risk assessed
for venous thromboembolism during the
reporting period.
The data made available to the National Health
Service Trust or NHS Foundation Trust by the
Health & Social Care Information Centre with
regard to the rate per 100,000 bed days of cases
of C.difficile infection reported within the Trust
amongst patients aged 2 or over during the
reporting period.
Prescribed info
The data made available to the National Health
Service Trust or NHS Foundation Trust by the
Health & Social Care Information Centre with
regard to the number and, where available, rate
of patient safety incidents reported within the
Trust during the reporting period, and the
number and percentage of such patient safety
incidents that resulted in severe harm or death.
70.20%
67.7%
79.5%
62.1%
2011/12
69%
62%
89%
33%
2012/13
65%
63.25%
94.19%
35.33%
Q1
90.10%
84.10%
100%
15.70%
Q2
90.10%
88.30%
100%
20.40%
Q3
90%
90.80%
100%
32.40%
Q1
90.10%
93.70%
100%
80.80%
Q2
90.50%
94.00%
100%
80.90%
Q3
90.10%
94.30%
100%
84.60%
2010/11
23.30%
29.60%
71.80%
0%
2011/12
17.30%
21.80%
51.60%
0%
Related NHS Outcomes
Framework Domain & Who
will report on them
Trust
Value
National
Average
High
Value
2011/12
2012/13
01/04/11-01/09/11 Incidents
6202
- rate per 100 admissions
- severe harm -number
- percentage
- death
- number
- percentage
01/04/12-01/09/12 Incidents
8.3
5
0.1
8
0.1
6485
- rate per 100 admissions
- severe harm - number
- percentage
- death
- number
- percentage
9.19
3
0
2
0
Low
Value
3723
6845
1397
23.5
0.7
5.2
0.15
4060
10.08
155
2.8
20
0.7
6485
2.75
0
0
0
0
859
6.7
23.7
0.6
5.5
0.14
13.61
90
2.5
19
0.5
1.99
0
0
0
0
6
Mortality Indicator
The data made available to Derby Hospitals NHS Foundation Trust by the Health and Social Care
Information Centre with regard to:
(a) The value and banding of the summary Hospital Level Mortality Indicator (SHMI) for the Trust for the
reporting period;
(b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for
the Trust for the reporting period.
The Derby Hospitals NHS Foundation Trust considers that this data is as described for the following
reasons:
57 | P a g e
•
Derby’s rate was 109.1 which is within the expected range. Throughout the year the Trust has
queried numbers of deaths attributed to it as there have been discrepancies in the data, with a
significant number of additional deaths, as compared to Trust data.
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score and so the
quality of its services, by:
• Scrutiny of issues relating to mortality by the Mortality Review Group
• Review of selected cases which have led to changes in care
Patient Reported Outcome Measures
The data made available to Derby Hospitals NHS Foundation Trust by the Health and Social Care
Information Centre with regard to the Patient Reported Outcomes Measures Scores for:
I.
Groin hernia surgery
II.
Varicose vein surgery
III.
Hip replacement surgery
IV.
Knee replacement surgery
The Derby Hospitals NHS Foundation Trust considers that this data is as described for the following
reasons:
• The questionnaires are distributed and completed and returned by patients
• The score relates to patient uptake of the questionnaire
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score and so the
quality of its services, by:
• Continuing the distribution of Questionnaires as per the Guidance
• Monitor data as it is released to the Derby Hospitals NHS Foundation Trust
Readmission Rates
The data made available to Derby Hospitals NHS Foundation Trust by the Health and Social Care
Information Centre with regard to:
The percentage of patients aged:
I.
0-14 and
II.
15 or over, readmitted to hospital within 28 days of being discharged from a hospital that forms
part of the Trust during the reporting period.
The Derby Hospitals Foundation Trust considers that this data is as described for the following reasons:
• There has been a slight increase in the admission rate for both sets of data
• Derby Hospitals NHS Foundation Trust reports on the 30 day re-admissions according to Payment
by Results rules. Overall there is a slight increase but this remains stable overall
For the financial year 2010/11 the Derby Hospitals NHS Foundation Trust’s readmission rate was at
5.31%. It then increased to 5.56% in 2011/12 and has remained stable this year (2012/13) at 5.52%.
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score and so the
quality of its services, by:
• Established Hospital Re-admissions Group which has focused on Cardiology and Respiratory
Medicine with high re-admission rates
• Developed a dashboard containing current data which is accessible by key managers within the
organisation
• Undertaken a re-admissions audit for Clinical Commissioning Group.
• Enhanced discharge project
• Undertaking re-admission audits for patients who re-attend at the Emergency Department.
58 | P a g e
•
Amber Care Project for End of Life Care
Patient Experience
The data made available to the Derby Hospitals NHS Foundation Trust by the Health and Social Care
Information Centre with regard to - the Trust’s responsiveness to the personal needs of patients.
The Derby Hospitals Foundation Trust considers that this data is as described for the following reasons:
• The national goal to improve responsiveness to the personal needs of patients is a CQUIN which
focuses on 5 specific questions
• Derby Hospitals is in a cluster with 45 other Trusts. To be considered in the upper quartile this should
mean the top 11 out of 45. The Derby Hospitals NHS Foundation Trust’s score of 70.2 places Derby
Hospitals at point 37 which is within the top ten
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score and so the
quality of its services, by:
• Continuing to scrutinise individual sections of the calculations from the 5 survey questions
• Key actions are part of the Patient Experience work plan in development for 2013/14
Staff Experience
The data made available to the Trust by the Health and Social Care Information Centre with regard to –
the percentage of staff employed by, or under contact to the Trust during the reporting period who would
recommend the Trust as a provider of care to their family or friends.
The Derby Hospitals Foundation Trust considers that this data is as described for the following reasons:
• In 2012/13 there is a 4% difference in the score from the previous year for this indicator. The Trust
has undergone significant organisational change for this period, moving from 4 divisions to 3.
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score and so the
quality of its services, by:
• We have introduced a staff impressions survey to enable us to gather more detailed information on a
regular basis so that we can understand staff responses.
Venus Thromboembolism
The data made available to the Trust by the Health and Social Care Information Centre with regard to –
the percentage of patients who were admitted to hospital and who were risk assessed for venous
thromboembolism during the reporting period.
The Derby Hospitals Foundation Trust considers that this data is as described for the following reasons:
• This data demonstrates the percentage of all adult inpatients who have had a VTE risk assessment
on admission to hospital using the clinical criteria of the national audit tool. This data is submitted
monthly to Unify as part of the national CQUIN requirements. Derby Hospitals NHS Foundation Trust
has taken the following actions to improve this score and so the quality of its services, by
• Increasing and sustaining the percentage of recorded risk assessments to 95% in line with National
Guidance
Clostridium difficile (C.diff)
The data made available to the Trust by the Health and Social Care Information Centre with regard to –
the rate per 100,000 bed days of cases of C.difficile infections reported within the Trust amongst patients
aged 2 or over during the reporting period.
The Derby Hospitals Foundation Trust considers that this data is as described for the following reasons:
• This data demonstrates the number of patients with a positive test result 72 hours or more after
admission. The target for 12/13 was no more than 49 cases and the Trust ended the year with 65
59 | P a g e
•
•
•
cases, 16 over its national trajectory. Derby Hospitals NHS Foundation Trust has taken the following
actions to improve this score and so the quality of its services, by
Continuous review and assessment to ensure that all actions to minimise the risk of patients
developing the infection have been undertaken.
Route Cause Analysis is undertaken on all Trust acquired cases of C.diff. The outcomes of this are
shared with clinical teams and action plans are put in place.
A review group has been established to approve and implement policy and to review all patients with
the infection to ensure optimum treatment and supportive care for patients.
Safety Incidents
The data made available to the Trust by the Health and Social Care Information Centre with regard to –
the number, and where available, rate of patient safety incidents reported within the Trust during the
reporting period, and the number and percentage of such patient safety incidents that resulted in severe
harm or death.
The Derby Hospitals Foundation Trust considers that this data is as described for the following reasons:
• 6 monthly retrospective reports are published by the NHS Commissioning Board and are monitored
closely
• The Trust supports an effective safety culture via the increased reporting of incidents
• Increase in incident reporting against the same period last year which reflects the Derby Hospitals
NHS Foundation Trust’s position of 6th highest incident reporter out of 39 large acute organisations
listed by the NHS Commissioning Board.
Derby Hospitals NHS Foundation Trust has taken the following actions to improve this score and so the
quality of its services:
•
•
Continue to monitor and review all classification of incidents to ensure correct rating
Ensure Datix is updated appropriately.
EMERGENCY READMISSIONS WITH 28 DAYS OF DISCHARGE FROM HOSPITAL
Indicator description: Percentage of emergency admissions occurring within 28 days of the last, previous
discharge from hospital.
Indicator requirement as per Monitor Guidance:
Numerator:
The number of finished and unfinished continuous inpatient spells that are emergency
admissions within 0-27 days (inclusive) of the last, previous discharge from hospital
(see denominator).
Including:
those where the patient dies
Excluding: those with a main speciality upon readmission coded under obstetric; and
those where the re-admitting spell has a diagnosis of cancer (other than benign or in
situ) or chemotherapy for cancer coded anywhere in the spell
Denominator:
The number of finished continuous inpatient spells within selected medical and surgical
specialities, with a discharge date up to 31 March within the year of analysis.
Excluding: day cases, spells with a discharge coded as death, maternity spells
(based on speciality, episode type, diagnosis), and those with mention of a diagnosis of
cancer or chemotherapy for cancer anywhere in the spell. Patients with mention of a
diagnosis of cancer or chemotherapy for cancer anywhere in the 365 days prior to
admission are also excluded.
Trust readmission rate for FY 11/12
Trust readmission rate for FY 12/13
Number of admissions:
Number of admissions:
50634
49206
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Number of readmissions:
4873
Number of readmissions:
4812
Readmission rate:
9.6%
Readmission rate:
9.8%
MAXIMUM WAITING TIME OF 62 DAYS FROM URGENT GP REFERRAL TO FIRST TREATMENT
FOR ALL CANCERS
Indicator requirement as per Monitor Guidance:
Detailed descriptor:
PHQ03: Percentage of patients receiving first definitive treatment for cancer within
62 days of an urgent GP referral for suspected cancer.
Date definition:
all cancer two month urgent referral to treatment wait.
Denominator:
total number of patients receiving first definitive treatment for cancer following an
urgent GP (GDP or GMP) referral for suspected cancer within a given period for all
cancers (ICD-10 C00 to C97 and D05)
All of the values for the numerator and denominator should be for financial year 2012/13 (from 1st April
2012 to 31 March 2013).
Trust 62d standard compliance for FY 11/12
Numerator:
Denominator:
984
1131.5
Compliance rate: 86.96%
PART 3
Trust 62d standard compliance for FY 12/13
Numerator:
Denominator:
977.5
1180
Compliance rate: 82.84%
QUALITY PERFORMANCE GOVERNANCE ARRANGEMENTS
The Trust has an infrastructure for quality monitoring which stems from the Quality Committee which is a
formal sub-committee of the Trust Board and is chaired by a Non Executive Director.
Within this reporting structure there are a number of Committees and Groups with clear roles and
responsibilities for monitoring the quality of care delivered in the Trust. The main committees are:
Clinical Effectiveness, Knowledge and Audit, Infection Control, Clinical Risk and Patient Experience.
These committees all have a number of sub-groups reporting to them, which include Mortality, Critically
Ill Patient Group, Incident Reporting, Safeguarding and Clinical Change Management. The main
committees report to the Quality Review Committee, which in turns reports into the Quality Committee.
This structure in place below the Trust Board ensures ownership of the Quality Agenda throughout the
organisation. The Trust Board accountability lies with the Medical Director and the Director of Patient
Experience and Chief Nurse.
A Quality Report is submitted to the Board on a monthly basis detailing progress against agreed
priorities. Additional reports regarding Trust Quality objectives are added below.
3.1.BOARD TO WARD PROGRAMME
The Board to Ward programme was launched in November 2011, since April 201219 visits have been
undertaken. An Executive and Non-Executive Board Member carry out each visit jointly. The focus of
the programme is:
•
Relationship Development - the visiting team will have the opportunity to meet with staff, patients
and carers in the clinical area. Two way communication during these visits means that both teams
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•
•
•
will be able to share key messages. It is also a time when the care environment can demonstrate
areas of good practice.
Visible Leadership - this programme supports the clear message that the delivery of high quality
care across the organisation is important to the Trust Board. This is the message that is important
internally for patients and staff, and externally for the public and key stakeholder organisations.
Supporting the embedding of the Quality Strategy - the visits provide the forum to ensure that
there is a wide understanding of the strategy across the organisation, the Executive/Non-Executive
receive an update on the current clinical delivery, and it brings to the life for the team some of the
areas that are being demonstrated in the reports at Trust Board Meetings.
Seeking further understanding and assurance of Patient Experience – where appropriate the
team explore the experience of the patient through informal discussion
The format of the Board to Ward visits is structured around the 15 Steps Audit Tool. This tool helps the
team to gain an understanding of how patients and service users feel about the care provided and what
gives them confidence. It helps to identify the key components of high quality care that are important to
patients and carers from their first contact with a care setting.
The audit focuses on 4 key areas and includes if the ward /department is:
•
•
•
•
Welcoming
Safe
Caring and Involves Patients
Well organized and calm
Themes from the visits include:
•
•
•
•
•
Good team working
Positive leadership
Positive feedback from patients/families/Carers
Staffing Levels
Discharge Planning
CHANGES MADE TO THE REPORT
Changes have been made to this report since the draft version that was sent out to Clinical
Commissioning Group, Healthwatch, Improvement and Scrutiny Committees for their statements for
inclusion in this report.
The changes are:
•
•
Additional indicators
Data sources for indicators and actions have been included.
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Annex 1:
STATEMENTS FROM CLINICAL COMMISSIONING GROUPS, HEALTHWATCH DERBYSHIRE,
IMPROVEMENT AND SCRUTINY COMMITTEES, AND THE TRUST COUNCIL OF GOVERNORS
STATEMENT FROM COUNCIL OF GOVERNORS DERBY HOSPITALS NHS FOUNDATION TRUST
Since last year’s report the Core Regulations Working Group has continued to meet on a regular basis.
There are 8 governors on the Group and it is a Sub-Committee of the Council of Governors. The Group
has recently improved the audit paperwork to gain a deeper insight from staff, particularly on patient
experience issues.
During 2012/13, 11 areas have been audited including, outpatient, wards, and diagnostic, therapy and
day case units. On each inspection 2 staff and 4 patients are interviewed. In 2013/14 Community
Services will be included in the schedule of audits.
The Group has also been involved in the National 15 Steps challenge which looks at quality from a
patient’s perspective. When on a ward, Governors walk round and take note of their first impressions.
The idea is to see the ward through the patient’s eyes. The observations are around, ‘Welcoming,
Safety, Caring and Involving and Well Organised and Calm’.
Detailed findings of the core regulation inspections including any concerns/ compliance issues continue
to be regularly discussed and submitted to the Assistant Chief Nurse. This person attends our bimonthly
meeting to give assurance that any actions required have been addressed and allows for any further
discussion required. Verbal feedback is given to the ward (person in charge on the day followed by a full
written report with actions). Recently the Group have designed a system to ensure any actions that
need to be carried out are completed. This triangulation gives the confidence that improvements are
being made.
A comprehensive evidence file is kept in the trust membership office together with feedback and the
forward programme of inspections. Minutes of all our meetings go to the full council of governors.
Following the inspections completed to date the working group have been satisfied with the level of
compliance against the sixteen core regulations.
As last year in submitting this report there has been liaison with other governor groups that look at
services provided by the Trust, including the Patient Experience and Environment Group (PEEG) and
Facilities Management team inspection for Patient, Environment, Privacy and Dignity (PEAT) on which
governors also participate.
By auditing ward and clinic areas the Governors are able to listen to patients views. Findings are then
reported back to the Council of Governors, which gives Governors the confidence to raise any questions
or issues with Senior Management and to answer any concerns from members of the public.
The Core Regulations Working Group discussed this report at a wider Governors meeting in March 2013
and this statement was approved to be included in the Quality Account for the Trust 2012/2013.
STATEMENT FROM CLINICAL COMMISSIONING GROUP
Thank you for forwarding a copy of your Quality Account 2012/13 for our consideration. Please find
attached the CCG Statement for inclusion into your Quality Account. In line with the guidance, the CCG
has reviewed the information and content of your Quality Account within our internal governance
processes and at the CCG Board.
Lynn Woods
Chief Nurse & Director of Quality
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General Comments
NHS Southern Derbyshire Clinical Commissioning Group (the CCG) is the co-ordinating commissioner
for the NHS contract held with Derby Hospitals NHS Foundation Trust (the Trust). In this role the CCG is
responsible for ensuring pre-publication clearance of the Quality Account produced by the Trust for
2012/13.
Measuring & Improving Performance
The Quality Account submitted by the Trust has been subject to a detailed review by the CCG ensuring
that the data and information reported in the account is consistent with the data submitted to the CCG.
The CCG is pleased to confirm that it agrees with all the contract related data stated in the Quality
Account. However the CCG is concerned that the format and language is not accessible to the public
and reads like an internal NHS report.
Commentary
Many of the initiatives described are agreed as part of the Trust’s contract with the CCG and some are
incentivised financially.
Infection Prevention & Control:
The Trust has failed to achieve the 2 national targets set for MRSA bloodstream infections and
Clostridium Difficile infections. However a considerable amount of work has taken place collaborating
with the Health Community with many initiatives undertaken to support the reduction in infections and the
continual strive to meet these challenging targets.
Pressure ulcers:
The Trust was set a target to eliminate avoidable grade 2, 3 and 4 pressure ulcers by the end of
December 2012. This ambition whilst being very challenging is an important reflection of care; the trust
achieved a 63% reduction by December and the continued reduction is part of the quality contract for
2013/14.
Patient Experience:
The Quality Account highlights a wide range of initiatives to continually improve patient experience. The
net promoter score (called the Friends & Family Test) is now a national requirement and measures
whether a patient would recommend the Trust to a friend or family member. Although the performance
has been consistent over the year the Trust did not meet the contract requirement for this indicator.
In the contract for the coming year 2013-14 the CCG has agreed a number of quality schemes that
attract quality incentive payment. These include care of people at the end of life, people with dementia,
staff experience, safe and well planned discharges and a range of initiatives specifically linked to nursing
care.
STATEMENT FROM HEALTHWATCH DERBY
Healthwatch Derby welcome the opportunity to comment on the Derby Hospitals NHS Foundation Trust
Quality Account 2012/13 and notes the continued effort to both improve services and enter into
meaningful engagement with the community it serves. However the time frame of 4 weeks from being
made aware of the document to being able to provide Derby Hospitals NHS Foundation Trust with a full
response was not sufficient. In future it is hoped that at least 12 weeks is allowed for consultation so the
document can be discussed in full and awareness of what Derby Hospitals NHS Foundation Trust is
trying to achieve can be comprehended and digested by the audience it seeks to reach. Healthwatch
Derby looks forward to working more closely with Derby Hospitals NHS Foundation Trust in the near
future to help ensure that the patient voice is truly captured and service improvements are effectively
achieved.
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STATEMENT FROM HEALTHWATCH DERBYSHIRE
In their Quality Accounts for 2012/13, Derby Hospitals NHS Foundation Trust set out their Quality
Strategy for 2011-14. The objectives within this strategy are Putting Patients First, Right First Time,
Investing our Resources Wisely, Developing our People and Ensuring Value through Partnerships.
These objectives are clearly of the utmost importance, and a clear, cross cutting Quality Strategy which
underpins the work of the Trust is welcomed by Healthwatch Derbyshire, especially in light of the
recently published final report by Robert Francis QC in to the systemic failings at Mid Staffordshire NHS
Foundation Trust.
The Quality Accounts mention the development of PLACE audits (Patient Led Inspections for the Care
Environment). Healthwatch Derbyshire welcomes initiatives to involve and engage patients in Trust
activity, and would welcome more detail in the Quality Accounts about how, when and where the results
and action plan generated will be published. It would also be useful to know how the Trust will develop
and monitor any action plan arising to reassure the reader that PLACE audits will be a truly meaningful
exercise.
The Quality Accounts also detail the development of a range of nutrition and hydration initiatives.
Healthwatch Derbyshire applaud these initiatives, but would encourage the Trust not to overlook the
basics of nutrition and hydration as an integral part of this work. Patient experience recorded by
Derbyshire LINk (the former organisation to Healthwatch Derbyshire) indicated some instances where
requirements were not met, such as being able to see and reach a menu when being asked to choose
food, being able to reach food and drink when served, being able to open sealed food, and receiving the
correct food as ordered. These basic principles are crucial to the provision of nutrition and hydration, and
must be right first time, every time, so not to undermine the development of these important nutrition and
hydration initiatives.
The Trust also outline plans to introduce a Discharge Hub as part of a multi-agency approach to help
with the management of hospital discharge. Healthwatch Derbyshire would welcome any initiative to help
streamline and improve hospital discharge, as this has been a persistent hot topic and area of concern
and complaint locally and nationally.
The Quality Account also features a section on patient experience, which provides the reader with a view
of the range of learning and development plans in place to support staff in improving the patient
experience.
Additionally, information is provided regarding the systems used to collect feedback and comment from
patients such as dignity and respect, and real time patient experience feedback. The Quality Accounts
indicate that responses to both initiatives have been positive, however Healthwatch Derbyshire would
welcome the inclusion of more detail regarding the system used to ensure that all feedback is used
productively to help drive up standards.
We would just like to make a general comment that future Quality Account reporting is constructed in a
more user friendly format. It is evident that various toolkits are used to measure performance but some
statistics reported lack clarity.
We would just like to point out that the draft version of the Quality Account that Healthwatch Derbyshire
was asked to comment on did not include the ‘Statement of Quality from the Chief Executive.’ It would
have been nice to have made reference to the content of this in our response.
Healthwatch Derbyshire, and formerly Derbyshire LINk, has enjoyed a positive and productive
relationship with the Trust during this reporting period, and the Trust has shown a willingness to receive
and act upon the patient feedback presented to it.
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Healthwatch Derbyshire hopes that this relationship will continue and develop, at the public and patient
comments collected previously by Derbyshire LINk which will continue and develop further under the
recently formed Healthwatch Derbyshire, can play a crucial role in providing the Trust with intelligence,
collated by a local independent body.
Healthwatch Derbyshire is looking forward to a positive working relationship with the Trust, working to
deliver shared organisational objectives of working to improve patient experience.
STATEMENT FROM DERBYSHIRE COUNTY COUNCIL IMPROVEMENT AND SCRUTINY
COMMITTEE
I am writing on behalf of Councillor Gill Farrington, Chairman of the Improvement and Scrutiny
Committee - People.
Thank you for sending a copy of the Trust’s draft Quality Account 2012/13 for the Committee to comment
on. Unfortunately the Committee will not be able to provide a comment to the Trust for inclusion in this
year’s Quality Account. This is due to the Council being in a pre-election period ahead of the 2nd May
County Elections and as such there are no meetings of the Committee scheduled before your Trust’s
deadline for comments.
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Annex 2:
STATEMENT OF DIRECTORS’ RESPONSIBILITIES IN RESPECT OF THE QUALITY REPORT
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts)
Regulations 2010 as amended to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality
reports which incorporate the above legal requirements) and on the arrangements that foundation trust
boards should put in place to support the data quality for the preparation of the quality report.
In preparing the quality report, directors are required to take steps to satisfy themselves that:
• the content of the quality report meets the requirements set out in the NHS Foundation Trust Annual
Reporting Manual 2012-13;
• the content of the Quality Report is not inconsistent with internal and external sources of information
including:
•
•
•
•
•
•
•
•
Board minutes and papers for the period April 2012 to May 2013
Papers relating to Quality reported to the Board over the period April 2012 to May 2013
Feedback from the commissioners dated
Feedback from the Governors dated March 2013
Feedback from Healthwatch
The Trust’s complaints data for 2012/13, and the report published under regulation 18 of the Local
Authority Social Services and NHS Complaints Regulations 2009
The Head of Internal Audit’s annual opinion over the trust’s control environment dated May 2012
CQC quality and risk profiles dated April 2012
The 2012 national patient survey published April 2013
The 2012 national staff survey published 28th February 2013
• The Quality Report presents a balanced picture of the NHS foundation trust's performance over the
period covered;
• The performance information reporting in the Quality Report is reliable and accurate
• There are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Report, and these controls are subject to review to confirm that they are
working effectively in practice;
• The data underpinning the measure of performance reported in the Quality Report is robust and
reliable, conforms to specified data quality standards and prescribed definitions, is subject to
appropriate scrutiny and review, and the Quality Report has been prepared in accordance with
Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations published
at www.monitor-nhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality
for the preparation of the Quality Report (available at www.monitor-nhsft.gov.uk/
annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
John Rivers, Chairman, 28 May 2013
Susan James, Chief Executive, 28 May 2013
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Annex 3:
INDEPENDENT ASSURANCE REPORT
Independent Auditor’s Limited Assurance Report to the Council of Governors of Derby Hospitals
NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Derby Hospitals NHS Foundation Trust to
perform an independent assurance engagement in respect of Derby Hospitals NHS Foundation Trust’s
Quality Report for the year ended 31 March 2013 (the ‘Quality Report’) and specified performance
indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2013 in the Quality Report that have been subject to limited
assurance consist of the following national priority indicators as mandated by Monitor:
•
Maximum cancer waiting time of 62 days from urgent GP referral to first treatment for all cancers;
and
•
Emergency readmissions with 28 days of discharge from hospital.
We refer to these national priority indicators collectively as the “specified indicators”.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in accordance
with the assessment criteria referred to in on page 67 of the Quality Report (the "Criteria"). The
Directors are also responsible for the conformity of their Criteria with the assessment criteria set out in
the NHS Foundation Trust Annual Reporting Manual (“FT ARM”) issued by the Independent Regulator of
NHS Foundation Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything
has come to our attention that causes us to believe that:
•
the Quality Report does not incorporate the matters required to be reported on as specified in
Annex 2 to Chapter 7 of the FT ARM;
•
the Quality Report is not consistent in all material respects with the sources specified below; and
•
the specified indicators have not been prepared in all material respects in accordance with the
Criteria.
We read the Quality Report and consider whether it addresses the content requirements of the FT ARM,
and consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is materially
inconsistent with the following documents:
•
•
Board minutes for the period April 2012 to the date of signing this limited assurance report (the
period);
papers relating to Quality reported to the Board over the period April 2012 to the date of signing this
limited assurance report;
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•
•
•
•
•
•
•
feedback from Governors;
feedback from local Healthwatch Derbyshire dated May 2013;
the Trust’s complaints report published under regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009, dated 20/05/2013;
the latest national patient survey dated 2012;
the latest national staff survey dated 2012;
Care Quality Commission quality and risk profiles dated 28/02/2013, 02/04/2012, 30/06/2012, and
31/10/2012;
The Head of Internal Audit’s interim annual opinion over the Trust’s control environment dated
24/04/2013.
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with those documents (collectively, the “documents”). Our responsibilities do not
extend to any other information.
We are in compliance with the applicable independence and competency requirements of the Institute of
Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance
practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of Derby
Hospitals NHS Foundation Trust as a body, to assist the Council of Governors in reporting Derby
Hospitals NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure
of this report within the Annual Report for the year ended 31 March 2013, to enable the Council of
Governors to demonstrate they have discharged their governance responsibilities by commissioning an
independent assurance report in connection with the indicators. To the fullest extent permitted by law,
we do not accept or assume responsibility to anyone other than the Council of Governors as a body and
Derby Hospitals NHS Foundation Trust for our work or this report save where terms are expressly
agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on
Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of Historical
Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE
3000’). Our limited assurance procedures included:
•
•
•
•
•
evaluating the design and implementation of the key processes and controls for managing and
reporting the indicators;
making enquiries of management
limited testing, on a selective basis, of the data used to calculate the specified indicators back to
supporting documentation;
comparing the content requirements of the FT ARM to the categories reported in the Quality
Report; and
reading the documents.
A limited assurance engagement is less in scope than a reasonable assurance engagement. The nature,
timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited
relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information,
given the characteristics of the subject matter and the methods used for determining such information.
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The absence of a significant body of established practice on which to draw allows for the selection of
different but acceptable measurement techniques which can result in materially different measurements
and can impact comparability. The precision of different measurement techniques may also vary.
Furthermore, the nature and methods used to determine such information, as well as the measurement
criteria and the precision thereof, may change over time. It is important to read the Quality Report in the
context of the assessment criteria set out in the FT ARM and the Directors’ interpretation of the Criteria
on page 67 of the Quality Report.
The nature, form and content required of Quality Reports are determined by Monitor. This may result in
the omission of information relevant to other users, for example for the purpose of comparing the results
of different NHS Foundation Trusts. .
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators in the Quality Report, which have been determined locally by Derby Hospitals NHS
Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that
for the year ended 31 March 2013:
•
the Quality Report does not incorporate the matters required to be reported on as specified in
annex 2 to Chapter 7 of the FT ARM;
•
the Quality Report is not consistent in all material respects with the documents specified above;
and
•
the specified indicators have not been prepared in all material respects in accordance with the
Criteria.
PricewaterhouseCoopers LLP
Chartered Accountants
Cornwall Court
19 Cornwall Street
Birmingham
B3 2DT
29 May 2013
The maintenance and integrity of the Derby Hospitals NHS Foundation Trust’s website is the
responsibility of the directors; the work carried out by the assurance providers does not involve
consideration of these matters and, accordingly, the assurance providers accept no responsibility for any
changes that may have occurred to the reported performance indicators or criteria since they were
initially presented on the website.
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ABBREVIATIONS USED:
Abbreviation Used
AKI
ANTT
BMI
C.diff
CCOT
CDS
CLRN
CQC
CQUIN
CT
CVC
DNACPR
E.coli
ED
EMCSN
EWS
EPMA
GP
IBD
ICOG
ICNARC
HRS
HSMR
HPA
HTA
KPI
LCP
LGBT
LIPS
MAU
MRC
MRSA
MRSAb
MSSA
NCEPOD
NHS
NICE
NICU
NIHR
NMBR
NNAP
NPSA
NRLS
PALS
PAS
PbR
PCT
PDSA
PEAT
In Full
Acute Kidney Injury
Aseptic Non Touch Technique
Body Mass Index
Clostridium difficile
Critical Care Outreach Team
Commissioning Data Set
Comprehensive Local Research Network
Care Quality Commission
Commissioning for Quality and Innovation
Computerised Tomography
Central Venous Catheter
Do Not Attempt Cardio Pulmonary Resuscitation
Escherichia coli
Emergency Department
East Midlands Cardiac and Stroke Network
Early Warning Score
Electronic Prescribing and Medicines Administration
General Practitioner
Inflammatory Bowel Disease
Infection Control Operational Group
Intensive Care National Audit and Research Centre
Health Research Sectors
Hospital Standardised Mortality Rate
Health Protection Agency
Health Technology Assessment
Key Performance Indicator
Liverpool Care Pathway
Lesbian, Gay, Bisexual and Transgender
Leading Improvements in Patient Safety
Medical Admissions Unit
Medical Research Council
Methicillin Resistant Staphylococcus Aureus
Methicillin Resistant Staphylococcus Aureus bacteraemia
Methicillin Sensitive Staphylococcus Aureus
National Confidential Enquiries of Patient Outcomes and Death
National Health Service
National Institute for Health and Clinical Excellence
Neonatal Intensive Care Unit
National Institute for Health Research
National Mastectomy and Breast Reconstruction
National Neonatal Audit Programme
National Patient Safety Agency
National Reporting and Learning System
Patient Advice and Liaison Service
Patient Administration System
Payment by Results
Primary Care Trust
Plan, Do, Study, Act
Patient Experience Assessment Team
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PLACE
PROMS
PUPG
QIPP
RCA
RCP
SBAR
SHMI
SLAM
SUS
VTE
Patient Led Assessment for the Care Environment
Patient Reported Outcomes Measures
Pressure Ulcer prevention Group
Quality, Innovation, Productivity and Prevention
Root Cause Analysis
Royal College of Physicians
Situation, Background, Assessment , Recommendation
Summary Hospital Level Mortality Index
Service Level Activity Monitoring
Secondary User Service
Venous Thrombo Embolus
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If you would like any part of this document translated into
your own language, or require a version in large print,
please contact us on:
Tel: 01332 783475
If you would like further information about the Trust, the services we
provide, or anything you have read within this report,
please contact:
The Communications and PR Department
Derby Hospitals NHS Foundation Trust
Royal Derby Hospital
Uttoxeter Road
Derby
DE22 3NE
Tel: 01332 785770
dhft.communications@nhs.net
Royal Derby Hospital
Uttoxeter Road
Derby
DE22 3NE
London Road Community Hospital
London Road
Derby
DE1 2QY
G11917/0513